Subarachnoid hemorrhage is a pathological condition characterized by the development of bleeding flowing into the area of ​​the subarachnoid space, that is, into the cavity located between the pia mater and the arachnoid mater. There are 2 main types of development of subarachnoid hemorrhage. In one case, there is a traumatic subarachnoid hemorrhage, which is a consequence of severe traumatic brain injury.

In another case, subarachnoid hemorrhage is a consequence of sudden hemorrhage due to an acute circulatory disorder of the hemorrhagic type. It is worth noting that subarachnoid hemorrhage accounts for only 5% of all cases of cerebral circulatory disorders, and such a pathological condition occurs, as a rule, in people aged 40 to 70 years, but there are known cases of the development of a similar pathology in newborns.

The main reasons for the development of subarachnoid hemorrhage

Traumatic subarachnoid hemorrhage is of least interest when considering the etiology of this condition, since it is always a consequence of severe traumatic brain injury. Primary or, as it is also called, spontaneous subarachnoid hemorrhage, as a rule, develops as a result of a violation of the integrity of a blood vessel in the brain, and in the vast majority of cases, when a vessel aneurysm ruptures.

Cerebral aneurysms are abnormal thickenings of the sac-like type, in which the walls forming the aneurysm are reinforced by fibrous tissue, which further leads to a decrease in their ability to resist the existing pressure. Tissue in the area of ​​blood vessel aneurysms is prone to rupture, so the presence of such an anomaly can provoke extensive hemorrhage at any time, even without the influence of obvious external or internal factors.

In approximately 50% of cases, it is the aneurysm that provokes the appearance of subarachnoid hemorrhage. An aneurysm of the blood vessels of the brain can reach sizes from 2-3 mm to 2 cm, therefore, the larger such formations, the higher the risk of extensive hemorrhage in the brain. Other common causes of subarachnoid hemorrhage include:

• cavernomas;
• arteriovenous fistulas;
• arteriovenous malformations;
• blood diseases;
• vascular tumors;
• systemic vasculitis;
• toxic damage to arterial walls;
• fungal infection of arteries;
• atherosclerosis of the blood vessels of the brain;
• thrombosis.

Most often, the development of subarachnoid hemorrhage is associated with a sharp increase in blood pressure, for example, with a strong cough, heavy lifting, and even against the background of strong emotional experiences. Often, spontaneous bleeding into the subarachnoid space can develop as a result of bleeding in the pituitary gland, myxoma of the heart, penetration of malignant tumor metastases into the brain, as well as rupture of the artery that goes around the brain stem.

Predisposing risk factors for the development of subarachnoid hemorrhage include hypertension, frequent consumption of alcoholic beverages, active and passive smoking, uncontrolled use of contraceptives, as well as the use of certain hormonal agents, including hormone replacement therapy for thyroid diseases.

Symptoms of subarachnoid hemorrhage and possible consequences

As a rule, the pre-hemorrhagic period of development of subarachnoid hemorrhage does not have pronounced manifestations that can make the patient aware of the imminent onset of cerebral hemorrhage. A similar asymptomatic course of the pre-hemorrhagic period is observed in more than 50% of patients, but for the rest, signs of impending problems may include painful sensations in the head, spreading to the forehead and eye sockets.

The development of migraine is often observed, which can last from 2-3 hours to several days. Rare manifestations of the pre-hemorrhagic period of development of subarachnoid hemorrhage include epileptic seizures of unknown origin, decreased visual acuity or even loss of individual visual fields, and also dysfunction of nearby nerves, including in the form of diplopia, facial hemispasm, etc.

The hemorrhagic period, that is, the actual development of subarachnoid hemorrhage, has a number of characteristic symptoms. First of all, it should be noted that in approximately 95% of cases, such a violation of the blood supply to the brain develops rapidly. With spontaneous subarachnoid hemorrhage, patients experience:

• sharp intense pain in the head;
• burning sensation in the head;
• nausea;
• vomit;
• epileptic seizures;
• bradycardia;
• slow breathing;
• increased body temperature;
• meningeal symptoms;
• short-term loss of consciousness;
• prolonged loss of consciousness, passing into coma;
• paresis;
• speech disorders;
• memory disorders;
• mental disorders;
• visual impairment.

IN The severity and range of symptomatic manifestations largely depend on the location of the blood vessel rupture. As subarachnoid hemorrhage progresses, in the vast majority of cases there is a release of adrenaline into the blood, which increases blood pressure and can lead to re-bleeding, so people who survive this condition remain at an increased risk of recurrence for the next 2 weeks. The consequences of the development of subarachnoid hemorrhage can be very diverse, and some of them are reversible, while others are irreversible.

The consequences of such a pathological condition can have very different intensities and depend on how extensive the bleeding was, how long the ischemia of brain tissue lasted, and in addition, the age of the patient and other factors.

The most unfavorable outcome is the death of the patient due to prolonged oxygen starvation of the brain, and in addition, disruption of the functioning of the separated systems due to the saturation of brain tissue with blood.

Patients often experience a lot of discomfort associated with the loss of certain functions, and in addition, undergoing a long course of rehabilitation.

Diagnosis of subarachnoid hemorrhage

Modern diagnostic methods make it possible to accurately detect cerebral hemorrhage. When the first signs of subarachnoid hemorrhage appear, the patient must be immediately taken to a medical facility. To confirm the diagnosis, collecting an anamnesis is not enough, especially since often upon arrival of an ambulance the patient is already in an unconscious state and cannot independently determine the nature of the symptoms present.

