Subarachnoid hemorrhage is a condition that is caused by cerebral hemorrhage when blood begins to accumulate in the subarachnoid spaces of the cerebral membrane. This pathology is characterized by intense and severe pain in the head, short-term loss of consciousness, its confusion, which can be combined with hyperthermia and a complex of meningeal symptoms. Subarachnoid hemorrhage is diagnosed in accordance with CT data and brain angiography. If it is impossible to carry out such studies, pathology is recognized by the presence of blood in the cerebrospinal fluid. The basis of the traditional treatment in this case is the relief of angiospasm, as well as the shutdown of cerebral aneurysm from the bloodstream, which is carried out through surgical intervention.
Characteristic symptoms
Acute and very intense headache with subarachnoid hemorrhage reaches its highest peaks within literally a few seconds. When aneurysm ruptures or immediately after it, short-term loss of consciousness may occur. In some cases, this only happens after some time has passed. Patients, as a rule, behave very restlessly in this case, they may experience convulsive seizures. Sometimes the focal symptoms of neuralgia join the clinical picture of this condition, which in most cases become irreversible within a few hours or even minutes after the rupture of the aneurysm.
A detailed description of subarachnoid hemorrhage (ICD 10 I60) is given below.
In the first hours, in the absence of pronounced swelling and syndrome of wedging tonsils of the cerebellum, the mobility of the neck muscles is not expressed. However, in the course of the first day, the development of chemical meningitis begins, and symptoms of irritation of the cerebral membrane increase. In this case, moderate or severe clinical signs of meningism appear, vomiting occurs, a bilateral pathological plantar reflex, a change in the pulse and the process of respiratory activity. In the first 5-7 days, the temperature may increase, which is accompanied by a prolonged headache and confusion.
With secondary hydrocephalus, the occurrence of headache, stunning and motor disorders that are present for a month is possible. Relapses of bleeding can exacerbate pre-existing symptoms.
How arises
Subarachnoid hemorrhage occurs rapidly, sharply, when nothing portends such a condition, is characterized, as a rule, by the occurrence of sudden intense diffuse headaches of the type of “stroke”, which are often accompanied by nausea and vomiting. Typical in this situation are short-term fainting and the development of meningeal syndrome. Long-term loss of consciousness indicates severe forms of hemorrhage, when blood is poured into the ventricular system, in which there is a rapid attachment of neurological symptoms. This suggests a subarachnoid-parenchymal hemorrhage in the brain.
Meningeal syndrome is the main differential diagnostic sign of this pathology. Depending on the massiveness of the subarachnoid hemorrhage (ICD code - 10 I60), symptoms can be expressed in different ways and persist from one day to 4 weeks.
Along with the occurrence of severe neurological symptoms, such hemorrhage may be accompanied by some viscero-vegetative changes.
Very often, at the time of subarachnoid hemorrhage in the brain, an increase in blood pressure is observed. This symptom is considered a reaction of the body to a stressful situation, which at the same time has a compensatory character, since it supports cerebral perfusion pressure in the event of acute intracranial hypertension at the time of hemorrhage. High blood pressure, especially in patients who are chronically affected by hypertension, often causes an erroneous recognition of this acute condition as a hypertensive crisis.
In cases of severe subarachnoid hemorrhage, serious disturbances in the activity of the heart and respiratory organs can occur.
In the acute period of such a pathological process, an increase in temperature is often observed up to subfebrile numbers and the development of leukocytosis. These symptoms may also be misinterpreted as signs of an infectious disease.
The severity of the patient's condition at the time of hemorrhage and the subsequent course of the pathological process depend mainly on its massiveness and etiology. It is very difficult, as a rule, when a cerebral aneurysm ruptures.
The causes of subarachnoid hemorrhage are discussed below.
Reasons for the development of pathology
Spontaneous or, as it is commonly called in medical terminology, primary hemorrhage (SAH) occurs, as a rule, due to rupture of aneurysm of certain superficial vessels of the brain. Somewhat less often, it is observed with a rupture of atherosclerotic or mycotic aneurysms, arteriovenous malformation, or hemorrhagic diathesis. In traumatic brain injuries, subarachnoid hemorrhages of the brain are also very common.
