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Subarachnoid hemorrhage - diagnosis and treatment of a life-threatening condition

Subarachnoid hemorrhage is a widespread pathological condition that ranks third in the frequency of occurrence among all types of cerebral strokes. Most often it develops in people aged 30 to 55 years.

Content

What is subarachnoid hemorrhage?

The human brain is covered with three shells:

  • external (solid);
  • average (arachnoid);
  • internal (vascular).

The space that lies between the hard and arachnoid shells is called subdural, and between the arachnoid and the vasculature is subarachnoid (or subarachnoidal).

Shells of the brain

The shells of the brain, between which cavities form

The outflow of blood into the subarachnoid space or the accumulation of its folds, caused by a violation of microcirculation, vasospasm and damage to the cerebral cortex, is called subarachnoid.

This pathological condition can also be referred to as intracranial hemorrhage, hemorrhagic stroke or SAK.

Subarachnoid haemorrhage

Subarachnoid hemorrhage due to rupture of vessels is a very dangerous condition

The risk group for the development of hemorrhage in the brain includes patients:

  • hypertension;
  • autoimmune and degenerative diseases of cerebral vessels;
  • who take anticoagulant drugs, i.e., drugs that reduce the ability of blood clotting;
  • with tumors of the brain and its membranes;
  • with aneurysmal formations of cerebral vessels;
  • with infectious and fungal lesions of the arteries and veins of the head;
  • with drug addiction from cocaine.

Classification of hemorrhages in the subarachnoid space: non-traumatic, traumatic, primary, isolated and other

If the vessel is damaged, the blood outlet can occur not only under the subarachnoid membrane, but also into neighboring anatomical structures. Therefore, the following types are distinguished:

  • isolated - SAK is limited to the shells of the brain;
  • subarachnoid-parenchymal hemorrhage - occurs in the brain tissue;
  • subarachnoid-ventricular - hemorrhage into one of the ventricles (anatomical formation of the brain);
  • subarachnoidal-parenchymal-ventricular hemorrhage - affects not only the substance, but also the ventricles of the brain.
rupture

The main cause of subarachnoid hemorrhage is a violation of the integrity of the wall of the intracranial artery

For reasons of origin, the SAC distinguishes:

  • traumatic - mechanical energy when struck in the head is so strong that it can cause a rupture of the artery or vein of the shell or parenchyma of the brain. The consequences of such an impact are unpredictable and depend on its strength, the caliber of the vessel and the place of hemorrhage;
  • non-traumatic - develops due to abnormality of vessel development, infectious processes, pathology of the blood coagulation system, or a momentary increase in blood pressure.

Primary, or spontaneous, SAK occurs only with malformations of the cerebral vasculature. The secondary is caused by a variety of external factors that provoke a break in the vein or artery.

Causes and factors of development of IAC

Factors that can lead to subarachnoid hemorrhage are conditionally divided into several groups:

  1. Structural or anatomical - pathology of the development of the vascular wall or a violation of its integrity.
  2. Violation of hemodynamics caused by high blood pressure.
  3. Dysfunction of the blood clotting system.

Most often, the cause of subarachnoid hemorrhage is the rupture of a saccular aneurysm, the size of which can range from 2 mm to several centimeters.

Less often, CAA causes pathologies of venous outflow from the brain, tumor destruction of blood vessels, atherosclerotic lesions of the arteries, which lead to their stratification.

Toxic substances and some medications affect the condition of the vascular wall, which leads to its rupture in weak places. For example, Mannitol, which is used for intracranial hypertension, has the property of causing a recoil syndrome in connection with complex biochemical processes. A sharp re-increase in pressure indices spasms the cerebral arteries and can provoke their rupture.

Often subarachnoid hemorrhage occurs after a traumatic brain injury.

Rare pancreatitis, which in neglected forms leads to the release of enzymes of the pancreas into the blood, which damages the cerebral vascular membrane, is a very rare cause of SAK. A similar phenomenon occurs in surgical interventions on the gland.

Elena Malysheva about subarachnoid hemorrhage - video

Symptoms and signs of subarachnoid hemorrhage

Clinical manifestations of SAC are divided conditionally into three periods, each of which has its own symptomatology. It depends on the pathogenetic processes that occur after the rupture of the vessel.

