Subarachnoid hemorrhage. Subarachnoid hemorrhage: causes, symptoms, how to treat, prognosis

As a result of a rupture of an aneurysm or a deformed artery (usually at the base of the brain), blood leaks into the space between the pia mater and the arachnoid membrane of the brain. Increased intracranial pressure and pressure on brain tissue cause neurological symptoms, often associated with local necrosis.

Symptoms of subarachnoid bleeding

The most characteristic symptom of subarachnoid bleeding is sudden extremely strong headache with an intensity previously unknown to the patient. Typically radiates towards the back of the skull.

The appearance of this symptom is a direct indication for urgent hospitalization and investigations in the direction of intracranial bleeding, even if no other symptoms are observed ( affects about 20-30% of patients).

Headaches often accompany:

• photophobia
• breathing disorders
• promotion blood pressure when heart rate increases

In more severe forms, this is accompanied by neurological symptoms, such as unequal pupils, paralysis or paresis, speech disorders or impaired mobility of the eyeballs.

The patient may have confusion, disorientation regarding time, space, self, and may also experience complete loss of consciousness or epileptic convulsions. During the first hours of illness, symptoms of meningitis (for example, a stiff neck) appear.

Subarachnoid bleeding is a disease of young people with cerebral aneurysms or developed atherosclerosis. The likelihood of bleeding and the severity of the course increase blood clotting disorders and arterial hypertension.

Subarachnoid hemorrhage is the cause of death in 10-15% of patients. This is associated with hypertension, disturbances in the functioning of the respiratory centers and regulation of the heart. The immediate cause of death is sudden stop of blood circulation.

Subarachnoid hemorrhage - treatment

Patients with suspected subarachnoid bleeding should be called as soon as possible ambulance for transportation to a specialized hospital due to the possibility of a sharp deterioration in general condition and complications.

Diagnosis includes imaging studies such as computed tomography (CT), magnetic resonance (NMR), most often in combination with contrast study of cerebral vessels (angiography). This allows you to localize the site of bleeding and identify the presence of other aneurysms, which may later cause attacks of the disease. The diagnosis is confirmed by lumbar puncture: the presence of blood is noted in the obtained cerebrospinal fluid.

Treatment involves opening the skull and closing the bleeding vessel or aneurysm with special clips. Whenever possible, other aneurysms found are strengthened, which increases the patient's chances for a healthy future.

Thanks to the progress of radiology and arterial catheterization techniques in recent years More and more often, a procedure is performed that is based on placing a catheter in a large vessel (usually the neck). Under X-ray control, the surgeon inserts it to the site of bleeding and places it in a special block that closes the vessel and blocks the flow of blood. This is safer and less burdensome, as it avoids prolonged general anesthesia and opening of the skull.

Subarachnoid bleeding - complications

Subarachnoid hemorrhage is a serious disease that is characterized by the occurrence of many serious complications. Despite early diagnosis and specialized treatment ends in death in almost 50% of patients. During acute phase The disease may develop cerebral edema, which prolongs the treatment period and worsens the prognosis, as well as the appearance of secondary attacks.

Patients who have experienced a subarachnoid hemorrhage often struggle with persistent paresis, paralysis of the limbs, or problems with speech, vision, problems concentrating, remembering, etc.

Subarachnoid hemorrhage - rehabilitation

Rehabilitation after subarachnoid hemorrhage is typical for stroke. The main principle is to start motor rehabilitation as quickly as possible – first passive and then active.

A set of exercises for improvement and possible physiotherapeutic treatment is selected individually depending on the patient’s condition. The whole process takes for a long time, and noticeable improvement (partial increase in muscle strength, increased efficiency) can only appear after several months of regular work.

Risk factors for subarachnoid hemorrhage

• This condition can develop at any age, but is more common between 40 and 70 years of age.
• Female gender.
• Belonging to the Negroid race.
• Smoking.
• Alcohol.
• Excess body weight.
• Lack of control or insufficient correction of arterial hypertension.
• Taking anticoagulants.

Causes of subarachnoid hemorrhage

Aneurysmal hemorrhage accounts for 80% of all SAH and results from rupture of a saccular aneurysm at the base of the brain. Aneurysms are considered an acquired disease, but there is often a genetically determined inferiority of the vascular wall; in 0.4-2.5% of cases, an aneurysm is the result of inflammation in the artery wall; dissecting and traumatic aneurysms account for less than 1% of cases.

The cause of nonaneurysmal hemorrhage in 10% of cases is arteriovenous malformation; in 5% – such rare causes as arterial dissection, intoxication, sickle cell anemia, anticoagulant therapy, trauma; in 5% of cases the cause is not established.

• arterial and arteriovenous aneurysms;
• arteritis;
• diseases of the blood system;
• vascular development abnormalities;
• vascular changes in hypertension, atherosclerosis;
• infectious and toxic diseases;
• malignant neoplasms;
• injuries.

Classification of subarachnoid hemorrhage

• According to the degree of distribution of hemorrhages: limited (within one lobe), extensive, massive (more than one lobe), multiple.