First of all, to identify the problem, a lumbar puncture is performed, which involves taking cerebrospinal fluid, that is, cerebrospinal fluid, from the spinal canal. Often, even when collecting cerebrospinal fluid, it is immediately possible to determine that hemorrhage is occurring. The thing is that normally the cerebrospinal fluid is transparent, while with subarachnoid hemorrhage some of the blood cells enter the cerebrospinal fluid, so it becomes pink or red.

Hemorrhagic stroke with subarachnoid bleeding is quite common, so for a full diagnosis, computed tomography should be performed. Computed tomography allows you to assess the prevalence of blood in the subarachnoid space, determine the appearance of the parenchymal and ventricular components of hemorrhage, the presence of dislocation and cerebral edema and other possible pathologies accompanying the development of subarachnoid hemorrhage. Angiographic examination allows us to make a more accurate prognosis regarding the possibilities of recovery.

Treatment of subarachnoid hemorrhage

Treatment of patients with severe subarachnoid hemorrhage is carried out in the neurosurgery department or in intensive care, depending on the general condition. The causes of subarachnoid hemorrhage, as well as parameters such as the degree of damage to the circulatory system and brain tissue, and the patient’s age largely determine the strategy for treatment and rehabilitation measures.

First of all, brain shunting may be prescribed to reduce intracranial pressure. Among other things, diuretins and vasodilators are prescribed. Diuretics are an excellent preventative against cerebral edema, while vasodilators help prevent the formation of blood clots. In some cases, patients may undergo therapeutic lumbar punctures, which can reduce intracranial pressure, but this remedy is used only if the first procedure performed has brought the patient significant relief from headaches.

Hemostatic therapy and elimination of the source of bleeding using minimally invasive surgical means allows the restoration of normal blood supply to the brain within 5-7 days. Next, a course of rehabilitation is required, which can take more than 6 months, and it is not always possible to completely restore lost functions. To prevent this from happening, prevention of subarachnoid hemorrhage is necessary.

• An attack of sudden and severe headache: a severe headache, also called a “thundering headache”. Patients who have suffered a subarachnoid hemorrhage say it was “the worst headache of their entire life.” This attack is accompanied by the following symptoms:
  • photophobia (painful sensations in the eyes when looking at any light source or when being in a lit room);
  • nausea and vomiting that does not bring relief;
  • loss of consciousness;
  • convulsive seizures - involuntary contractions of the muscles of the limbs or the whole body (sometimes with loss of consciousness);
  • psychomotor agitation (erratic activity, possibly causing physical harm to oneself and others).

• In addition, it is possible to develop symptoms associated with dysfunction of the area of ​​the cerebral cortex and cranial nerves, which are directly adjacent to the hemorrhage:
  • strabismus;
  • disturbances in the sensitivity of the skin of the body;
  • speech impairment (slurred speech, inability to understand speech in a familiar language, inability to speak).

Forms

• Depending on the reasons that caused subarachnoid hemorrhage or provoked its appearance, the following forms are distinguished:
  • spontaneous subarachnoid hemorrhage - occurs for no apparent reason, against the background of violations of the integrity of the arterial wall (for example, with infectious lesions, congenital anomalies);
  • traumatic subarachnoid hemorrhage - occurs with traumatic brain injury (head injury), accompanied by damage to the wall of the intracranial arteries.

• Depending on the severity of the patient’s condition with subarachnoid hemorrhage, the following degrees of severity are distinguished (Hunt-Hess scale):
  • 1st degree - there are no pronounced neurological disorders, there is only a slight headache and mild stiffness (tension) of the neck muscles;
  • 2nd degree - moderate or severe headache with photophobia (painful sensations in the eyes when looking at any light source or when standing in a lit room), possible vomiting, stiff neck is also noted, neurological disorders may include damage to the oculomotor nerves (strabismus, incomplete movements of the eyeballs );
  • 3rd degree - mild disturbances of consciousness (drowsiness, delayed response when contacting a patient) in addition to headache, severe tension in the neck muscles. In addition, minor focal symptoms are possible (associated with dysfunction of the cerebral cortex and cranial nerves - strabismus, weakness in the limbs);
  • 4th degree - significant impairment of consciousness (the patient does not answer questions, does not respond to pain), there are signs of gross neurological pathology (strabismus, weakness in the limbs, nystagmus (oscillatory movements of the eyeballs)), severe tension in the neck muscles;
  • 5th degree - development of deep coma (complete lack of consciousness, absence of voluntary movements, lack of response to calls and painful stimulation), decerebrate rigidity (a sharp increase in muscle tone, while the whole body is stretched, arms and legs are extended, arms are pressed to the body).

Causes

• The cause of subarachnoid hemorrhage is a violation of the integrity of the wall of the intracranial artery located on the outer surface of the cerebral hemispheres or on its base (that is, not in the depths of the brain substance), with the outflow of blood into the subarachnoid space (the slit-like space between the membranes of the brain). The reasons for the violation of the integrity of the arterial wall may be the following.
  • Traumatic brain injury (head injury with brain contusion and possible damage to arteries).
  • Spontaneous rupture of the artery wall, modified under the influence of various damaging factors:
    • increased arterial (blood) pressure;
    • alcohol abuse;
    • drug use;
    • infections: with syphilis (a disease that is predominantly sexually transmitted and affects all organs and tissues), the arteries of the brain are often damaged.
  • Rupture of a cerebral artery aneurysm (saccular dilatation of the vessel with thinning of its wall). May occur after injury, brain infection).
  • Rupture of arteriovenous malformation of the brain (an anomaly in the development of brain vessels, which develops in utero, and after birth can increase in size. It is a tangle of intertwining arteries and veins).

