From this article you will learn: what is subarachnoid hemorrhage( abbreviated to SAK), what are the causes of its development and consequences. Symptoms and diagnostics of this disease, methods of treatment and rehabilitation.
content of the article:
- What is the subarachnoid space
- reasons subchondral bleeding
- Characteristic symptoms
- Diagnostics
- Therapies
- Complications SAH
- Rehabilitation after SAH
- forecast
subarachnoid( subarachnoid) hemorrhage( SAH) is called dangerous to stroke the kind of life caused by bleeding into the space, surrounding the brain.
This hemorrhage irritates the membranes of the brain, increases intracranial pressure and damages the neurocytes( brain cells).
According to statistical data, SAK develops in 6-10 people per 100 000 population per year, making up 5-10% of all types of strokes. Although this is a fairly rare disease, but very dangerous.
One third of patients with SAK survive with a good prognosis, another third - remain disabled, the last third - die.
Neurosurgery and neurosurgeons are engaged in treatment of SAC.
What is the subarachnoid space
There are three shells around the brain:
- Soft is the innermost shell that is closest to the brain.
- Spiderweb( arachnoid) is the middle shell.
- Solid - the most external shell, which is adjacent to the skull.
The subarachnoid space is located between the arachnoid and the soft membrane. It is filled with cerebrospinal fluid, blood vessels pass through it, the rupture of which leads to subarachnoidal hemorrhage.
Click on photo to enlarge The causes of subchondral hemorrhage
SAK most often caused by rupture of an aneurysm of the brain. An aneurysm is a protrusion in a blood vessel, which develops due to the weakness of the vascular wall.
When blood passes through a weakened vessel, its pressure causes the vascular wall to bulge outward. Aneurysms are most often located at the junction of vessels from the main trunk.
Vascular aneurysm rupture leads to subarachnoid hemorrhage Sometimes this protrusion can burst, which leads to hemorrhage. Approximately 80% of all SAKs develop this way.
The reasons for the development of brain aneurysms are unknown, although scientists have been able to identify certain risk factors for their occurrence. These include:
- Smoking.
- High blood pressure.
- Abuse of alcoholic beverages.
- Drinking cocaine.
- Presence of brain aneurysms in relatives.
- Some rare diseases, such as autosomal dominant polycystic kidney disease.
Most brain aneurysms are not ruptured. However, some people recommend that doctors conduct SAK prophylaxis if they have protrusions in the vessels of the brain.
Subarachnoid hemorrhage can be caused by the more rare causes, to which belong:
- Head and neck injuries in which a hemorrhage to the brain or other surrounding structures penetrates into the subarachnoid space.
- Arteriovenous malformations are a congenital anomaly of the vascular system, in which arteries and veins are connected together by tangles of pathological vessels.
- Tumor of the brain that damages the blood vessels - SAK can be caused by both malignant and benign tumors.
- Infectious diseases of the central nervous system - for example, encephalitis( inflammation of the brain).
- Fibromuscular dysplasia is a rare disease that can cause narrowing of blood vessels.
- Moyemoy's disease is a rare disease that leads to the closure of the arteries of the brain.
- Vasculitis is an inflammation of the blood vessels of the brain, which can be caused by various causes, including infections and autoimmune processes.
Symptoms of symptoms
Prodromal symptoms
An aneurysm of the brain usually does not cause any symptoms before it ruptures. Before the rupture of the aneurysm( 10-20 days before the accident), 10-50% of patients may have prodromal symptoms:
- Headache( 48%).
- Dizziness( 10%).
- Pain in the eye( 7%).
- Doubling in the eyes( 4%).
- Visual loss( 4%).
- Convulsions( 4%).
Prodromal symptoms usually develop due to a small leakage of blood from the vessel, an aneurysm in the size or embolism( clogging of the vessel).
Symptoms of SAK
The most typical manifestation of SAK is the sudden appearance of a severe headache. In a third of patients with this disease, headache is the only manifestation of the disease.
The headache is very strong, patients often describe it as the most painful in a lifetime. Some of the patients even look back with suspicion that someone hit them on the back of the head. Then the headache becomes dull, its duration is usually 1-2 weeks.
Approximately 10% of cases of sudden appearance of severe headache are caused by the development of SAK.
Subarachnoid hemorrhage may have other symptoms, including:
- stiffness in the neck;
- nausea and vomiting;
- hypersensitivity to light;
- visual impairment and double vision;
- speech impairment;
- weakness in one half of the body;
- loss of consciousness;
- convulsions.
