The brain is surrounded by three membranes that create a barrier for it: hard, arachnoid (arachnoid), soft. The arachnoid membrane is located between hard and soft, from the latter it is separated by a subarachnoid space filled with cerebrospinal fluid, which performs a protective function, participates in metabolic processes. The cerebral arteries and arterioles of this area are located in the lumen of the cerebrospinal fluid canals.
Bleeding that occurs in this cavity is a form of stroke that threatens with severe disability and, in 50% of cases, death.
Subarachnoid hemorrhage (SAH) acts as a consequence of a traumatic brain injury or rupture of a cerebral aneurysm (this is the name of a place with an enlarged lumen of an artery). In the latter case, damage to small aneurysms most often occurs, but the greatest risk is the violation of large ones.
This hemorrhage can occur at any age, but in the elderly, the risk of it increases. ICD-10 classifies a disorder depending on the localization of bleeding, which can occur from the middle cerebral, basilar, vertebral and other arteries, characterized by multiple lesions. The main codes are I60.0 – I60.9.
Etiology and mechanism of development of pathology
When a lesion occurs due to a ruptured aneurysm, it is said that the hemorrhage is spontaneous. The main reasons are associated with cardiovascular pathologies, blood diseases:
- anomalies of cerebral vessels;
- hypertonic disease;
- inflammation of the walls of blood vessels (vasculitis);
- cerebral vein thrombosis;
- hemorrhage in the pituitary gland;
- chronic alcoholism, intoxication with ethyl alcohol;
- sickle cell anemia;
- myxoma of the heart (benign neoplasm);
- blood clotting disorders (due to illness or taking anticoagulants).
In TBI (bruises, fractures), the outflow of blood into the brain – namely, into its subarachnoid region – is the most common complication . Traumatic subarachnoid hemorrhage can occur both due to direct damage to blood vessels, and as a consequence of their spasm, which accompanies injury.
In patients with chronic alcoholism who are at risk, SAH often occurs after the brain has been injured: falls of a person in a state of strong alcoholic intoxication often occur.
In a child, after birth, subarachnoid hemorrhage can occur as a result of traumatic and / or premature birth. It happens more often than other intracranial hemorrhages in newborns.
The blood that flows into the subarachnoid space spreads through the cerebrospinal fluid canals, which leads to an increase in the volume of cerebrospinal fluid and an increase in intracranial pressure. After this, blood clots form, which block the cerebrospinal fluid pathways, which leads to aggravation of intracranial hypertension, inflammation of the meninges.
Recovery
Rehabilitation after the treatment of subarachnoid hemorrhage takes about six months . During this period, a person is forced to regularly take medications and be examined by a neurologist. Relatives must necessarily monitor his health.
As for the indications for recovery, there are not too many of them. A person should give up bad habits and lead a calm lifestyle. It should be borne in mind that this pathology belongs to the category of recurrent diseases.
Manifestation of pathology
The main symptom that characterizes the outpouring of blood in the brain tissue is a severe, sharp headache, which can also “pulsate” in the back of the head. Other symptoms accompanying the development of bleeding:
- nausea and repeated vomiting (sometimes vomiting may occur without prior nausea);
- convulsive syndrome;
- loss of consciousness, coma;
- increased blood pressure;
- stiff neck and limited head movement;
- drooping of the upper eyelids (ptosis);
- decreased vision;
- double vision, squint;
- profuse sweating and salivation;
- increased body temperature;
- arrhythmia, tachycardia;
- stereotyped movements, psychomotor excitability.
The listed symptoms do not occur in the patient at the same time: most of them may appear, only a headache, sometimes they are completely absent.
The increase in blood pressure after hemorrhage can be regarded as a compensatory mechanism that avoids cerebral infarction. In the absence of organ damage, it may be recommended to avoid the use of antihypertensive drugs in the acute stage of bleeding into the subarachnoid area.
The consequences that threaten subarachnoid hemorrhage are severe and come quickly : in 15% of cases, the patient does not have time to provide resuscitation benefits, the remaining 30–35% die due to repeated bleeding in the first month after the first SAH. Death usually occurs due to ischemia and subsequent circulatory arrest.