Diagnostics

• Analysis of complaints and medical history:
  • how long ago did similar complaints appear (headache, vomiting, photophobia (painful sensations in the eyes when looking at any light source or when being in a lit room));
  • whether the development of this headache was preceded by any event (severe straining (for example, during defecation), a sharp increase in arterial (blood) pressure, traumatic brain injury), or whether it developed spontaneously (for no apparent reason);
  • whether the patient abuses alcohol or smokes;
  • whether there was a previous increase in blood pressure, whether the patient took drugs that lower arterial (blood) pressure (hypotensive drugs).
• Neurological examination: assessment of the presence and level of consciousness, search for signs of possible neurological pathology (with combined hemorrhage also in the brain, weakness in the limbs, blurred speech, facial asymmetry, etc. are possible).
• Blood test: may reveal signs of a clotting disorder.
• Lumbar puncture: using a special needle, a puncture (puncture) is made in the subarachnoid space of the spinal cord at the lumbar level (through the skin of the back) and 1-2 ml of cerebrospinal fluid (liquid that provides nutrition and metabolism in the brain and spinal cord) is taken. Since the subarachnoid space of the spinal cord communicates directly with the subarachnoid space of the brain, in the presence of hemorrhage between the membranes of the brain, blood or its remains can be detected in the cerebrospinal fluid.
• CT (computed tomography) and MRI (magnetic resonance imaging) of the head: allows you to study the structure of the brain layer by layer and detect the location and volume of hemorrhage.
• Echo-encephalography: the method allows you to assess the presence of displacement of the brain relative to the bones of the skull under the influence of pressure from intracranial hemorrhage.
• TCD (transcranial dopplerography): the method allows you to evaluate blood flow through the arteries located in the cranial cavity. To do this, the ultrasonic sensor is applied directly to the skull (in the temporal areas). With subarachnoid hemorrhage, a spasm (narrowing) of cerebral vessels is often detected, caused by blood entering the subarachnoid space (the slit-like space between the membranes of the brain, that is, between the substance of the brain itself and the bones of the skull).
• MRA (magnetic resonance angiography): the method allows you to evaluate the patency and integrity of the arteries in the cranial cavity.

Treatment of subarachnoid hemorrhage

• Urgent hospitalization in a neurological or neurosurgical department with constant monitoring of the patient's condition.
• Hemostatic therapy: drugs that improve blood clotting (hemostatics).
• Decrease in arterial (blood) pressure when its values ​​are too high (more than 220/100 mmHg).
• Drugs that reduce spasm of the cerebral arteries (calcium channel blockers).
• Drugs that improve the restoration of nervous tissue (neuroprotectors, neurotrophics).
• Complete care for a bedridden patient: physical therapy, breathing exercises, skin treatment, hygiene procedures.
• Restoration of impaired neurological functions: classes with a speech therapist, physical therapy.
• Surgical removal of a hematoma (collection of blood) from the subarachnoid space (slit-like space between the membranes of the brain), if possible (for superficial hematomas): either aspiration of the blood is performed (through a syringe needle inserted into the hematoma) or removal of the hematoma through a burr hole (hole in the bones of the skull).

Complications and consequences

• Persistent neurological defect: slurred speech, weakness in the limbs (up to complete inability to move in them), increased muscle tone in the limbs, etc. Often these neurological defects lead to permanent disability, for example, due to difficulties in moving independently.
• Formation of “delayed” cerebral infarctions: due to the development of vasospasm (narrowing of the cerebral arteries when blood enters the membranes of the brain), necrosis of part of the brain tissue is possible.
• Risk of death: more often occurs with large volumes of hemorrhage and long-lasting spasm (narrowing) of the cerebral arteries.

Prevention of subarachnoid hemorrhage

• A nutritious diet with limited consumption of fatty and fried foods, increased intake of fresh vegetables and fruits.
• Moderate physical activity: jogging, swimming.
• Walks in the open air.
• Quitting smoking and alcohol abuse.
• Control of arterial (blood) pressure: if necessary, take antihypertensive drugs (lowering blood pressure).
• Controlling blood sugar levels: a diet limiting sweet and starchy foods, insulin therapy, taking medications that lower blood glucose levels.

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Subarachnoid hemorrhage (SAH) is a pathology that is accompanied by the accumulation of blood in the space between the two membranes of the brain: the arachnoid and the pia mater. This pathology is a type of stroke and is observed in 1-10% of cases of acute cerebrovascular accidents.

Blood entering the subarachnoid cavity is accompanied by characteristic neurological symptoms and often leads to death.

Causes

Hemorrhage into the subarachnoid space is a separate subtype. The pathogenesis of the disorder consists in an increase in the volume of fluid in the subarachnoid space due to blood flowing from the ruptured vessel. This leads to severe irritation of the pia mater. In response to blood loss, vasospasm occurs, which provokes ischemia of other parts of the brain and can cause or.