Approximately 30-40% of cases of SAK develops at rest. In the remaining 60-70% of cases, hemorrhage occurs during physical or emotional stress.
Diagnostics
When a patient enters a hospital with suspected SAK, doctors first find out his symptoms, collect an anamnesis, perform a general and neurological examination.
To confirm the diagnosis and determine the source of bleeding, the following examinations are carried out:
- Computed tomography( CT) is a non-invasive( i.e., non-intrusive) X-ray examination providing a detailed image of the anatomical structures of the brain. This method is very useful for detecting blood around the brain. A newer technology - CT angiography - is to inject contrast into the bloodstream, so that you can see the vessels of the brain. CT angiography can detect a source of bleeding.
- Spinal puncture is an invasive procedure in which a needle is inserted into the subarachnoid space of the spinal canal. This method allows you to get a cerebrospinal fluid, the presence in which the blood speaks of subarachnoid hemorrhage. Spinal puncture is performed if a CT scan failed to establish a diagnosis, and the patient has typical symptoms of SAH.
- Magnetic resonance imaging( MRI) is a non-invasive examination that uses a magnetic field and radio waves to obtain a detailed image of the soft tissues of the brain. Magnetic resonance angiography is the same as MRI, except that it is used to examine the blood vessels of the brain.
- Angiography is an invasive procedure in which a catheter is inserted through the artery into the vessels of the brain. After the correct placement of the catheter, the doctor introduces a contrast through it and makes a series of fluoroscopes that allow you to see the structure of the vessels, their patency and the presence of SAK.
Snapshot of brain CTD Methods of treatment
If a person is diagnosed with ASH or there is a reasonable suspicion of the presence of this disease, he is hospitalized in the intensive care unit, neurology or neurosurgery. These departments should be equipped with medical devices and medicines to maintain the vital functions of the body( breathing and circulation).
Initial treatment of SAK is directed to:
- Stabilization of the patient's condition.
- Preventing rebleeding.
- Prevent further damage to the brain.
Medication
Drug therapy is used for:
- Lowering blood pressure and improving blood supply to damaged areas of the brain.
- Preventing seizures, which can cause the effects of the condition and worsen brain damage.
- Relief of headache.
The most commonly prescribed drug for SAA is nimodipine. This drug reduces the risk of worsening cerebral circulation, preventing a secondary spasm of the cerebral arteries. Nimodipine is usually taken for 3 weeks before the risk of secondary cerebral ischemia disappears.
Side effects of nimodipine include:
- Feeling of hot flashes.
- Nausea.
- Heart palpitations.
- Headaches.
- Skin rash.
To relieve the headache painkillers are used - morphine, codeine and paracetamol.
Subarachnoid hemorrhage is also treated with the following drugs:
- Anticonvulsants( eg, phenytoin) - to prevent seizures.
- Antiemetic drugs( for example, promethazine) - help to eliminate such consequences as nausea and vomiting.
Surgical treatment of
If the examination revealed that CAA was caused by an aneurysm of the brain, doctors can recommend a surgical procedure to restore the affected vessel and prevent a second episode of bleeding. Two main techniques are used: neurosurgical clipping and endovascular occlusion.
Neurosurgical clipping
Neurosurgical clipping is performed under general anesthesia. On the skin of the head, the neurosurgeon makes a cut, then removes a small portion of the skull bone, gaining access to the patient's brain. After detecting an aneurysm, the doctor applies a tiny metal clip to her neck. Over time, the place of clipping overgrows with vascular membranes, which prevents an increase in aneurysm in size and its repeated rupture.
Scheme of neurosurgical clipping Endovascular occlusion
Endovascular occlusion( overlap) is also most commonly performed under general anesthesia. The procedure begins with the introduction of a thin catheter into the femoral artery in the groin. Then the catheter under the X-ray control through the blood vessels is injected into the aneurysm of the brain. Through it, a tiny platinum helix is introduced into the aneurysm. Once the cavity of the aneurysm is filled with a spiral, the blood does not enter it. This prevents an increase in the size of the protrusion and reduces the risk of a rupture.
Endovascular occlusion of aneurysm Comparison of
operations The choice between neurosurgical clipping and endovascular occlusion depends on the size, location and shape of the aneurysm. Neurosurgeons often give the advantage of occlusion, since this surgery has a lower risk of short-term complications( such as convulsions) than clipping. However, the long-term benefits of endovascular intervention over a neurosurgical operation are unknown.