• By localization: convexital, basal, spinal.

• According to the pace of development: acute, subacute (hours, days).

• According to the degree of involvement of brain structures: SAH and subdural, subpial, parenchymal, ventricular hemorrhages.

• By origin: aneurysmal and non-aneurysmal.

• According to the mechanism of occurrence: traumatic and spontaneous (all others).

Stages of subarachnoid hemorrhage

(regardless of the reason)

1. Hemorrhage into the subarachnoid space and the spread of blood through the system of cerebrospinal fluid spaces.

2. Blood coagulation in the cerebrospinal fluid, which leads to a blockage of the cerebrospinal fluid pathways, an increase in cerebrospinal fluid hypertension and the formation of internal hydrocephalus.

3. Lysis of blood clots with the release of vasoactive products into the CSF (prostaglandins, catecholamine, serotonin, angiotensin, hemoglobin and fibrin breakdown products), causing spasm of vascular smooth muscle fibers, and then constrictive stenotic arteriopathy (CSA).

Stages of KSA:

I – contraction of smooth muscle cells;

II – thickening of the intima-media layer, wrinkling of the internal elastic membrane, damage to the endothelium, thrombosis of the artery;

III – necrosis of smooth muscle elements, fibrocellular thickening of the intima.

Degrees of vasospasm (CVA) according to the degree of vessel narrowing:

moderate stenosis – a decrease in the diameter of the vessel by 20-25%;

severe stenosis – a decrease in the diameter of the vessel by 50-75%;

critical stenosis – a decrease in the diameter of the vessel by more than 75%.

Clinical debut refers to 4-7 days after subarachnoid hemorrhage. The maximum severity of changes is observed at 10-13 days.

An intense headache appears suddenly (“explosion in the head”, “blow to the head”), at first it is diffuse, and after some time it is accentuated more in the area of ​​the back of the head, neck, and shoulder girdle; accompanied by nausea, vomiting, which does not bring relief, and photophobia.

The patient is characterized by pronounced anxiety, often a disturbance of consciousness from stupor to coma, meningeal signs develop within 3-12 hours. Epileptiform seizures may occur. Focal neurological symptoms are not typical, but paresis of the oculomotor nerve (with an aneurysm of the posterior communicating artery), aphasia and hemiparesis (with a parenchymal component), and bilateral paresis of the abducens nerves (with increasing intracranial hypertension) may develop. The focality of symptoms indicates the development constrictive-stenotic arteriopathy.

Upon objective examination: hyperthermia, brady- or tachycardia, increased blood pressure.

The severity of the condition of patients with subarachnoid hemorrhage is determined in accordance with the W. Hunt, R. Hess scale and the World Federation of Neurosurgeons scale.

SAH severity scale (W. Hunt, R. Hess)

The degree of damage determines the management tactics of a patient with this pathology. Patients whose condition corresponds to grades I–III are subject to surgical treatment, while grades IV–V are treated conservatively.

World Federation of Neurological Surgeons (WFNS) severity scale

"*" - aphasia, hepiparesis/hemiplegia

"**" - diagnosed unruptured aneurysm

Symptoms of various etiological types of SAH

With aneurysmal subarachnoid hemorrhage, periods are distinguished:

1. Latent

2. Prodromal – local or “migraine” headache, dizziness, which may be accompanied by photophobia, vomiting, diplopia, blurred vision and consciousness, and short-term stiff neck.

3. Hemorrhagic - damage to the II, III, V, VI pairs of the cranial nerve, short-term speech disorders, sensitivity, epileptic seizures or status with transient pyramidal symptoms, clinic of sphenoidal fissure syndrome, transient ischemic attack. Hypothalamic disorders: vasomotor disorders (pallor of the skin, increased blood pressure, tachycardia, hyperthermia, increased breathing, total vasospasm), catabolic (hyperglycemia, azotemia), neurodystrophic (papules, blisters, maceration, ulcerations, bedsores, cachexia in the last 2-3 weeks of illness).

The hemorrhagic period has 3 phases:

1) initial – the first three days after aneurysmal hemorrhage,

2) expanded – up to 1 month after aneurysmal hemorrhage;

3) outcome phase:

√ with a compensated course of the hemorrhagic period, regression of pathological symptom complexes occurs with the patient’s recovery;

√ with a subcompensated course, persistent organic damage to the brain occurs;

√ with a decompensated course, irreversible structural multiorgan changes develop, leading to death.

4. Period of recurrence of subarachnoid hemorrhage.

5. Residual or post-hemorrhagic period.

Differential diagnosis of subarachnoid hemorrhage

Carried out with a number of diseases nervous system:

• cerebral venous thrombosis,
• disorders of spinal circulation,
• cervical osteochondrosis with cervicalgia syndrome,
• migraine,
• syncope, epilepsy,
• tumors of the central nervous system (xanthochromia in the cerebrospinal fluid),
• sinusitis.
• meningoencephalitis (bullous rash with SAH).

ECG changes in the form of a wide and deep negative T wave may require the exclusion of acute myocardial infarction.

