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Subarachnoid hemorrhage
Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover the brain. This area is called the subarachnoid space.

Causes, incidence, and risk factors In 85% of cases of spontaneous SAH, the cause is rupture of a cerebral aneurysma weakness in the wall of one of the arteries in the brain that becomes enlarged. They tend to be located in the circle of Willis and its branches. While most cases of SAH are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture. In 1520% of cases of spontaneous SAH, no aneurysm is detected on the first angiogram. About half of these are attributed to non-aneurysmal perimesencephalic
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hemorrhage, in which the blood is limited to the subarachnoid spaces around the midbrain (i.e. mesencephalon). In these, the origin of the blood is uncertain.[1] The remainder are due to other disorders affecting the blood vessels (such as arteriovenous malformations), disorders of the blood vessels in the spinal cord, and bleeding into various tumors.[1] Cocaine abuse and sickle cell anemia (usually in children) and, rarely, anticoagulanttherapy, problems with blood clotting and pituitary apoplexy can also result in SAH. Subarachnoid blood can be detected on CT scanning in as many as 60% of people with traumatic brain injury. Traumatic SAH (tSAH) usually occurs near the site of a skull fracture or intracerebral contusion. It usually happens in the setting of other forms of traumatic brain injury and has been linked with a poorer prognosis. It is unclear, however, if this is a direct result of the SAH or whether the presence of subarachnoid blood is simply an indicator of severity of the head injury and the prognosis is determined by other associated mechanisms. Subarachnoid hemorrhage can be caused by:

Bleeding from an arteriovenous malformation (AVM) Bleeding disorder Bleeding from a cerebral aneurysm Head injury Unknown cause (idiopathic) Use of blood thinners cerebral aneurysm

Risks include:

Aneurysm in other blood vessels Fibromuscular dysplasia (FMD) and other connective tissue disorders High blood pressure History of polycystic kidney disease Smoking A strong family history of aneurysms

Symptoms The main symptom is a severe headache that starts suddenly and is often worse near the back of the head. Patients often describe it as the "worst headache ever" and unlike any other type of headache pain. The headache may start after a popping or snapping feeling in the head. The classic symptom of subarachnoid hemorrhage is thunderclap headache (a headache described as "like being kicked in the head", or the "worst ever", developing over seconds to minutes). This headache often pulsates towards the occiput (the back of the head).
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Other symptoms: Decreased consciousness and alertness Eye discomfort in bright light (photophobia) Mood and personality changes, including confusion and irritability Muscle aches (especially neck pain and shoulder pain) Nausea and vomiting Numbness in part of the body Seizure Stiff neck Vision problems, including double vision, blind spots, or temporary vision loss in one eye Eyelid drooping Pupil size difference Sudden stiffening of back and neck, with arching of the back (opisthotonos; not very common) Vomiting seizures decreased level of consciousness Intraocular hemorrhage (bleeding into the eyeball) may occur in response to the raised pressure: subhyaloid hemorrhage (bleeding under the hyaloid membrane, which envelops the vitreous body of the eye) and vitreous hemorrhage may be visible on fundoscopy. This is known as Terson syndrome Oculomotor nerve abnormalities (affected eye looking downward and outward and inability to lift the eyelid on the same side) or palsy (loss of feeling) may indicate bleeding from the posterior communicating artery The combination of intracerebral hemorrhage and raised intracranial pressure (if present) leads to a "sympathetic surge", i.e. over-activation of the sympathetic system. This is thought to occur through two mechanisms, a direct effect on the medulla which leads to activation of the descending sympathetic nervous system and a local release of inflammatory mediators which circulate to the peripheral circulation where they activate the sympathetic system. As a consequence of the sympathetic surge there is a sudden increase in blood pressure; mediated by increasedcontractility of the ventricle and increased vasoconstriction leading to increased systemic vascular resistance. The consequences of this sympathetic surge can be sudden, severe, and are frequently life threatening. The high plasma concentrations of adrenaline also may cause cardiac arrhythmias (irregularities in the heart rate and [8] rhythm), electrocardiographic changes (in 27% of cases) and cardiac arrest (in 3% of cases) may occur rapidly after the onset of hemorrhage. A further consequence of this process is neurogenic pulmonary edema[10] where a process of increased pressure within the pulmonary circulation causes leaking of fluid from the pulmonary capillaries into the air spaces, the alveoli, of the lung.