The causes of subarachnoid cerebral hemorrhage are the following:

• . The presence of an aneurysm (protrusion of the wall) of large cerebral vessels is the etiological factor of SAH in 70-85% of cases. The most common cause of hemorrhage is rupture of a saccular aneurysm. Strokes of aneurysmal origin have a less favorable prognosis than spontaneous nonaneurysmal bleeding.
• Dissection of large arteries (vertebral, carotid). In most cases, blood enters the space between the membranes of the brain due to dissection of the wall of the vertebral artery in the cervical region. A more rare etiological factor is dissection of the internal carotid artery. The most common causes of vessel dissection are considered to be severe displacement of the cervical vertebrae, whiplash injury, osteopathic and surgical manipulations.
• Traumatic brain injury. Skull fractures, open head injuries, contusions and compression of the brain cause damage to large cerebral vessels, which leads to blood spilling between the membranes of the brain. A subtype of this factor is birth trauma of the newborn, which can occur with a narrow pelvis of the woman in labor, developmental anomalies and large size of the fetus, as well as pregnancy pathologies (intrauterine infections, postmaturity, rapid and early labor). Less than 15% of clinical cases of SAH have a traumatic etiology.
• Other causes (occur in less than 5% of cases). These include cerebral and spinal neoplasms, secondary foci of malignant tumors (for example, cardiac myxomas), vasculitis, angiopathy of amyloid origin, disorders of blood composition and hemodynamics (coagulopathy), pituitary hemorrhage, rupture of the circumferential artery in the brain stem, etc.

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21.10.2019

In approximately 10% of patients, hemorrhage into the subarachnoid space has an unclear etiology. This pathology, which is called non-aneurysmal perimesencephalic hemorrhage, is characterized by the absence of an exact source of bleeding, mild stroke symptoms and a favorable prognosis. It is assumed that such hemorrhages can be caused by rupture of the walls of small vessels, which makes it possible to close the rupture site using the body's resources.

In rare cases, hemorrhage may occur due to vascular pathologies (and fistulas). With this etiology of the disease, predominantly mixed (subarachnoid and parenchymal) hemorrhage is observed.

Concomitant diseases of the main cause of hemorrhage (saccular aneurysm) are the following pathologies:

• genetic disorders that lead to disruption of the formation of connective tissue, skin and blood vessels (Ehlers-Danlos, Grönblad-Strandberg and Marfan syndromes, alpha-antitrypsin deficiency, etc.);
• hereditary predisposition;
• developmental anomalies of the arteries of the circle of Willis;
• neurofibromatosis;
• renal polycystic disease;
• dilatation of small vessels (telangiectasia);
• arterial-venous malformations;
• coarctation of the aorta;
• Moyamoya disease.

Risk factors for developing SAH are:

• arterial hypertension;
• alcohol abuse;
• taking drugs (most often cocaine and other stimulants);
• atherosclerosis and high concentration of low-density lipoproteins in the blood;
• obesity;
• smoking;
• hormone replacement therapy and COC use;
• pregnancy and childbirth.

Symptoms

Symptoms of subarachnoid hemorrhage include the following:

• severe headache (most often due to severe stress or tension);
• pain in the neck (only with dissection of the vertebral artery in the cervical region);
• depression or loss of consciousness (depending on the volume of blood in the subarachnoid space and the location of the lesion, this symptom can vary from mild stupor to a rapid fall into a coma);
• meningeal syndrome (vomiting, neck tension, increased sensitivity, intolerance to sounds and light);
• epileptic seizures (in 10% of cases);
• psychomotor agitation, predominance of the tone of the sympathetic nervous system;
• ophthalmological disorders (decreased visual acuity, ophthalmoplegia, retinal hemorrhage, nystagmus, etc.);
• respiratory disorders (with aneurysms of the lower segment of the cerebral artery).

Survivors of subarachnoid hemorrhage (SAH) describe it as the worst pain of their lives.

It leaves behind problems with speech and muscles, increases the possibility of heart attacks, and the survival of patients depends entirely on the timeliness of medical care.

How do you understand that blood has entered the brain, what are its consequences, and how can you reduce the likelihood of its occurrence?

Subarachnoid hemorrhage is a type in which blood is released into the subarachnodal space of the brain (the area between its cavities that is filled with cerebrospinal fluid).

The release can occur as a result of the development of vascular pathologies, head injuries, and blood clotting disorders. In this case, the patient experiences a severe headache. The frequent absence of other symptoms can make diagnosis difficult.

This condition also occurs as a result of damage to the brain parenchyma. In this case, specific neurological signs will be observed: disruption of the facial muscles (hemiparesis).

A complete list of possible causes of subarachnoid hemorrhage (SAH) is given in the table below:

The pathogenesis of hemorrhage can be described as the collection of fluid in the subarachnoid cavity - the space between the pia mater and the arachnoid membrane. This cavity contains cerebrospinal fluid, which rises from the spinal cord, wraps around both hemispheres of the brain and descends back.

When bleeding begins, blood flows to the basal cisterns (located at the base of the brain). And it begins to enter the cerebrospinal fluid, which leads to spasms of the arteries, death of neurons and swelling of the brain. The amount of cerebrospinal fluid increases due to the blood, which leads to an increase in pressure in the brain cavity and can contribute to its displacement.

Classification

In neurology, three classifications of disease severity are used.

Hunt-Hess scale, according to which the degree of severity is determined by the symptoms that appear:

• 1st: mild headache and increased tone of the neck muscles;
• 2nd: headache gets worse. At this stage, neurological symptoms begin to appear (eye pain, strabismus, paresis (partial impairment of motor function));
• 3rd: a slight neurological deficit appears, characterized by drowsiness and a decrease in reaction speed;
• 4th: serious neurological deficit - stunning, loss of reaction, partial paralysis of one side of the body, lack of response to external stimuli;
• 5th: deep coma, sharp increase in muscle tone.