Adverse factors that worsen the prognosis are:
- depression or loss of consciousness;
- elderly age;
- moderate or severe traumatic brain injury;
- delayed diagnosis and delayed treatment;
- the appearance of repeated hemorrhage;
- concomitant diseases (vascular pathology, hemophilia, liver disease, alcoholic encephalopathy, etc.);
- a history of myocardial infarction;
- large aneurysm and large bleeding.
Signs in newborns
Subarachnoid hemorrhage in newborns due to birth trauma suggests the following symptoms that appear immediately after birth or in the first days of life:
- convulsions;
- hypertonicity;
- impaired consciousness, respiratory arrest (apnea);
- increased congenital reflexes;
- increased physical activity, agitation;
- spontaneous, so-called cerebral, cry (indicating pain);
- difficulty eating (it is difficult for a child to suck);
- bulging fontanelle;
- divergence of cranial sutures and increased head volume;
- increased sensitivity to stimuli (for example, to touch).
As a result, the child may develop: hydrocephalus, meningitis, cerebral palsy. The presence and severity of complications depend on the severity of the underlying disease: in some cases, the consequences may be completely absent or minimal and can be corrected by a neurologist in the first year of life.
Rehabilitation period
The recovery time after subarachnoid bleeding depends on the severity of its course, but takes at least 6 months.
Rehabilitation is carried out under the supervision of doctors in a hospital and directly depends on drug therapy, as well as on:
- patient hygiene;
- remedial gymnastics and physical education;
- classes with a speech therapist.
Patients who have suffered a hemorrhage may face several problems that can significantly lengthen the rehabilitation period:
- constant fatigue (solved by walking, with a gradual increase in time);
- insomnia (sleep and rest schedule);
- persistent headaches (they are treated only with medication);
- problems with sensitivity and motor function (physiotherapy and physiotherapy exercises help);
- vision problems (requires a visit to an ophthalmologist);
- partial or complete memory loss (its restoration is carried out with medication).
All problems that arise are resolved with the attending physician, who will refer the patient to other specialists (for example, an ophthalmologist). As a prophylaxis, both the first and subsequent hemorrhage, it is recommended to eat well, quit smoking / alcohol / drugs, engage in physiotherapy exercises and monitor the level of pressure.
Diagnosis of violation
The main method that allows you to diagnose hemorrhage in the brain – in the subarachnoid space – is computed tomography. Subsequently, MRI becomes highly sensitive, but in the first days, CT should be preferred.
Despite the fact that an examination using ultrasound – neurosonography – is available for newborns, which allows you to evaluate the brain through the fontanelle, computed tomography is also indicated for the diagnosis of SAH.
An additional way of making a diagnosis (or the main one when tomography is not available) is a lumbar puncture. It should also be performed in cases where CT does not show signs of a disorder, but clinical symptoms indicate it (this, for example, can occur a few days after the onset of headaches). It is carried out three times, and according to the results, the presence of erythrocytes and bilirubin in the cerebrospinal fluid is assessed.
It is important to carry out differential diagnostics, which will allow to exclude other cerebral hemorrhage – hemorrhagic stroke , as well as meningitis, migraine and sinus thrombosis of the dura mater.
There may be cases when a subarachnoid hemorrhage is mistaken for a migraine. This happens when only the main symptom is present – a severe headache, and consciousness remains intact. Such errors negatively affect the prognosis of the disease and increase the risk of re-bleeding within three weeks.
Hemorrhage, during which blood flows directly into the brain – a hemorrhagic stroke – is more common with SAH, leading to a misdiagnosis. According to ICD-10, it and SAK are referred to as cerebrovascular diseases, but they are different disorders.
As a result of an erroneous diagnosis, incorrect treatment is prescribed, which is not aimed at eliminating the underlying cause, which leads to complications.
In some cases, classical angiography is performed – an X-ray examination of the vessels with the introduction of a contrast agent for better visualization. It can be performed simultaneously with endovascular surgery.
