Subarachnoid cerebral hemorrhage prognosis. Subarachnoid cerebral hemorrhage: symptoms, choice of treatment tactics and consequences

• 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 (oscillating 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 serious pathology that occurs spontaneously or due to trauma. bleeding into the subarachnoid space of the brain. The prevalence of the disease is about 5-7%, among patients people of mature age predominate, women suffer from this pathology almost twice as often as men, the maximum incidence occurs in the period of 45-60 years.

Usually the cause of SAH is a violation of the integrity or, then it is considered one of the types (acute circulatory disorders in the brain). About 20% of such hemorrhages develop due to traumatic brain injury.

Rapidly increasing brain damage due to vascular disorders and ischemic changes, its swelling causes high mortality: 15% of patients die even before admission to the hospital; every fourth patient does so on the first day after hemorrhage; by the end of the first week, mortality reaches 40%, and in the first six months – 60%.

Traumatic subarachnoid hemorrhage is associated with traumatic brain injury when a blow to the head leads to rupture of blood vessels and bleeding. The course of this type of SAH can be aggravated by the presence of damage to other organs (polytrauma), but with severe brain contusion it fades into the background, giving way to more serious changes in the brain tissue.

Doctors usually deal with spontaneous subarachnoid hemorrhage, which occurs suddenly due to pathology of the cerebral vessels. This condition develops acutely and often without obvious causes, but requires emergency medical care and hospitalization in a neurosurgical hospital.

Causes of subarachnoid hemorrhages

Since spontaneous SAH is the most common, we will focus on them. The causes of spontaneous bleeding into the subarachnoid space are primarily associated with vascular pathology of the brain:

• Arterial aneurysm;
• Vascular malformations;
• Inflammatory and dystrophic processes of vascular walls (amyloidosis);
• Some hereditary syndromes with impaired differentiation of connective tissue;
• and infections of the brain or spinal cord;
• Inappropriate use.

ruptured brain aneurysm

Among all causes of non-traumatic SAH, cerebral aneurysm is the leading one., usually located in the area of ​​the carotid, anterior cerebral, and communicating arteries, that is, fairly large vessels that supply blood to large areas of the brain. An aneurysm is usually saccular, that is, in the form of a vascular cavity that has a neck, body and bottom. The size of an aneurysm can reach two centimeters, and the consequences of rupture of a giant vascular cavity are often fatal. SAH can also be called basal because it often develops in the area of ​​the basal cisterns (between the cerebral peduncles, in the area of ​​the optic chiasm and the frontal lobe).

Somewhat less frequently, the cause of hemorrhage in the subarachnoid space is a vascular malformation, which, as a rule, is congenital. Typically, malformations cause parenchymal intracerebral hemorrhage, but in approximately 5% of cases, when they rupture, blood enters the subarachnoid space.

vascular malformation

It is worth noting the risk factors which increase the likelihood of non-traumatic subarachnoid hemorrhage in the presence of an aneurysm, malformation or other vascular pathology. These include smoking and alcoholism, high blood pressure, uncontrolled and long-term use of hormonal contraceptives, pregnancy, and lipid metabolism disorders. Caution should also be exercised by athletes who experience excessive physical activity, which can also cause SAH.

SAH can also occur in newborn babies, and its causes are severe and birth injuries. Symptoms boil down to severe agitation and screaming of the child, convulsions, and sleep disturbances. In some cases, hemorrhage is indicated only by convulsions, in the intervals between which the child looks completely healthy. The consequences of the disease can be developmental disorders of the child, as well as caused by a blockade of cerebrospinal fluid circulation.

Manifestations of subarachnoid hemorrhages

Symptoms of SAH appear suddenly, often in the midst of complete health, and consist of:

1. Severe headache;
2. Convulsive seizures;
3. Nausea and vomiting;
4. Severe psychomotor agitation;
5. A complex of eye symptoms (visual impairment, fear of light, pain in the eye area).