Fisher scale, classifies the patient’s condition according to the amount of hemorrhage shown on the results of computed tomography or MRI:

• hemorrhage is not detected;
• lesion size 1 mm;
• lesion more than 1 mm;
• intraventricular hemorrhage or damage to the brain parenchyma (the magnitude does not matter).

Glasgow Coma Scale (GCS), determines the severity of the disease by neurological deficit (the condition is assessed by points, where 15 is clear consciousness and 3 is deep coma):

• GCS 15 - absence of neurological deficit;
• 13-14 GCS - moderate or deep stunning;
• 8-10 GCS - stupor (numbness, lethargy);
• 6-7 GCS - moderate coma;
• 4-5 GCS - thermal coma;
• GCS 3 - deep coma.

There is also a classification that combines some factors from the above methods of assessing the patient’s condition. The Ogilvy and Carter scale takes into account the age of the patient, the severity of the patient according to the Hunt-Hess and Fisher scales and the size of the aneurysm. Severity is assessed by the number of signs present and absent.

Symptoms

Signs of SAH occur suddenly. The clinical picture of the disease is characterized by a sharp and acute headache that cannot be tolerated. For a large number of people, headache is the only symptom of the disease. But pain can also appear with other brain diseases.

The remaining signs are divided as follows:

Most often, subarachnoid hemorrhage occurs against the background of physical or emotional outbursts.

Differential diagnosis

The most effective method is computed tomography (CT).

It is used to determine:

• site of hemorrhage;
• data on the liquor system;
• presence of cerebral edema.

In addition, in order to detect hemorrhage, the following methods can be used, either partially or in combination (in each specific clinical case, the methods used may differ):

Diagnostic method	Detectable symptoms
Neurological examination	If a patient exhibits several symptoms, hemorrhage is often detected during examination.
Blood analysis	Detects abnormalities in coagulation; is prescribed as an additional diagnostic method.
Lumbar puncture	A puncture is made at the lumbar level to collect cerebrospinal fluid from the spinal cord. A puncture is performed if a computed tomography scan does not show changes in the brain or it is not possible to carry out it.
Echo-encephalography (ECHO-EG)	SAH increases pressure inside the skull. This can cause the brain to become misaligned. This is exactly what ECHO-CG reveals.
Magnetic resonance imaging (MRI)	A more accurate method that can replace CT. But due to less availability, it is used much less frequently.
Transcranial Dopplerography (TCDG)	Ultrasound diagnostics of the brain. It can also help identify blood flow disorders.
Magnetic resonance angiography (MRA)	This method allows you to obtain an image of the blood vessels and arteries of the brain and determine their integrity.

How is the treatment carried out?

Emergency care for a person with such bleeding can only be provided by doctors using intravenous injections to reduce agitation and headaches. Self-administration of any medications can aggravate the situation (for example, aspirin is contraindicated in patients).

If bleeding is suspected, the patient must be taken to the hospital. Therapeutic actions should begin to be carried out by the ambulance team at the prehospital stage. Subarachnoid hemorrhage is fatal in 50% of cases, and a third of patients die in the ambulance.

The patient is taken to the neurological, neurosurgical department or intensive care unit.

After the diagnosis is established or confirmed, the patient is prescribed drugs that increase blood clotting and drugs that lower blood pressure.

Drug therapy

Drug treatment includes the primary stage (stopping bleeding) and eliminating headaches.

If the course of the disease is accompanied by convulsions or seizures, medications can be used to reduce these manifestations of the disease.

During drug treatment, the following drugs are prescribed:

• reducing arterial spasms;
• laxatives and diuretics (help reduce edema of the brain);
• painkillers;
• reducing cramps;
• antiemetics;
• tranquilizers.

Surgical intervention

Brain surgeries are performed in cases where intracerebral hemorrhage is caused by an aneurysm, as well as in case of massive hemorrhage in the brain, characterized by impaired consciousness, loss of speech and motor function (in this case, the hematoma is removed).

There are two types of surgery:

• Neurosurgical clipping. The operation involves placing a metal clip on the aneurysm, which will prevent growth and rupture. The operation is performed on the open brain under general anesthesia, in the case of an aneurysm of the middle cerebral artery (occlusion has great risks, since access to the artery is difficult).
• Endovascular occlusion. The operation involves inserting a coil into the aneurysm, which, like a staple, prevents growth and rupture. The operation is performed on a closed brain (a coil is inserted through a catheter, which is led from the femoral artery through the carotid and vertebral arteries to the aneurysm) and under general anesthesia. This type of surgery is performed more often, especially in cases where the patient's condition is unstable and open-brain surgery may worsen it. Also, preference is given to occlusion in case of aneurysm of the basilar artery and posterior cerebral artery, since clipping in this case is impossible.

In case of aneurysm of the anterior cerebral and anterior communicating artery, both operations can be performed.

Surgery can also be called removal of a hematoma through holes in the skull. The operation is performed only if the blood clot is on the surface.

Rehabilitation period

Recovery time after subarachnoid hemorrhage depends on the severity of its occurrence, 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;
• therapeutic exercises and physical education;
• classes with a speech therapist.

