Subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space, which usually occurs due to rupture of the aneurysm.

The cause of

Aneurysms are localized enlargement of the arteries. They may be congenital or may develop on the basis of congenital defect intima and media of the vessel, and then the ball - globular or spindle - fusiform. They are often localized to Wilisovom hexagonal and often there are more in the same person.Acquired aneurysms, whether on the basis of arteriosclerosis, diffuse are.

SAH may arise from arteriovenous malformations. Usually it comes tuft enhanced arterial and venous vessels with arterial input and output, venous vessels. By SAH can lead to the rupture of blood vessels wall defect without aneurysm. Blood will flow in suarahnoidni space at different speeds, depending on the size of the vessel that was ruptured but once the blood stream can damage the brain tissue.

The clinical picture

History is typical - Sudden head pain (like a punch), usually in the back of the head with the expansion of the neck, and sometimes down the spinal column to the lumbar regions and the frontal part of the head.Due to the rapid increase in speed occurs nausea, vomiting and disturbance of consciousness up to coma.

Because stimulus meninges meningeal signs appear, but they can sometimes be poorly expressed or absent. In case of damage to brain tissue can be found focal signs (hemiparesis half-body paralysis, seizures).

A very important finding is bradycardia (slow heart rate), which can be 40-50 beats per minute, and can serve as an indirect indicator of the size of the intracranial pressure.

The presence of blood in the subarachnoid space usually leads to vasospasm, which began to develop 3 - 4 days after bleeding, and lasts about three weeks. This serious complication of SAH leads to further, often diffuse brain damage becomes apparent reduction in the level of consciousness, mutism, or focal signs.

Prognosis depends on the severity of bleeding, the development and severity of vasospasm. Better prognosis in the absence of SAH aneurysm or AV malformation or with negative angiographic findings.Mortality is high, and recurrences are common, especially in the first six months.

Diagnosis

It is based on clinical findings, lumbar puncture, fundus findings, angiography, CT (scan).

Treatment

Conservative treatment consists of rest in the strictest (the patient may not even get up for their physiological needs). By all means necessary to prevent unrest (neuroleptics, benzodiazepines) and seizures (phenobarbital sodium, diazepam, parenterally), since they can cause new bleeding. Blood pressure control is also very important measure of compensation and 2-3 liters of fluid per day. Since arrhythmias are very common and neurogenic pulmonary edema can occur very early cardiopulmonary monitoring is necessary. Sometimes it is useful careful lumbar puncture and hipervolemic hemodilution using dextran. Hyperosmolar solutions can reduce brain edema and reduce inrakranijalni pressure.

It is very important issue when it comes to surgical intervention, and in which patients. The general agreement is that it can intervene before the development of vasospasm, ie. the first three days, in patients who are not in a coma. The others should wait for the withdrawal of vasospasm before the start artériographie studies and planning intervention, which is usually about three weeks.