In about half the cases, the cause of intracranial hemorrhage is aneurysm of the vessels located in the brain. These pathological formations can be congenital or acquired. Visually, an aneurysm is a saccular formation on the vessel wall, in which the neck, body and bottom are distinguished. The diameter of such a vascular sac, as a rule, ranges from a few millimeters to a couple of centimeters. Aneurysms with a diameter of more than 2 cm are considered gigantic. Subarachnoid hemorrhage (ICD code I60) occurs equally in men and women, and very often bears a hereditary character.
Statistical data
Aneurysm ruptures occur most often between the ages of 30 and 50, and this is observed in almost 90% of cases. Unexploded formations of a similar nature are found in about 6-7%, and the asymptomatic course of the disease in 0.5% of patients. The rupture of aneurysms almost always occurs in the area of their bottom, where under a microscope, you can often see small point holes covered by thrombotic masses. Typical localization of aneurysms is in the places of branching of vessels of the I and II order. Their most frequent localization is observed in the supraclinoid sections of the internal carotid arteries (40% of cases), in the anterior cerebral and anterior connecting arteries (30% of cases), in the middle cerebral artery (20%), in the vertebral-basilar system (10%). Multiple aneurysms, as a rule, are rare and are observed in about 15% of cases of the development of this pathology.
With subarachnoid hemorrhages due to prolonged spasms of large arteries, diffuse ischemia of this organ develops in the base of the brain, which most often leads to posthemorrhagic changes in cognitive functions, for example, inhibition, dementia. An increase in intracranial pressure is also noted.
Therapeutic methods
The occurrence of subarachnoid hemorrhage requires urgent therapeutic measures. Patients in this situation are subject to emergency hospitalization in the neurosurgical department of the hospital.
At the same time, correction of high blood pressure, normalization of arterial pressure are carried out, antiemetic drugs and analgesics are used. In cases where the patient lacks consciousness, all of the above activities are carried out against the background of mechanical ventilation.
To eliminate vasospasm in the brain, patients are prescribed Nimodipine (Nimotop). Due to the fact that through parenteral administration this substance can cause arterial hypotension, which can lead to secondary ischemic brain damage, it is advisable to take it inside every 4 hours. In cases of lack of consciousness, the drug is administered, usually through a probe. Tablets should not be washed down with juices, as this can cause metabolic disorders.
In cases where angiospasm occurs against a background of normal or moderate blood pressure, aneurysm should be clipped. It is also considered appropriate to increase the pressure with the help of "Dopamine" or other means.
To remove cerebral edema with subarachnoid hemorrhage (ICD 10), Dexamethasone, Mannitol, and Glycerol are used intravenously. When hyponatremia occurs, as a rule, it is sufficient to reduce the amount of isotonic fluid introduced into the blood. When the development of hypovolemia is observed, isotonic saline solutions or Ringer's solution are administered to eliminate it. In cases of detection of inadequate ADH production, restriction of fluid administration and the use of Furosemide after subarachnoid hemorrhage are indicated.
Reduction of non-occlusive hydrocephalus is carried out by repeated lumbar puncture.
General measures for this pathology are similar to those carried out with ischemic stroke. In this case, the patient is shown bed rest, getting up is only allowed from the 4th week after hemorrhage, and before that, his motor activity gradually increases.
To solve the issue of surgical treatment, a total angiography of the cerebral vessels is performed.
When the patient's condition allows, aneurysm is clipped in the first two days after its rupture. In extremely severe cases, when it comes to saving human life, endovasal intervention is performed. A similar technique is also used in patients with aneurysms at high surgical risk, as well as in the presence of aneurysms with a very narrow neck.
Treatment of subarachnoid hemorrhage should be timely.
In cases where urgent surgery is not possible, it is carried out in a planned manner approximately 2 weeks after hemorrhage (during the “cold period”). Sometimes, for example, with hematomas of the temporal lobe, an emergency surgical intervention should be performed, which is aimed at correcting a life-threatening condition, even in cases when the main operation, which is clipping aneurysm, is impossible.
The risk of death during surgical treatment is approximately 6%, and the risk of developing severe forms of neurological deficit is approximately 13%.
What is the diagnosis for symptoms of subarachnoid hemorrhage?