Patients who have suffered a hemorrhage may encounter several problems that can significantly lengthen the recovery period:

• constant fatigue (solved by walking, with a gradual increase in time);
• insomnia (sleep and rest schedule);
• constant headaches (they can only be treated with medication);
• problems with sensitivity and motor function (physiotherapy and physical therapy 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 preventative measure for both first and subsequent hemorrhage, it is recommended to eat well, quit smoking/alcohol/drugs, engage in physical therapy and monitor your blood pressure levels.

Possible complications and consequences

The possibility of complications and their severity depends on the causes of intracerebral hemorrhage and the timeliness of medical care. The faster the patient is taken to the hospital, the greater his chances of survival and successful treatment.

The most severe consequence is cerebral vasospasm (vascular spasm leading to). This complication develops in a third of patients and can lead to cerebral infarction and death.

And also subarachnoid hemorrhage can provoke the development of:

• epilepsy (occurs in 5%);
• neurological defects (problems with speech/motor function)
  hydrocephalus;
• depression/anxiety and other mental problems.

Forecast

Subarachnoid hemorrhage is an extremely dangerous disease with a mortality rate of 50%.

Most patients die during the first month in hospital, a little less on the first day and before medical care is provided.

The prognosis for the occurrence of complications and consequences is very unfavorable - most of the patients have disabilities and only 25% of all those who have suffered this condition fully recover.

Subarachnoid hemorrhage is a diagnosis that plunges into shock both the patient suffering from such an illness and his friends and relatives. Like any pathological process in the brain, the disease has an etiology that is dangerous to human health and can threaten not only loss of capacity, but also death.

In this article we will talk about the features of the disease, its root causes and symptoms, knowledge of which will help you seek medical help in time, and also consider the specifics of diagnosis, treatment and rehabilitation of the disease, and effective ways to prevent it.

Features of the disease

To understand what subarachnoid cerebral hemorrhage is, a short excursion into physiology, namely into the structure of the hemispheres, will help. Physiologically, the meninges consist of three balls:

• external, solid configuration;
• medium, spider type;
• internal, which is the vascular cover.

There is space between all the balls: the area between the first two balls is called subdural, and the area between the choroid and tunica media is called subarachnoid.

In a normal state, all membranes have an integral structure, which ensures protection of the hemispheres and normal brain activity. A case in which, due to difficulties in blood circulation, vascular spasms or traumatic events, an outpouring of blood occurs in the subarachnoid zone is identified as subarachnoid. Subarachnoid hemorrhage, abbreviated as SAH, may also be referred to as intracranial hemorrhage or stroke.

Hemorrhage of the subarachnoid type is often characterized by spontaneity, occurs against the background of a segmental or large-scale rupture of cerebral blood lines, and is accompanied by sharp and intense headaches, bouts of vomiting, and loss of consciousness. This is a very dangerous condition, often causing sudden death for the patient, and the chances of saving a person directly depend on the promptness of first aid and the intensity of blood filling in the subarachnoid zone.

Causes of effusion

Help for the progression of pathology is a violation of the tightness of the walls of the vascular highways of the hemispheres. The causes of subarachnoid hemorrhage can have different etiologies, mainly the following:

1. Complex head injuries, which are accompanied by traumatic brain injuries, brain contusions or direct rupture of arteries in the hemispheres.
2. An unexpected rupture of the artery wall, which can be caused by infectious diseases, a rapid increase in pressure, or may also occur due to the use of alcoholic beverages or drugs.
3. Vascular malformation deformity.

Symptoms of pathology

Often, the progression of the pathology begins to make itself felt to a person with unpleasant symptoms, with its etiology of a neuralgic nature, several days before the onset of a massive outpouring. During this period, a characteristic feature is the thinning of the vessel wall, through which blood begins to leak in small volumes. This condition is accompanied by nausea and dizziness, visual impairment. In the absence of timely diagnosis and adequate treatment, the disease progresses, one or more vessels rupture, and blood begins to intensively fill the subarachnoid segments of the brain. Similar symptoms may be accompanied by traumatic subarachnoid hemorrhage if the head injury is not particularly intense.

Symptoms of extensive bleeding are pronounced, accompanied by sharp, explosive, diffuse pain in the head, followed by irradiation to the shoulders, neck and occipital region. Subarachnoid hemorrhage in the brain of a progressive type is often accompanied by nausea with bouts of vomiting, photophobia, disturbances of consciousness, often with fainting precedents and coma. The period from the onset of massive effusion to coma can range from several minutes to half a day.

In newborns, subarachnoid hemorrhage is predominantly a consequence of trauma during childbirth and is characterized by the formation of hematomas in the hemispheres. Cerebral hemorrhage in newborns is accompanied by the following symptoms:

• shrill, intense crying of a child against the background of increased physical activity;
• convulsive attacks;
• lack of sleep;
• involuntary eye movement, visual strabismus;
• extreme severity of innate reflexes;
• increased muscle tone;
• convexity of the fontanel with intense pulsation;
• jaundiced body color.

Symptoms of the pathology in a newborn can appear either immediately after birth or within several days, depending on the scale of the effusion in the hemispheres. If the problem is identified in a timely manner, modern medicine allows the child to be resuscitated, in most cases without negative consequences for his future life.

Prevalence of the disease and stages of its progression

Precedents associated with SAH of the brain are a fairly common phenomenon. According to statistics, the most common cases are considered to be cases of subarachnoid effusion due to trauma, accounting for about sixty percent of all cases.

Less common are precedents for the development of pathology due to changes in blood circulation in the cerebral vessels, diagnosed in seven percent of patients with this pathology. Most often these are patients of advanced and retirement age, as well as people with alcohol or drug addiction. The rarest cases are cases of spontaneous progression of the disease, their prevalence is less than one percent.