Treatment
If the patient has signs of subarachnoid hemorrhage, he is immediately admitted to a neurological hospital.
When vascular pathologies that require surgical intervention are identified, the decision on the timing of the operation is made on an individual basis . This is influenced by the age of the patient, the amount of hemorrhage, the severity of symptoms, and general health.
If there are no indications for an operation, conservative treatment is carried out. The main tasks of such therapy include:
- stabilization of the patient’s condition;
- relapse prevention;
- maintaining homeostasis;
- treatment of the disease that led to the hemorrhage.
With the help of drugs, you should stop bleeding and reduce the risk of complications.
- To relieve spasm and reduce ischemia, calcium antagonists are prescribed.
- To prevent the development of seizure activity, the appointment of phenytoin is indicated.
- For the treatment of hypertension, nitroprusside is prescribed. With the help of this tool, it is possible to prevent the threat of recurrent bleeding.
- Endothelial antagonists and magnesium sulfate are used as symptomatic agents.
Caution! The video shows an operation on an open brain to remove a subarachnoid hemorrhage (click to open)
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Therapy
Treatment should be carried out along several lines. It includes:
- stabilization of the patient;
- elimination of the source of blood flow (by surgery);
- rehabilitation of cerebrospinal fluid;
- correction of complications;
- preventing the risk of re-hemorrhage.
The patient is shown a resuscitation aid connected to a ventilator (artificial lung ventilation) or a referral to the intensive care unit, depending on the severity of the lesion.
To stop bleeding and reduce the risk of its recurrence, emergency surgical treatment is often performed: using clipping or endovascular occlusion. The method is chosen based on the localization of the aneurysm and the patient’s condition. Clipping involves the imposition of a special clip on the site of the aneurysm. With endovascular occlusion, a ring is delivered to the lesion site using a catheter, which creates a thrombus and ensures that the blood flow stops.
In the first 3 days, it is necessary to sanitize the cerebral fluid in order to avoid the development of inflammation, as well as to alleviate the condition in the acute period. It is carried out using lumbar punctures: the affected cerebrospinal fluid is removed and replaced with special solutions.
The appearance of severe persistent headaches should alert: prolonged diagnosis and absent treatment negatively affect the course of the underlying disease, which threatens with severe complications and death.
Complications of SAH
Relatively successful passage of the acute phase does not always mean that the brain has not suffered due to hemorrhage. Various consequences can be observed.
- Vascular spasm can lead to delayed ischemia, which in turn can lead to death or disability. According to statistics, this complication occurs in a third of cases. If subarachnoid hemorrhage is diagnosed as spontaneous, a special drug treatment (using nimodipine) is indicated to prevent spasm. In some cases, this agent can be delivered directly to the site of the aneurysm using catheterization.
- Hydrocephalus is often an accompanying phenomenon of cerebral hemorrhage (in any structure). It can appear in the early days or during the recovery period. In the acute phase of SAH, the reduction of dropsy is facilitated by lumbar punctures, which are performed for diagnostic and sanitation purposes. Subsequently, an invasive treatment of this pathology is indicated (with the help of drainage, bypass surgery or endoscopy).
Some patients may develop pneumonia, arterial hypertension, cardiac decompensation, convulsive syndrome, gastric and duodenal ulcers.
Delayed effects relate to cognitive functions, emotional reactions, hormonal levels. Observed:
- decreased attention and memory;
- stiffness of intellectual processes;
- the development of dementia (dementia);
- lethargy;
- anxiety, anxiety;
- clinical depression;
- symptoms of damage to the hypothalamic-pituitary system – manifestations of hypopituitarism, which develops due to a lack of hormones
Subarachnoid hemorrhage is a severe form of cerebrovascular disease, which is fatal in half of the cases. Various cardiovascular pathologies and blood diseases lead to it. The risk zone includes newborns who have experienced a traumatic birth and / or were born prematurely, the elderly, and those who abuse alcohol. This lesion must be distinguished from other diseases – cerebral hemorrhage (hemorrhagic stroke) and migraine, with which it is often confused in the initial phase. Timely, thorough diagnosis and the right treatment increase the chances of survival.