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Classification: Grade Signs and symptoms Asymptomatic or minimal headache and slight neck stiffness Survival 70%

1 2

Moderate to severe headache; neck stiffness; no neurologic deficit 60% except cranial nerve palsy Drowsy; minimal neurologic deficit 50%

3 4

Stuporous; moderate to severe hemiparesis; possibly early decerebrate 20% rigidity and vegetative disturbances Deep coma; decerebrate rigidity; moribund Fisher grading 10%

Grade 1 2 3 4

Appearance of hemorrhage None evident Less than 1 mm thick More than 1 mm thick Diffuse or none with intraventricular hemorrhage or parenchymal extension

This scale has been modified by Claassen and coworkers, reflecting the additive risk from SAH size and accompanying intraventricular hemorrhage 0-none 1 Minimal SAH w/o IVH 2 - Minimal SAH with IVH 3 - Thick SAH w/o IVH 4 - Thick SAH with IVH);. The World Federation of Neurosurgeons (WFNS) classification uses Glasgow coma score (GCS) and focal neurological deficit to gauge severity of symptoms.[24]
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Grade GCS 15 1314 1314 712 <7

Focal neurological deficit Absent Absent Present Present or absent Present or absent

1 2 3 4 5

A comprehensive classification scheme has been suggested by Ogilvy and Carter to predict outcome and gauge therapy. The system consists of five grades and it assigns one point for the presence or absence of each of five factors: age greater than 50 Hunt and Hess grade 4 or 5 Fisher scale 3 or 4 aneurysm size greater than 10 mm and posterior circulation aneurysm 25 mm or more

Signs and tests Signs include: A physical exam may show a stiff neck Lumbar puncture: At least three tubes of CSF are collected.[6] If an elevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap").[3] While there is no official cutoff for red blood cells in the CSF no documented cases have occurred at less than "a few hundred cells" per high-powered field. The CSF sample is also examined for xanthochromiathe yellow appearance of centrifugated fluid. More sensitive is spectrophotometry (measuring the absorption of particular wavelengths of light) for detection of bilirubin, a breakdown product of hemoglobin from red blood cells. Xanthochromia and spectrophotometry remain reliable ways to detect SAH several days after the onset of headache. An interval of at least 12 hours between the onset of the headache and lumbar puncture is required, as it takes several hours for the hemoglobin from the red blood cells to be metabolized into bilirubin. A brain and nervous system exam may show signs of decreased nerve and brain function (focal neurologic deficit)

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An eye exam may show decreased eye movements -- a sign of damage to the cranial nerves (in milder cases, no problems may be seen on an eye exam) a head CT scan (without contrast dye) should be done right away. In 5 - 10% of cases, the scan may be normal, especially if there has only been a small bleed. If the CT scan is normal, a lumbar puncture (spinal tap) must be performed. Other tests that may be done include: Cerebral angiography of blood vessels of the brain CT scan angiography (using contrast dye) Transcranial Doppler ultrasound -- to look at blood flow in the arteries of the brain Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) (occasionally)

CT scan of the brain showing subarachnoid hemorrhage as a white area in Treatment Surgery may be done to:

Remove large collections of blood or relieve pressure on the brain if the hemorrhage is due to an injury Repair the aneurysm if the hemorrhage is due to an aneurysm rupture

If the patient is critically ill, surgery may have to wait until the person is more stable. Surgery may involve:

Craniotomy (cutting a hole in the skull) and aneurysm clipping -- to close the aneurysm Endovascular coiling -- placing coils in the aneurysm to reduce the risk of further bleeding

If no aneurysm is found, the person should be closely watched by a health care team and may need more imaging tests. Treatment for coma or decreased alertness includes:

Draining tube placed in the brain to relieve pressure

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Life support Methods to protect the airway Special positioning

A person who is is conscious may need to be on strict bed rest. The person will be told to avoid activities that can increase pressure inside the head, including:

Bending over Straining Suddenly changing position

Treatment may also include:

Medicines given through an IV line to control blood pressure Nimodipine to prevent artery spams Painkillers and anti-anxiety medications to relieve headache and reduce pressure in the skull Phenytoin or other medications to prevent or treat seizures Stool softeners or laxatives to prevent straining during bowel movements

Expectations (prognosis) How well a patient with subarachnoid hemorrhage does depends on a number of different factors, including:

Location and amount of bleeding Complications

Older age and more severe symptoms can lead to a poorer outcome. People can recover completely after treatment, but some people may die even with aggressive treatment. Complications Repeated bleeding is the most serious complication. If a cerebral aneurysm bleeds for a second time, the outlook is much worse. Changes in consciousness and alertness due to a subarachnoid hemorrhage may become worse and lead to coma or death. Other complications include:

Complications of surgery Medication side effects

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Seizures Stroke

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