As for the etiology of the disease, the most common situations in medical practice are the occurrence of SAH due to rupture of arteries located in the circle of Visilli. Such precedents account for about eighty-five percent of all registered cases, half of them end in death, while fifteen percent of patients do not even have time to get to a medical facility.

Cerebral hemorrhage is a disease that most often affects the adult population, however, the pediatric category is no exception. In children, this pathology often occurs due to trauma. Subarachnoid hemorrhage in newborns can be the result of a prolonged or too rapid natural labor, when there is a mismatch between the mother’s birth canal and the baby’s head, as well as a consequence of the baby being without oxygen for a long time. The progression of pathology in a child can be provoked by infectious diseases of the mother, pathologies of brain activity in a child of the congenital category, and fetal hypoxia.

Medicine classifies SAH of traumatic origin into three stages of development:

1. Progression of intracranial hypertension against the background of mixing of gushing blood with cerebrospinal fluid, increasing the latter in volume.
2. An increase in hemispheric hypertension to extreme maximums, due to the formation of blood clots in the cerebrospinal fluid channels, their blocking and disturbances in the circulation of cerebrospinal fluid.
3. Dissolution of blood clots, followed by intensification of inflammatory processes in the hemispheres.

Classification of disease severity

To assess the severity of a patient’s condition, medical specialists use three methodologies for ranking the course of pathology.

Most often in practice, the Hunt-Hess scale is used to categorize the patient’s condition, which has five degrees of damage to the human brain:

1. The first degree of the disease is considered the least life-threatening if therapy is started in a timely manner, and is characterized by a high percentage of patient survival. At this stage, the disease is asymptomatic with minor headaches and the onset of stiffness of the neck muscles.
2. The second degree of the disease is characterized by a distinct loss of mobility of the occipital muscles, intense headaches, and paresis of the nerves of the hemispheres. The prospects for a favorable outcome do not exceed sixty percent.
3. The third degree of the disease manifests itself in a person as a moderate deficiency of the neuralgic category, stunning. The patient's chance of survival does not exceed fifty percent.
4. The fourth level of pathology is characterized by the patient’s frozen state, and a first-degree coma may occur. Typical for this stage are failures of the autonomic system and severe hemiparesis. Chances of life are about twenty percent.
5. Last degree of progression: second or third level coma. The prognosis for the patient is disappointing, survival rate is no more than ten percent.

The second, no less popular in medical practice for assessing a patient’s condition, is the Fisher gradation, which is based on the results of computed tomography:

1. If a CT examination does not visually detect bleeding, the disease is assigned the first degree of severity.
2. The second stage is assigned to pathology if the scale of the effusion does not exceed one millimeter in thickness.
3. If the lesion is more than one millimeter in size, the third level of pathology progression is diagnosed.
4. When blood spreads inside the ventricles and in the parenchyma, the fourth degree of progression of SAH is diagnosed.

The SAH severity scale according to the World Federation of Neurosurgeons ranks the disease as follows:

1. The first stage is fifteen points on the GCS, no neurological deficit.
2. The second level is from thirteen to fourteen points, with the absence of neurological impairment.
3. Third level – scores are similar to the previous version, with signs of disorders in the nervous and peripheral systems.
4. The fourth stage of progression is assigned from seven to twelve points on the Glasgow Coma Scale.
5. The last stage of the disease: less than seven points were diagnosed according to the GCS.

Diagnosis of pathology

Subarachnoid hemorrhage belongs to the category of the most complex and life-threatening cases. Its diagnosis involves conducting a complex of hardware examinations of the patient in order to confirm the diagnosis, as well as determine the stage of development, localization of hemorrhage, and the degree of disorders in the vascular system and hemispheres.

The main examination procedures include:

1. Initial examination of the patient, analysis of his complaints.
2. Visual assessment of a person’s condition, monitoring of his consciousness and the presence of neurological abnormalities.
3. A laboratory blood test that can be used to determine the criteria for blood clotting.
4. Cerebrospinal fluid puncture. If about twelve hours have passed since the onset of hemorrhage, its results, namely the presence of blood in the cerebrospinal fluid, can confirm the progression of SAH.
5. or computed tomography allows you to identify the presence and location of the effusion, as well as assess the general condition of the brain. CT is more informative in the situation with SAH, which is why this type of examination is often prescribed to patients.
6. If there is a suspicion of brain displacement as a result of injury, echoencephalography is prescribed to confirm or refute this fact.
7. Transcranial Doppler ultrasound is performed to monitor the quality of blood flow in the cerebral arteries and its deterioration as a result of narrowing of the blood vessels.
8. Magnetic resonance angiography of the arteries helps to assess their integrity and patency.

Based on the results of the study, the patient will be diagnosed in accordance with the International Classification of Diseases, Tenth Revision. SAH is classified in the section “Diseases of the circulatory system,” a subgroup of cerebrovascular diseases, and may have an ICD-10 code from I160.0 to I160.9, depending on the location of the source of the effusion.

Treatment methods

The methodology for treating pathology involves both drug treatment and surgical intervention, depending on the stage of the disease and its complexity. The feasibility of therapy and its direction can only be determined by a qualified specialist solely on the basis of diagnostic results. Primary measures should be focused on stopping bleeding, stabilizing, preventing or reducing the volume of brain swelling.