Over the course of several days, the patient's condition may progressively deteriorate due to an increase in blood volume, repeated hemorrhage, increased cerebral edema and vasospasm. During the same period, fever appears due to brain damage.

Usually, in the early stage, general cerebral symptoms come to the fore, associated with enlargement - nausea and vomiting, headache, convulsions. The so-called meningeal signs are clearly manifested - stiff neck, fear of light, the characteristic position of the patient with his legs adducted and his head thrown back. The phenomena of local brain damage develop somewhat later, but they may also be present in only a quarter of patients. Focal symptoms include paresis and paralysis, disorders of speech function, swallowing, and signs of involvement of cranial nerves.

Hemorrhage into the subarachnoid space is dangerous due to its complications, which develop in almost every patient. Among them, the most severe are vascular spasm and ischemia of nervous tissue, cerebral edema, and relapse of the disease.

The risk of relapse of SAH is highest in the acute stage, but persists throughout the patient’s life. The course of repeated hemorrhage is usually more severe and is accompanied by inevitable disability, and in some cases it can lead to death.

Vasospasm and secondary vasospasm occur in all patients with SAH, but the manifestations of this dangerous complication may not be expressed, especially against the background of intensive therapy. Maximum ischemia is observed by the end of the second week after hemorrhage and manifests itself similarly: disturbance of consciousness up to coma, focal neurological symptoms, signs of involvement of the brain stem with impaired breathing, cardiac function, etc. This complication is often associated with a sharp and significant deterioration in the patient’s condition in acute period of SAH. With adequate prevention and early treatment, vasospasm and ischemia resolve within a month, but disturbances in the activity of individual brain structures can remain for life.

Dangerous complications of SAH can be the spread of blood into the ventricular system, swelling of the brain and dislocation of its structures, as well as various disorders of the internal organs - pulmonary edema, heart failure, arrhythmias, disorders of the pelvic organs, acute ulcers of the digestive tract, etc.

Treatment

Subarachnoid hemorrhage is a very dangerous pathology, requiring intensive therapy and careful monitoring of the patient. The main goals of treatment are to normalize or at least stabilize the patient's condition, perform early surgical intervention, and eliminate the symptoms of SAH.

The main treatment measures are aimed at:

• Normalization of the respiratory and cardiovascular system, maintaining the electrolyte state and basic biochemical blood parameters at an acceptable level;
• Combating cerebral edema and increased intracranial pressure;
• Prevention and treatment of vascular spasm and ischemia of nervous tissue;
• Relief of negative symptoms and treatment of neurological disorders.

To date, no effective conservative approaches have been developed to remove blood clots from the cranial cavity and eliminate aneurysmal dilatation of the vessel, therefore surgery is inevitable.

Patients with suspected subarachnoid hemorrhage should be hospitalized immediately At the same time, it is necessary to remember about the possibility of ongoing or repeated bleeding from the vessels of the malformation. Strict bed rest is indicated, preferably tube feeding, which must be carried out in case of coma, difficulty swallowing, severe vomiting, and ischemic changes in the intestine.

So-called basic therapy that most patients need includes:

1. Artificial ventilation;
2. Prescribing antihypertensive drugs (labetalol, nifedipine) and monitoring blood pressure levels;
3. Control blood glucose concentrations by administering insulin or glucose for hyperglycemia or hypoglycemia, respectively;
4. Elimination of fever above 37.5 degrees with the help of paracetamol, physical methods of cooling, administration of magnesium;
5. Combating cerebral edema: drainage of the cerebral ventricles, use of osmotic diuretics, sedatives, muscle relaxants, mechanical ventilation in hyperventilation mode (no longer than 6 hours);
6. Symptomatic therapy, including anticonvulsants (seduxen, thiopental, induction of anesthesia in severe cases), control of nausea and vomiting (cerucal, vitamin B6), sedative treatment for severe psychomotor agitation (sibazon, fentanyl, droperidol), adequate pain relief.