Diagnosis of hemorrhage
This pathology is diagnosed with a lumbar puncture, when a bloody cerebrospinal fluid is revealed, which flows under high pressure.
A few hours after the hemorrhage, this fluid acquires a xanthochromic color due to hemolysis of red blood cells. The presence of blood in the subarachnoid region can be detected by CT of the head. However, lumbar punctures may be appropriate not only for diagnostic, but also for therapeutic purposes. If the development of repeated subarachnoid hemorrhage is not observed, then the cerebrospinal fluid begins to gradually clear, and its composition is finally normalized by the 3rd week.
Acute hemorrhage sometimes resembles myocardial infarction, and this can be facilitated by states of loss of consciousness and changes in the ECG. With the development of focal neurological manifestations, this pathology should be differentiated with parenchymal hemorrhage.
Angiography and computed tomography are also needed to plan surgical treatments. It is very advisable to conduct a study of all the main arteries of the head, since several aneurysms can occur simultaneously.
With computed tomography, an aneurysm can be detected with its size more than 5 mm. In the hemorrhagic period, basal hemorrhage can be visualized, which is sometimes combined with intracerebral or intraventricular hemorrhage. Consider the effects of subarachnoid hemorrhage of the brain.
The consequences of subarachnoid hemorrhage
The main adverse factor for the outcome of this pathological condition is a low level of consciousness, the presence of blood in the subarachnoid spaces, the age of the patient, and the presence of vascular aneurysms in the vertebrobasilar pool.
In some patients with minor hemorrhages, a lethal outcome may be due to a prolonged period of cerebral ischemia during the onset of pathology. At the same time, the pressure of the fluid in the spinal cord rises to the level of pressure in the arteries of the brain and circulatory arrest is observed.
Hypertension after subarachnoid hemorrhages is considered compensatory, therefore hypotensive drugs used in connection with such formal signs can worsen brain perfusion. Some experts suggest that if hypotensive therapy is not used in combination with water loads, this can significantly reduce the risk of developing a heart attack. Arterial hypertension in the acute period of subarachnoid hemorrhage may not be corrected in cases where there are no signs of organ damage.
Hyponatremia is characterized by loss of sodium by brain tissue, and is not a consequence of hemodilution due to impaired ADH secretion. It requires correction, since it can provoke the development of cerebral ischemia.
Antifibrinolytic drugs can prevent re-bleeding caused by rupture of the aneurysm, however, they increase the risk of cerebral ischemia and, as a result, do not significantly affect the outcome of pathological hemorrhage.
Fludrocortisone has mineralocorticoid activity, and also reabsorb sodium in the tubules of the kidneys, which means it is able to prevent the occurrence of a negative sodium balance, ischemic effects and hypovolemia. The causes and consequences of subarachnoid hemorrhage should be known to everyone.
Forecast
The prognosis of treatment primarily depends on the severity of the attack in each individual patient. If medical care was not delivered on time, the likelihood of repeated hemorrhages after a neurosurgical intervention and, as a consequence, the fatal outcome of the patient is very high. Recovery after a hemorrhage lasts at least six months and is a very difficult period of rehabilitation. Daily medication, monitoring the general condition, regular visits to a neurologist - this is what is vital to restore health in such cases. In addition, a patient who has suffered an attack of cerebral hemorrhage needs to abandon bad habits and begin to lead a measured lifestyle in order to avoid the consequences of subarachnoid hemorrhage.
Pathology in the newborn
Subarachnoid hemorrhage in infants may be associated with birth trauma, it has manifestations such as meningeal and hydrocephalic syndrome, as well as focal symptoms that depend on the localization of the hemorrhage, manifesting immediately after birth.
Moderate hemorrhage in most newborns develops almost asymptomatically or can be detected on the second day. Signs of cerebral hemorrhage in newborns manifest as:
- Severe anxiety and general arousal.
- Brain scream.
- Cramps.
- Sleep inversions.
- Amplification of congenital reflexes.
- Increased muscle tone.
- Hyperesthesia.
- Jaundice
- Bulging fontanel.
Proper diagnosis and timely treatment help significantly reduce the risk of the formation of organic pathologies of the brain, contribute to their rapid rehabilitation and minimize adverse effects on the central nervous system, which lead to the development of cerebral palsy in children.
Traumatic Subarachnoid Hemorrhage
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