  1. Dogemorragichesky, or the period before the beginning of bleeding in the subarachnoid space, is manifested by periodic unilateral headaches, causeless dizziness, loss of vision. If the aneurysm of the vessel is in the parenchyma of the brain, the patient may have epileptic seizures, a split in the eyes, a fall of part of the visual fields, a spasm of the facial muscles. Diagnosis of this period is very difficult, since half of patients do not manifest an aneurysmal formation.
  2. Hemorrhagic period - the blood that flows from an aneurysm or a traumatically damaged vessel, gradually begins to fill not only the subarachnoid space, but also other brain formations (ventricles, a system of cisterns and liquor-bearing channels), thereby causing increased pressure in them and an increase in the volume of CSF liquid washing the brain and spinal cord). Clinically, this is manifested by acute headache, heat in the whole body, a sensation of the spread of hot fluid throughout the head. Dizziness intensifies and after a while there is a loss of consciousness, down to a coma. Two weeks later, there is also a loss of memory, a disorder of oral and written speech, a deterioration in mental health, as well as the development of paresis and paralysis. If the hemorrhage occurs in the brain stem, where the centers of respiratory and cardiac activity are located, then the lethal outcome is inevitable.
  3. Posthemorrhagic period - occurs after the elimination of bleeding, and its manifestations depend on the degree of damage to the structures of the brain and the speed of specialized medical care. Massive hemorrhage can lead to edema of the brain and hydrocephalus (an increase in the size of the cranium), which further burdens the course of the disease. Often after leaving the coma, the patient will have symptoms of amnesia, mental retardation, lack or decrease of sensitivity in the limbs.

Features of brain SAK in children and newborns

Causes of circulatory disorders and subarachnoid hemorrhage in newborns can give birth to trauma and prolonged exposure without oxygen. A low level of oxygen in the blood with a combination of other brain damage during labor can have a very unpleasant outcome, sometimes even lethal consequences.

In newborns under SAK, it is noted:

  • loud, shrill crying due to increased intracranial pressure;
  • convulsions;
  • sleep disorders;
  • increased motor activity at the slightest irritation;
    Newborn

    A piercing crying in a newborn is one of the signs of the SAK

  • severity of congenital reflexes during examination by a specialist;
  • high muscular tone;
  • bulging of a large fontanel;
  • icterus of the skin.

Older children diagnosed with ASD in infancy lag behind in physical and mental development, they have signs of increased blood pressure and a skull. Periodically, such patients suffer from epileptic seizures.

Diagnosis and differential diagnosis of the disease

Upon examination, the neurologist may suspect subarachnoid hemorrhage in the patient. But the symptomatology is very nonspecific, and sometimes the patient is in a coma, which further complicates the diagnosis and the determination of the obvious cause of brain disorders. Therefore, the main methods are instrumental:

  1. Computed tomography (CT) of the brain is the main diagnostic method for confirming or refuting the fact of subarachnoid hemorrhage. Approximately 85% of cases with the help of CT scan images of the zone of blood loss in the form of reduced compaction of the parenchyma of the brain.
  2. Magnetic resonance imaging is less sensitive in SAH than CT, but is very informative for hemorrhage into the brain stem.
  3. Spinal puncture (SMP) - a subarachnoidal or subarachnoidal-ventricular hemorrhage will indicate blood in the cerebrospinal fluid, because both the subarachnoid space and the ventricles have a connection to the spinal canal. But SMP is considered informative only 12 hours after a cerebral circulatory disturbance, because until this time, the blood cells in the CSF are not detected in the amount that is necessary to confirm the diagnosis.
    Spinal puncture

    Spinal puncture is informative 12 hours after cerebrovascular accident

  4. Ophthalmoscopy - allows you to determine the cause of damage to the cerebral vessels by their condition on the internal day (hypertension, infectious disease). If the ophthalmologist talks about edema of the optic disc, then most likely the diagnosis needs to be revised in favor of oncology.
  5. Electroencephalography - is shown with the newly emerged epileptic seizure. Registration of electrical activity of the brain allows you to determine the cause of this condition in the patient.
  6. Radiography of the skull - performed after a fall, a stroke of the head or at the time of the onset of symptoms of nervous system disorders to exclude bone-traumatic changes in the skull.
  7. Ultrasound examination of arteries and cerebral angiography - are conducted to clarify the causes of subarachnoid or parenchymal hemorrhage when considering the possibility of surgical treatment.

Differential diagnosis is carried out with ischemic stroke, which is characterized by:

  • occurrence of frequent, repeated symptoms, which indicate a violation of cerebral circulation, but pass within 12 hours;
  • presence of heart pathology, transfer of myocardial infarction, disturbance of heart rhythm;
  • ischemic disease of the lower extremities;
  • manifestation of symptoms during sleep, after taking a hot bath, physical fatigue;
  • gradual development of symptoms, with periodic fading and increasing manifestations with renewed vigor;
  • age over 55 years.