The main option for specific treatment of subarachnoid hemorrhage is surgery, the purpose of which is to remove blood that has entered the subarachnoid space and to exclude the aneurysm from the bloodstream to prevent recurrent hemorrhages. It is most effective to perform the operation no later than 72 hours from the moment of rupture of the aneurysm, since later cerebral vascular spasm develops and ischemia increases, aggravating the patient’s condition and the depth of damage to the nervous structures. However, given the severity of the pathology, significant difficulties and contraindications to surgical treatment may arise due to the patient’s condition.

Contraindications to surgery are:

• Coma and other types of depression of consciousness;
• Severe degree of ischemia in brain tissue;
• Presence of focal neurological symptoms;
• Progressive deterioration of the patient's condition.

If the above conditions are present, the operation is postponed until the activity of the central nervous system and other vital organs has stabilized. If the patient's condition is stable, then surgical treatment is performed as soon as possible from the moment of hemorrhage.

aneurysm clipping

Operation options when ruptured with blood leaking into the subarachnoid space are:

1. on the vessels feeding the aneurysm to turn it off from the circulation through open access (craniotomy).
2. Endovascular interventions, stenting.
3. Shunting and evacuation of blood from the ventricular system of the brain when it penetrates into the ventricles.

Endovascular (intravascular) operations can be performed exclusively in specialized hospitals where appropriate equipment is available. When performing such interventions, a catheter is inserted into the femoral artery, through which special coils or an inflating balloon are delivered to the site of the aneurysm, eliminating blood flow in the aneurysm, but the spilled blood is not removed.

It is still unknown whether endovascular operations have advantages over open ones, therefore the indications for them have not been precisely defined, but they are preferable in severe or unstable patient conditions, when trepanation is risky. In addition, when the aneurysm is localized in the deep parts of the brain, difficult to reach with a surgeon’s scalpel, with a risk of damage to the surrounding nervous tissue, multiple vascular malformations, and aneurysms without a well-defined neck, preference is given to endovascular surgery. The disadvantage of this method is the possibility of recurrent hemorrhage, which remains at a fairly high level for up to 4 weeks after treatment, so patients should be under constant close monitoring during this period.

A very serious complication of subarachnoid hemorrhage is vascular spasm and ischemic changes in the nervous system following the moment of bleeding. To combat them you need:

The consequences of subarachnoid hemorrhage are always very serious. and are associated, first of all, with the localization of the pathological process in the cranial cavity, damage to areas of the brain. Mortality in the first month from the onset of the disease reaches 40%, and in patients in a coma - 80%. Many patients, even after timely surgical treatment, retain neurological deficits. In addition, it is necessary to take into account the likelihood of relapse, mortality and severe disability after which are inevitable even with a relatively favorable course of the primary hemorrhage.

Video: lecture on subarachnoid hemorrhage

Video: cerebral hemorrhage in the program “Live Healthy!”

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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).

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.

WITH Ubarachnoid hemorrhage(SAH) is a clinical syndrome characterized by a certain nosological independence and caused by various etiological factors. Spontaneous SAH is considered to be hemorrhage non-traumatic nature (spontaneous SAH is a type of hemorrhagic stroke).

Etiology. The most common (80 - 85%) is SAH, which develops as a result of blood entering the subarachnoid space due to the rupture of a cerebral aneurysm. Aneurysms usually occur where arteries branch, usually at the base of the brain.

Risk factors for SAH (which are not very specific): hypertension, especially with significant daily fluctuations in blood pressure (BP), taking oral contraceptives, smoking, cocaine use, alcoholism, pregnancy and childbirth (modification of this risk factor requires the greatest responsibility). Among close relatives of patients with SAH, aneurysms are detected more often.

The most common causes of spontaneous non-aneurysmal SAH: small ruptures of intradural arteries, mycotic microaneurysms, immunodeficiency arteritis or arteritis due to drug abuse. The relapse rate is 1% per year.

Diagnostics. SAH should be suspected in the presence of characteristic clinical signs and confirmed by computed tomography (CT). If CT is not possible or if CT does not reveal SAH, a lumbar puncture (LP) is necessary. LP is also indicated for suspected inflammatory lesions of the meninges (with SAH, the temperature may rise to subfebrile levels).

