Subarachnoid Hemorrhage Disease

DESCRIPTION

Subarachnoid hemorrhage is the extravasation of blood into the subarachnoid space particularly of the basal cisterns and into the cerebral spinal fluid pathways.

Traumatic: More common and related to head trauma
Spontaneous: Rare; 50-60% of spontaneous subarachnoid hemorrhages are due to intracranial saccular aneurysms
System(s) affected: Nervous
Genetics: N/A
Incidence/Prevalence in USA: Spontaneous: Incidence is 10.9/100,000 per year
Predominant age:
- The majority of subarachnoid hemorrhages due to aneurysms occur in the fourth to seventh decades
- Subarachnoid hemorrhage due to arteriovenous (AV) malformation appears more commonly in the second, third, and fourth decades
Predominant sex: Subarachnoid hemorrhage due to aneurysm occurs slightly more commonly in females (55%).

SIGNS AND SYMPTOMS

Abrupt onset of headache associated with stiff neck and photophobia
May or may not lose consciousness
May develop focal neurological deficits such as hemiparesis or a dilated pupil
Subhyaloid hemorrhages are more common in anterior communicating artery aneurysms

CAUSES

Trauma
Intracranial saccular aneurysm
Intracranial A-V malformation
Hypertension
Rarely tumors and blood dyscrasias

RISK FACTORS

Intracranial aneurysms associated with coarctation of the aorta
AV malformations
Polycystic disease of the kidneys
Fibromuscular dysplasia of the renal arteries
Hypertension is not necessarily associated with saccular aneurysms, but is associated with rupture of an existing aneurysm

LABORATORY

N/A

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

N/A

SPECIAL TESTS

N/A

IMAGING

CT scan:
- The diagnosis is established in more than 95% of the cases with a CT scan. This demonstrates blood in the basal cisterns and may help in localizing the source of hemorrhage.
- It also can rule out mass effect so that if this study is negative a spinal puncture can be safely performed
- A small percentage of subarachnoid hemorrhages will be missed on the CT scan
Cerebral angiography
- Following the establishment of the diagnosis of subarachnoid hemorrhage, it is imperative to find out the source of bleeding, therefore, cerebral angiography is used to identify the source of hemorrhage such as a saccular aneurysm or AV malformation
- High definition MRA (magnetic resonance angiography) occasionally will establish the diagnosis, but angiography is still the gold standard for planning surgery
Other
- It must be remembered that occasional hemorrhage may occur from an AV malformation of the spinal cord or a vascular tumor in the spinal arachnoid space. Therefore, if no source of subarachnoid hemorrhage is found intracranially, consideration might be made for studies involving the subarachnoid space which would include MRI spinal scanning or myelography.

DIAGNOSTIC PROCEDURES

See above

APPROPRIATE HEALTH CARE

Initial therapy is carried out in the Intensive Care Unit

GENERAL MEASURES

The treatment is directed to prevent complications of subarachnoid hemorrhage which include rebleeding, hydrocephalus, and cerebral vasospasm
Vasospasm is treated with generous volume expansion and hypertension to promote cerebral perfusion after the aneurysm has been obliterated. This is not wise if an aneurysm is untreated.
Once the patient has stabilized and recovered from the initial hemorrhage, then a vigorous rehabilitation program is indicated

SURGICAL MEASURES

If the source of hemorrhage such as an aneurysm can be readily obliterated, this reduces the risk of rebleeding and allows more vigorous treatment with fluid and hypertensive therapy of cerebral vasospasm
Hydrocephalus should be treated with cerebral spinal fluid drainage and may require permanent shunting procedures
AV malformations may be obliterated with embolization and surgery
Radiosurgery shows promise in the treatment of small deep AV malformations
Endovascular obliteration of aneurysms is being performed in selected centers

ACTIVITY

Strict bedrest until source of hemorrhage is eliminated

DIET

N/A

PATIENT EDUCATION

N/A

PREVENTION/AVOIDANCE

Incidental aneurysms have a risk of hemorrhage of 2% per year so prophylactic surgery or endovascular treatment may be indicated

POSSIBLE COMPLICATIONS

Death
Paralysis

EXPECTED COURSE AND PROGNOSIS

Approximately 25-30% of the patients will die from a spontaneous subarachnoid hemorrhage due to an aneurysm. The highest morbidity is secondary to cerebral vasospasm.
If the aneurysm can be successfully obliterated and the vasospasm treated effectively, satisfactory outcome occurs in approximately 50-65% of patients
Approximately 25-30% of aneurysms will be multiple. It is advisable to treat multiple aneurysms during the same procedure, but if this is not possible, treatment is directed at the aneurysm most likely to have hemorrhaged.
Further surgical procedures may be necessary to obliterate additional aneurysms
AV malformations do not have as high morbidity and mortality associated with the hemorrhage. Both untreated aneurysms and AV malformations are likely to bleed at about 2% per year. Therefore in the younger age groups, incidentally found A-V malformations and aneurysms may require aggressive treatment.

ASSOCIATED CONDITIONS

N/A

AGE-RELATED FACTORS

Pediatric: N/A
Geriatric: In the elderly patient, incidental aneurysms and AV malformations may best be followed since the chance of hemorrhage is only 2% per year
Others: In younger and middle-aged people, surgery is recommended

PREGNANCY

In the pregnant female, increased blood pressure and blood volume may predispose to hemorrhages. Under life-threatening situations, surgical or endovascular procedures can be performed on a pregnant patient. However, with AV malformations, a less lethal lesion compared to aneurysms it may be worthwhile to allow the pregnancy go to term.

OTHER NOTES

N/A

ABBREVIATIONS

AV = arteriovenous

Clinical Investigations

ROLE OF HOMOEOPATHY

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