Patients who have undergone endovascular occlusion are discharged from the hospital faster than patients after neurosurgical clipping, they recover more quickly. But if these surgical interventions are performed on urgent indications, the time of discharge from the hospital and the recovery time depend more on the severity of the hemorrhage and its consequences, rather than on the type of operation.
Complications of SAK
Patients with subarachnoid hemorrhage may develop severe complications. The main ones are:
- Repeated bleeding is an early severe complication of SAH, which develops as a result of repeated rupture of brain aneurysms. The risk of its development is highest for a few days after the first episode of hemorrhage. With repeated bleeding, the probability of disability or death increases dramatically, so treatment of an aneurysm should be carried out as quickly as possible.
- Secondary ischemia of the brain is a frequent and serious complication that develops as a result of spasm of blood vessels. At the same time, the blood supply of the brain is dangerously deteriorating, which disrupts its functioning and causes damage to the neurocytes. This complication most often develops within a few days after the first episode of SAK.Symptoms of secondary cerebral ischemia include drowsiness, which can lead to coma, stroke-like symptoms, such as weakness in one half of the body. Nimodipine is used to prevent the development and treatment of vasospasm.
- Hydrocephalus is the accumulation of fluid in the brain, which increases intracranial pressure and can lead to damage to the neurocytes. Symptoms include headaches, nausea, visual impairment, difficulty walking. Subarachnoid hemorrhage is complicated by hydrocephalus quite often, as it can disrupt the production and drainage of cerebrospinal fluid and lead to its accumulation around the brain. Hydrocephalus is treated with a spinal puncture or implantation in the brain of a special catheter( shunt) that drains excess fluid.
With subarachnoid hemorrhage, long-term effects develop, including:
- Epilepsy is a disease in which normal brain function is disrupted, resulting in repetitive episodes of seizures. Epilepsy develops in 5% of patients with SAK.There are different types of seizures, their duration can be from a couple of seconds to several minutes. Epilepsy is treated with anticonvulsant drugs, such as phenytoin or carbamazepine.
- Cognitive impairment is a disease in which a person suffers from difficulties with memory, performing daily tasks, concentrating attention. Most cognitive functions improve over time, but memory problems can become permanent.
- Emotional problems are another chronic complication of SAK.Patients may develop depression or anxiety disorders( a constant feeling of anxiety and fear).To relieve them, antidepressants and psychotherapy are used.
Rehabilitation after SAK
The recovery time after SAA depends on the severity of the disease. Rehabilitation can be a very difficult process, patients can achieve first good results, and then fail. Rehabilitators, physiotherapists, speech therapists and physiotherapy physicians help to speed up rehabilitation and improve its results.
Rehabilitation after SAK:
| Issue | Description |
|---|---|
| Excessive fatigue | Most patients feel very tired during the first months after the development of SAK.Even simple tasks, such as shopping in the store, can deplete patients. Regular walks can be provided for 20-30 minutes in a relaxing atmosphere. |
| Sleep problems | Many patients develop insomnia after CAA.It can help meet a clear schedule - go to bed and get out of bed at the same time. Also it is necessary to allocate time for rest during work. |
| Headache | Although the headache is not as strong as at the time of hemorrhage, in many patients it is observed long enough. It can be controlled with pain medications( paracetamol).Reduce the frequency and severity of these headaches can be by taking a sufficient amount of fluid, restricting the use of alcohol and caffeine. |
| Loss of sensitivity or movements of | After CAA, some patients suffer from muscle weakness or impaired sensitivity in the limbs. They can be restored by training with a rehabilitator and a physician in physiotherapy. |
| vision problems Patients with SAC often have blurred vision, black spots, and double vision. In most cases, they gradually improve over a period of several months. Treatment is conducted by an ophthalmologist. |
Forecast
Although mortality from SAC has declined over the past three decades, this disease continues to be very dangerous. According to statistics:
- Approximately 10-15% of patients die before arriving at the hospital.
- About 25% of patients die within 24 hours.
- During the first month, 40% of hospitalized patients die.
- For half a year about half of all people with subarachnoid hemorrhage die. More than a third of surviving patients have a severe neurological deficit.
- Only 25% of patients say that their condition after the transferred SAK was completely restored.