The most typical clinical sign of SAH is a severe headache that suddenly appears or develops over seconds and minutes (the patient often describes it as a “sharp blow to the head”). After a few seconds, approximately half of the patients experience loss of consciousness, which in most cases recovers spontaneously. The clinical picture may resemble syncope or an epileptic seizure. At the same time, we must not forget that epileptic seizures often develop with SAH, and a number of patients experience neurogenic heart rhythm disturbances. Focal neurological deficits are often mild or moderate and may reflect the location of the aneurysm. Examples may be damage to the oculomotor nerve with rupture of an aneurysm of the posterior communicating artery, development of contralateral hemiparesis with rupture of an aneurysm of the middle cerebral artery, and abulia with aneurysms of the anterior communicating artery. Neck stiffness is common and may appear several hours after SAH.

Differential diagnosis for sudden headache is carried out with cerebral venous thrombosis, migraine, meningoencephalitis, intracerebral hemorrhage, acute hypertensive encephalopathy, sinusitis.

To assess the severity of SAH, the Hunt and Hess scale was proposed (W. Hunt, R. Hess, 1968):

(*) - in the presence of significant systemic pathology or severe vasospasm, the gradation increases by one.

In 1988, the World Federation of Neurological Surgeons proposed a new classification of SAH: World Federation of Neurological Surgeons (WFNS) grading scale of SAH:

(*) - gross neurological deficit is assessed - aphasia, hemiparesis, hemiplegia; cranial nerve palsies are not considered a neurological deficit.

The severity of SAH based on changes on CT is assessed using the Fisher scale:

Blood located in the subarachnoid space may not be detected on CT after 24 hours, and after 5 days it is not detected in 50% of cases. At a later stage, LP and MRI are used to detect SAH. If occlusive hydrocephalus or hematoma of the temporal region is detected on CT consultation with a neurosurgeon is necessary and emergency surgery. In addition to occlusive hydrocephalus caused by hemotamponade, at the end of the 1st, beginning of the 2nd week, the development of aresorptive hydrocephalus is possible.

There is an option nonaneurysmal perimesencephalic hemorrhage. In this case, the spilled blood is limited to the cisterns around the midbrain, the center of bleeding is located directly in front of the midbrain, and in some cases traces of the presence of blood are found only in front of the pons. This variant accounts for 10% of all SAH and 2/3 of SAH with normal angiograms and is benign in terms of prognosis.

In patients with SAH, it is recommended to examine the fundus of the eye, determine the sodium content in the blood, and assess the circulating blood volume (CBV). Fundus examination can reveal swelling of the optic discs; vitreous hemorrhage (Terson syndrome); subhyaloid or preretinal hemorrhage (a highly specific but insensitive sign for SAH). Determination of sodium in blood serum allows us to identify hyponatremia, which occurs in combination with hypernatriuria against the background of a decrease in blood volume. Another syndrome leading to water-electrolyte imbalance is the syndrome of inadequate secretion of antidiuretic hormone.

Treatment. Patients with SAH in severe condition (depression of consciousness) should be placed in intensive care units, where tracheal intubation and artificial ventilation are carried out in patients in a coma and with respiratory failure, and correction of electrolyte disorders. In all cases of SAH management, early provision of adequate intravenous access is necessary. The administration of fluids should be carried out under the control of daily diuresis, plasma osmolality and plasma sodium content. The basis should be balanced salt solutions. Adequate oxygenation is necessary. Blood pressure control is necessary - avoidance of hypo- and hypertension.

All patients with SAH are advised to consult a neurosurgeon. In non-severe conditions (grades I-III on the WFNS scale), clipping of the aneurysm is indicated in the first 48 to 72 hours after its rupture. In more severe patients (grade III - IV on the WFNS scale, high surgical risk, with aneurysms with a narrow neck), endovasal intervention can be used. If it is impossible to perform an urgent operation, surgical treatment is carried out during the “cold period” - no earlier than after 2 weeks.

