Subarachnoid hemorrhage is a condition that is caused by cerebral bleeding, when blood begins to accumulate in the subarachnoid spaces of the cerebral sheath. This pathology is characterized by intense and sharp pain in the head, short-term loss of consciousness, its confusion, which can be combined with hyperthermia and a complex of meningeal symptoms. Diagnose subarachnoid bleeding in accordance with CT data and angiography of the brain. If it is impossible to carry out such studies, the pathology is recognized by the presence of blood in the cerebrospinal fluid. The basis of traditional treatment in this case is the relief of angiospasm, as well as the exclusion of a cerebral aneurysm from the bloodstream system, which is carried out through surgical intervention.
Characteristic symptoms
Acute and very intense headache with subarachnoid hemorrhage reaches its highest peaks within just a few seconds. When an aneurysm ruptures or immediately after it, a short-term loss of consciousness can be observed. In some cases, this only happens after some time has elapsed. Patients tend to be very restless and may experience seizures. Sometimes 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 aneurysm rupture.
Detailed description of subarachnoid hemorrhage (ICD 10 I60) is given below.
In the first hours, in the absence of severe swelling and the syndrome of herniation of the tonsils of the cerebellum, the mobility of the neck muscles is not pronounced. However, during the first day, the development of chemical meningitis begins, and the symptoms of irritation of the meninges increase. In this case, moderate or pronounced 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 rise, which is accompanied by prolonged headache and confusion.
Secondary hydrocephalus may cause headache, stupor and motor disturbances that are present for a month. Recurrent bleeding may exacerbate alreadyexisting symptoms.
How it happens
Subarachnoid hemorrhage occurs rapidly, acutely, when nothing foreshadows such a condition, is characterized, as a rule, by the occurrence of sudden intense diffuse headaches of the "hit" type, which are often accompanied by nausea and vomiting. Typical in this situation are short-term fainting and the development of meningeal syndrome. Prolonged loss of consciousness indicates severe forms of hemorrhage, when there is an outpouring of blood into the ventricular system, in which there is a rapid addition of neurological symptoms. This indicates 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 a day to 4 weeks.
Along with the occurrence of severe neurological symptoms, such a hemorrhage may be accompanied by some viscero-vegetative changes.
Very often at the time of subarachnoid hemorrhage in the brain there is an increase in blood pressure. This symptom is considered to be the body's response to a stressful situation, which is also compensatory in nature, since it maintains cerebral perfusion pressure in the event of acute intracranial hypertension at the time of hemorrhage. High blood pressure, especially in patientswho suffer from chronic hypertension often causes this acute condition to be misdiagnosed as a hypertensive crisis.
In cases of severe subarachnoid hemorrhage, serious disorders of the heart and respiratory organs can occur.
In the acute period of such a pathological process, there is often an increase in temperature up to subfebrile numbers and the development of leukocytosis. These symptoms can also be misinterpreted as signs of infectious diseases.
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 proceeds very hard, as a rule, it occurs when an aneurysm of the cerebral vessels ruptures.
The causes of subarachnoid hemorrhage will be discussed below.
Causes 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 an aneurysm of certain superficial cerebral vessels. Somewhat less often, it is observed with a rupture of atherosclerotic or mycotic aneurysms, arteriovenous malformation, or hemorrhagic diathesis. Subarachnoid hemorrhage of the brain is also very common in traumatic brain injuries.
Approximately half of the cases of intracranial hemorrhage are caused by aneurysms of blood vessels located in the brain. These pathological formations canbe 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 larger than 2 cm in diameter are considered giant. Subarachnoid hemorrhage (ICD code I60) occurs equally in both men and women, and is very often hereditary.
Statistics
Ruptures of aneurysms occur most often between the ages of 30 and 50, and occur in almost 90% of cases. Unruptured formations of this nature occur in approximately 6-7%, and asymptomatic course of the disease - in 0.5% of patients. Rupture of aneurysms almost always occurs in the region of their bottom, where under a microscope one can often see small pinholes covered with 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 communicating arteries (30% of cases), in the middle cerebral artery (20%), in the vertebrobasilar system (10%). Multiple aneurysms are generally rare and occur in about 15% of cases.
With subarachnoid hemorrhages due to prolonged spasms of large arteries, diffuse ischemia of this organ develops in the base of the brain, which is more oftenall leads to post-hemorrhagic changes in cognitive functions, for example, lethargy, dementia. There is also an increase in intracranial pressure.
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, high blood pressure is corrected, blood pressure is normalized, antiemetic drugs and analgesics are used. In cases where the patient is unconscious, 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 orally every 4 hours. In cases of unconsciousness, the drug is administered, as a rule, through a probe. Tablets should not be taken with juices as this may cause metabolic disturbances.
In cases where angiospasm occurs against the background of normal or moderate blood pressure, clipping of the aneurysm should be performed. It is also considered appropriate to increase pressure with the help of "Dopamine" or other means.