First aid

First aid for subarachnoid hemorrhage does not provide for any specific procedures; it consists of immediately calling an ambulance. It is strictly forbidden to give the patient any medications to eliminate symptoms, as this can cause unpredictable consequences.

If a sick person has an epileptic seizure, you must try to create comfortable conditions for him by placing soft things under his head and other parts of the body. After the seizure ends, you need to lay the sick person on his side, try to fix his limbs and wait for the ambulance to arrive.

When a person is unconscious as a result of cardiac arrest, it is necessary to perform cardiopulmonary resuscitation, with the proportion of chest compressions to breaths being thirty to two.

When there is an outpouring into the hemispheres, the only rational help for the patient is his hospitalization as soon as possible. All restorative and therapeutic procedures are subsequently carried out exclusively under the guidance of specialists, based on the results of diagnosing the patient’s condition.

Drug treatment

Conservative therapy can be used in situations where there are no indicators for surgical intervention, as well as to normalize the patient’s condition in the preoperative and postoperative period.

The main objectives of drug treatment of subarachnoid hemorrhage are:

• achieving stability of the patient's condition;
• prevention of relapses;
• stabilization of homeostasis;
• eliminating the original source of the outpouring;
• carrying out treatment and preventive measures aimed at prevention.

Depending on the complexity of the disease and its manifestations, the patient may be prescribed the following medications:

The appropriateness, dosage and duration of taking medications are determined exclusively by the attending physician and are based on medical indicators. During the treatment process, the doctor monitors the dynamics and can change the quantitative and qualitative composition of the drugs if there are no positive results.

Surgery

Surgical intervention is often prescribed by medicine for existing intracranial hematomas of significant size or when SAH occurs as a result of a serious head injury. In a situation where the patient experiences massive bleeding, emergency surgical procedures are performed. In other cases, the timing of the operation may vary and depend on the condition and age of the patient, the volume of effusion and the complexity of the symptoms.

Medicine provides the following types of surgical intervention for subarachnoid effusion:

1. Removal of hemorrhagic contents by inserting a syringe or a specific needle.
2. Elimination of hematoma with opening of the skull.
3. Laser coagulation of blood vessels, if the effusion cannot be stopped with medications, sometimes with the application of specific clips to the damaged areas of the artery.

After surgery, the patient will have to undergo a mandatory course of drug therapy.

Rehabilitation procedures

Measures to restore the patient after subarachnoid hemorrhage are a mandatory continuation of therapy in the postoperative period. Depending on the complexity of the illness suffered, rehabilitation can last from six months to several years and has a complex structure.

After the incident, it is important for the patient to completely abandon bad habits, try to avoid stressful situations and maintain a healthy lifestyle. In addition, during the rehabilitation period, medicine provides for the use of medications, the action of which is aimed at preventing relapses.

Rehabilitation of the patient, depending on the severity of the illness experienced, may include the following areas:

• specific massages and hardware procedures to restore the patient’s muscle and motor activity;
• health treatments in special centers;
• therapeutic exercises to restore walking and coordination skills;
• classes with a psychologist to restore the patient’s psycho-emotional state.

During the recovery process at home, the patient will need proper care, as well as the support of loved ones.

Prognosis and possible complications

Subarachnoid cerebral hemorrhage is an insidious disease that very rarely goes away without a trace for a person. The most harmless complications are in the form of frequent migraines and disturbances in hormonal regulation of the body. Additionally, after experiencing an illness, the patient may experience a deterioration in brain activity, manifested in the form of psycho-emotional disorders, deterioration of attention and memory. However, such manifestations of the body after SAH are not considered particularly dangerous. Dangerous consequences include:

• vasospasm, which often provokes ischemic processes in the hemispheres;
• delayed ischemia, which affects more than a third of all patients, entails irreversible brain starvation with all the ensuing consequences;
• recurrent exacerbation of pathology;
• hydrocephalus;
• Rare complications include pulmonary edema and heart attacks.

The chances of a patient’s recovery after SAH depend on many factors, such as the person’s general physical health, his age, the stage of the disease and the extent of the effusion, and the promptness of first aid.

Often, it is a belated visit to a medical institution against the backdrop of a heavy outpouring that causes death for the patient or serious complications that do not allow the person to return his life to normal.

Preventive measures

Prevention of SAH, like many other diseases of the cardiovascular system, is not particularly difficult. The main rule, the observance of which helps to prevent cerebral hemorrhage, in addition to precedents with injuries, is a healthy lifestyle. A balanced diet, giving up bad habits, regular walks in the fresh air and moderate physical activity to keep the body in excellent condition, timely treatment of problems with blood vessels and heart under the supervision of doctors are the primary and effective preventive measures against the development of SAH and other complex ailments.

If a person has prerequisites for the development of SAH caused by cardiac problems, it is worth undergoing regular examinations, taking preventive medications prescribed by doctors as necessary to normalize blood pressure and heart rate, and monitor the state of one’s health.

In this case, careful attention to your body and a correct lifestyle are the most important preventive measures that help to avoid a complex and life-threatening incident.

Let's sum it up

Subarachnoid hemorrhage belongs to the category of the most dangerous diseases, which very often cause death. Of course, it is better to prevent such situations, however, if such a precedent occurs, it is worthwhile to immediately deliver the patient to a medical facility: a person’s life depends on the speed of diagnosis and provision of correct assistance.

Lead a full, healthy and correct lifestyle - this will help you avoid many health problems, is the key to the proper functioning of the body, and reduces the risk of developing not only SAH, but also other diseases.