The main indications for surgery for aneurysm ruptures are :
1 . risk of recurrent hemorrhage from the aneurysm (incidence 26% within 2 weeks, mortality 76%);
2 . prevention of ischemic complications (64%, fatal - 14%);
3 . the presence of an intracerebral hematoma with brain compression and dislocation (mortality without surgery 95%).

(! ) The radicality of excluding aneurysms by clipping is 98%, with endovasal intervention - 80%. Postoperative mortality ranges from 2 - 3 to 20%, depending on the severity of the condition.

To detect vasospasm, transcranial Doppler ultrasound can be performed. Vascular spasm in SAH can be a reflex at the time of aneurysm rupture and does not lead to cerebral infarction, as well as secondary, by the end of the 1st week, due to the effect of biologically active substances on the vascular wall (beginning on the 3rd - 4th day, reaching a maximum on 7 - 12th day). Detection and assessment of the degree of vasospasm can be carried out by determining the peak systolic blood flow velocity using ultrasound data.

Moderate vasospasm is determined when the blood flow velocity along the MCA is more than 140 cm/s, but up to 200 cm/s, while neurological symptoms can be reversible. Severe vasospasm is determined when the blood flow velocity is more than 200 cm/s and is accompanied by the detection of ischemia on CT. More accurately, the state of vasospasm is determined by the Lindegard index - the ratio of peak systolic velocity in the MCA and in the homolateral internal carotid artery. Vasospasm in the basilar artery is characterized by a ratio of peak systolic velocity to velocity in the extracranial section of the vertebral artery of more than 2.

"Three" applies G» therapy (induced hypervolemia, hemodilution, hypertension) to reduce vasospasm, which increases cerebral blood flow and prevents ischemic brain damage. It was noted that it is hypervolemic hemodilution that clearly reduces the severity of vasospasm, in contrast to isovolemic hemodilution, which negatively affects cerebral blood flow. It is suggested to maintain SBP at 160 ± 20 mmHg. Art. (SBP up to 200 mm Hg in patients with clipped aneurysm), and achieving hypervolemia and hemodilution by intravenous administration of 5% human albumin or hydroxyethyl starch. The optimal central venous pressure is 10 - 12 mm Hg, hematocrit - 33 - 35%.

(! ) To prevent vasospasm, all patients with SAH are recommended to receive nimodipine a (Nimotop) 60 mg intravenously or orally every 4 hours for 3 weeks (Evidence Level A).

The most discussed adverse event with the use of nimodipine is the possibility of a decrease in blood pressure, which cannot be a serious limitation of its use. Firstly, when systolic blood pressure decreases by more than 20 mm Hg. Art. from the initial one while taking nimodipine, in the absence of vasospasm or stable subcritical vasospasm, it is possible to reduce the dose of the drug. Secondly, the additional use of “three G” therapy allows you to maintain optimal blood pressure.

In patients with SAH, it is recommended to ensure complete bed rest before surgery for aneurysm, and in the absence of surgery, at least 7 days, with further staged expansion of the regime. If the etiology of SAH is unclear and/or surgical treatment is not possible, bed rest for a period of time is justified. 30 days. It is necessary to protect patients from stress and tension.

In SAH, early administration of analgesics to relieve pain is recommended. It is advisable to use analgesics that do not affect cyclooxygenase-1. The use of paracetamol is quite effective. Currently, the drug perfalgan is available on the market for intravenous administration.

Contraindicated use of epsilon-aminocaproic acid due to an increased risk of blood clots. The use of hemostatic agents to prevent recurrent hemorrhages from a ruptured aneurysm is not indicated. The effectiveness of tranexamic acid in the preoperative period was proven in one randomized prospective study.

Additional Information:

symposium “Subarachnoid hemorrhage (clinic, etiology, diagnosis, treatment)” Simonyan V.A., Lutsky I.S., Grishchenko A.B., Donetsk National Medical University. M. Gorky (