To relieve cerebral edema in subarachnoid hemorrhage (ICD 10), Dexamethasone, Mannitol, Glycerol are used intravenously. When hyponatremia occurs,as a rule, it is enough to reduce the amount of isotonic fluid injected into the blood. When hypovolemia develops, 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.
Non-occlusive hydrocephalus is reduced by repeated lumbar puncture.
General measures in this pathology are similar to those carried out in ischemic stroke. At the same time, the patient is shown bed rest, it is allowed to get up only from the 4th week after the hemorrhage, and before that, his motor activity gradually increases.
To resolve the issue of surgical treatment, a total angiography of cerebral vessels is performed.
When the patient's condition allows, the 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 an urgent operation is not possible, it is carried out in a planned manner approximately 2 weeks after the 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 the life-threatening condition, even if the main operation, which is the clipping of the aneurysm, is impossible.
The risk of death during surgery 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 bloody cerebrospinal fluid is detected, which flows out under high pressure.
A few hours after the hemorrhage, this fluid acquires xanthochromic color due to hemolysis of erythrocytes. The presence of blood in the subarachnoid region can be detected by CT of the head. However, lumbar punctures may be useful 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 finally normalizes by the 3rd week.
Acute hemorrhage sometimes resembles a myocardial infarction, and states of unconsciousness and ECG changes can contribute to this. With the development of focal neurological manifestations, this pathology should be differentiated from parenchymal hemorrhage.
Angiography and computed tomography are also required toplanning of surgical methods of treatment. It is highly advisable to study all the main arteries of the head, since several aneurysms can occur simultaneously.
Computer tomography can detect an aneurysm if it is larger than 5 mm. In the hemorrhagic period, basal hemorrhage can be visualized, which is sometimes combined with intracerebral or intraventricular hemorrhage. Consider the consequences of a subarachnoid hemorrhage of the brain.
Consequences of subarachnoid bleeding
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 basin.
In some patients with minor hemorrhages, death may be due to a long period of cerebral ischemia during the onset of the disease. In this case, the pressure of the fluid in the spinal cord rises to the level of pressure in the arteries of the brain and there is a circulatory arrest.
Hypertension after subarachnoid hemorrhage is considered compensatory, so antihypertensive drugs used in connection with such formal signs may impair brain perfusion. Some experts suggest that if antihypertensive therapy is not used in combination with water loads, this can significantly reduce the risk of developing a cerebral infarction. Arterial hypertension in the acute period of subarachnoid hemorrhage may not be corrected incases where there are no signs of organ damage.
Hyponatremia is characterized by a loss of sodium by the brain tissues, and is not a consequence of hemodilution due to impaired secretion of ADH. It requires correction, as it can provoke the development of cerebral ischemia.
Antifibrinolytic drugs can prevent rebleeding caused by aneurysm rupture, however, 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 reabsorbs sodium in the tubules of the kidneys, which means it can prevent the occurrence of a negative sodium balance, ischemic consequences and hypovolemia. Everyone should know the causes and consequences of subarachnoid hemorrhage.
Forecast
Prognosis of treatment primarily depends on the severity of the attack observed in each individual patient. If medical care was provided untimely, the probability of repeated hemorrhages after neurosurgical intervention is very high and, as a result, the patient's death. Recovery after a hemorrhage takes at least six months and is a very difficult period of rehabilitation. Daily intake of medications, monitoring the general condition, regular visits to a neurologist - this is what is vital for restoring he alth in such cases. In addition, a patient who has had an attack of cerebral bleeding shouldgive up bad habits and start leading a measured lifestyle in order to avoid the consequences of a subarachnoid hemorrhage.
Pathology in newborns
Subarachnoid hemorrhage in infants may be associated with birth trauma, has such manifestations as meningeal and hydrocephalic syndrome, as well as focal symptoms that depend on the location of the hemorrhage, manifesting immediately after birth.
Moderate hemorrhages in most newborns develop almost asymptomatically or can be detected on the second day. Signs of cerebral hemorrhage in newborns appear as:
- Great anxiety and general arousal.
- Brain scream.
- Convulsions.
- Sleep inversions.
- Enhancement of innate reflexes.
- Increase muscle tone.
- Hyperesthesia.
- Jaundice.
- Protrusion of the fontanel.
Proper diagnosis and timely treatment help to significantly reduce the risk of developing organic pathologies of the brain, contribute to their rapid rehabilitation and minimize adverse effects on the central nervous system that lead to the development of cerebral palsy in children.
Traumatic subarachnoid hemorrhage
This pathological condition develops as a result of TBI with strong blows to the head and with ruptures of the pial vessels, which are located in the subarachnoid space. Most often, the traumatic genesis of such a hemorrhage develops in a youngage, in adolescents and children with falls from a height, sports or street injuries, as well as in road accidents.
The consequences of traumatic subarachnoid hemorrhage (ICD 10 I60) depend on the type of vessel and massive bleeding, the age of the patient, the timeliness of diagnosis and hospitalization.