The therapeutic tactics of SAK

Treatment of subarachnoid hemorrhage is primarily aimed at adequate provision of emergency care, stopping blood loss, reducing intracranial pressure and reducing cerebral edema.

Urgent activities

  1. With epileptic seizure - do not interfere with muscle contraction, do not try to stick out your tongue. At this moment it is important to prevent additional traumatization of the patient, try to place soft objects under the body parts, and after the cramps end - to lay on one side with the fixation of the lower extremities.
  2. If you lose consciousness and stop breathing - call an ambulance, tilt the patient's head back, push the lower jaw and begin to carry out cardiopulmonary resuscitation with the ratio of pressing the sternum to the inspiration 30: 2.

When providing first aid, one should not try to put medicines in the oral cavity of the affected person.

Medication

  1. To stop bleeding, use Aminocaproic acid, Sodium etamzilate, Dicynon, Tranexam.
  2. To reduce intracranial pressure and cerebral edema under the control of electrolyte blood levels, Mannitol, Veroshpiron, Furosemide are used;
  3. To prevent ischemia of brain tissue and reflex spasm of blood vessels - Nimotop.
  4. To eliminate the inflammatory process, in particular after traumatic brain injury, antibiotics (Flemoclav, Sulbactomax, Cedoxime), as well as non-steroidal anti-inflammatory drugs (Ibuprofen, Diclofenac) are used.
  5. With indomitable vomiting - Cerucal, Metoclopramide.
  6. With repeated seizures - Finlepsin.
  7. With a rapid increase in the volume of CSF, shunting is performed, i.e., putting the catheter into the spinal canal or the ventricles of the brain to drain the accumulated fluid.

Drugs for SAC therapy - photo gallery

Surgical manipulations: course of operation

Surgical intervention is indicated with rapid deterioration of the patient's condition and formation of hematoma of considerable size. Surgical treatment includes:

  • patient preparation and anesthesia;
  • elimination of the hematoma (blood clots) with the help of a special aspiration needle and syringe, or by trepanation (opening) of the skull;
  • coagulation of the vessel with a laser in the event that the bleeding did not stop. It is also possible to impose special clips or ligatures on the damaged artery.

In case of craniocerebral trauma, operative treatment is the main method, since, in addition to eliminating the source of hemorrhage, a comparison of the displaced skull bones is performed.

Rehabilitation

Restoring the body after this kind of injury is a very complex and lengthy process. It is important not only the right home care, but also treatment in specialized centers. Rehabilitation activities include:

  • with a decrease or a complete lack of sensitivity, motor activity - massage procedures, muscle electrical stimulation, electrophoresis on the limbs;
  • acupuncture of areas with muscle spasm;
    Rehabilitation after SAC

    Rehabilitation measures should be applied by both specialists and relatives of the patient

  • procedures with paraffin, ozocerite, turpentine baths;
  • in the case of the development of Parkinson's syndrome - psychological training with muscle relaxation, acupressure, warming baths, antiparkinsonian drugs (Levodopa);
  • exercise therapy for the renewal of walking, balance and coordination skills;
  • with breathing and swallowing disorders - massage of the sublingual area, passive larynx and tongue movements, repeated training in swallowing and movement of food of different consistency in the mouth;
  • hypnosis;
  • psychological rehabilitation of not only the patient, but also his relatives

The use of traditional medicine in the development of subarachnoid hemorrhage is not only not expedient, but also absurd.

Prognosis, complications and consequences after SAC

The prognosis of successful treatment of subarachnoid hemorrhage largely depends not only on the patient's age category, the size of the damaged site, but also on the psychological support of relatives, mood, motivation and, of course, the presence of consciousness.

After the transferred SAK in the patient:

  • there may be phenomena of speech, memory, walking and coordination;
  • prolonged vasospasm may be complicated by delayed cerebral infarction;
  • massive hemorrhage, which affects large areas of the nervous tissue, leads to death.

Preventive measures

In order to prevent the development of SAC, it is necessary:

  • adhere to proper nutrition and exercise moderate physical activity;
  • in a timely manner, surgical removal of the diagnosed aneurysm formations of cerebral vessels;
  • do not allow the increase or fluctuation of blood pressure indicators;
  • correlate heart rhythm disturbances;
  • infectious or fungal vascular diseases to be treated in a hospital.

Timely diagnosis of predisposing factors of subarachnoid hemorrhage will help not only to avoid death, but also to prevent a high level of severe disability of patients with this pathology. It is important in the shortest possible time to determine the possibilities of surgical treatment with this or that breach of the blood supply to the brain in order to avoid serious complications.

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