A similar electrocardiographic picture is associated with the release of catecholamines, which affects the state of coronary blood flow. Most often, focal changes on the ECG with subarachnoid hemorrhage are observed over the age of 50-55 years.

Diagnosis of subarachnoid hemorrhage

• Transcranial Dopplerography;

• Lumbar puncture with examination of the cerebrospinal fluid, which in SAH has a pink or xanthochrome coloration;

• Computed tomography;

• Magnetic resonance angiography is used to identify arteriovenous malformations and aneurysms.

The neuroimaging picture is assessed using the Fisher scale:

Treatment of subarachnoid hemorrhage

• Conservative treatment
  

1. Bed rest,

2. Monitoring and correction of blood pressure, maintaining it 15-20% above the normal level with dobutamine or dobutrex, analgesia (paracetamol),

3. Sedation with short-acting drugs,

4. Anticonvulsant therapy based on seizures.

5. Control of Na levels (risk of hyponatremia),

6. Hemodilution to a hematocrit level of 31-34% (5% albumin, fresh frozen plasma, 5% glucose solution, saline solution are administered),

7. Maintaining central venous pressure at 8-10 mm Hg. Art.

8. The L-type calcium channel blocker nimodipine significantly reduces the frequency and severity of ischemic disorders after subarachnoid hemorrhage. For the purpose of neuroprotection, prevention and treatment of vasospasm, nimodipine is administered no later than the 4th day of subarachnoid hemorrhage and before the 14th day of illness. If carried out surgical treatment For hemorrhages, nimodipine therapy is carried out for at least 5 days. Freshly prepared nimodipine solution can be administered intracisternally directly during surgery.

• Surgical treatment

This also includes clipping the aneurysm through an open approach, performing transluminal balloon angioplasty (endovascular balloon dilation of a spasmodic vessel) in the first 3 days (taking into account risk factors, before the development of clinically significant vasospasm) or after 14 days (from the moment of resolution of vasospasm).

In the presence of cerebral vasospasm (linear blood flow velocity of the LSC more than 250 cm/sec) and increasing neurological deficit, surgical treatment of subarachnoid hemorrhage is not indicated. Negative prognostic factors: severity of the patient’s condition, large volume of bleeding. Surgical treatment in patients with aneurysms without rupture, it is performed in case of an aneurysm with a diameter of more than 7 mm, a history of SAH, or a family genetic predisposition.

Prognosis for subarachnoid hemorrhage

With the development of CSA with ischemia, the mortality rate of patients with SAH increases 2-3 times. Maximum vasospasm is observed with massive basal hemorrhage complicated by cistern tamponade. Repeated SAH are observed in 17-26% of patients and in 80% of cases lead to death. Complications of subarachnoid hemorrhage in the form of occlusive hydrocephalus develop in 27% of patients.

Rule of five (according to Charles Drake): out of 5 patients with SAH, 2 die, 2 become disabled, and only 1 does not experience recurrent hemorrhage.

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Survivors of subarachnoid hemorrhage (SAH) describe it as the worst pain of their lives.

It leaves behind problems with speech and muscles, increases the possibility of heart attacks, and the survival of patients depends entirely on the timeliness of treatment. medical care.

How do you understand that blood has entered the brain, what are its consequences, and how can you reduce the likelihood of its occurrence?

Subarachnoid hemorrhage is a type in which blood is released into the subarachnodal space of the brain (the area between its cavities that is filled with cerebrospinal fluid).

The release can occur as a result of the development of vascular pathologies, head injuries, and blood clotting disorders. In this case, the patient experiences a severe headache. The frequent absence of other symptoms can make diagnosis difficult.

This condition also occurs as a result of damage to the brain parenchyma. In this case, specific neurological signs will be observed: disruption of the facial muscles (hemiparesis).

Full list possible reasons The occurrence of subarachnoid hemorrhage (SAH) is given in the table below:

The pathogenesis of hemorrhage can be described as the collection of fluid in the subarachnoid cavity - the space between the pia mater and the arachnoid membrane. This cavity contains cerebrospinal fluid, which rises from the spinal cord, wraps around both hemispheres of the brain and descends back.

When bleeding begins, blood flows to the basal cisterns (located at the base of the brain). And it begins to enter the cerebrospinal fluid, which leads to spasms of the arteries, death of neurons and swelling of the brain. The amount of cerebrospinal fluid increases due to the blood, which leads to an increase in pressure in the brain cavity and can contribute to its displacement.

Classification

In neurology, three classifications of disease severity are used.

Hunt-Hess scale, according to which the degree of severity is determined by the symptoms that appear:

• 1st: mild headache and increased tone of the neck muscles;
• 2nd: headache gets worse. At this stage, neurological symptoms begin to appear (eye pain, strabismus, paresis (partial impairment of motor function));
• 3rd: a slight neurological deficit appears, characterized by drowsiness and a decrease in reaction speed;
• 4th: serious neurological deficit - stunning, loss of reaction, partial paralysis of one side of the body, lack of response to external stimuli;
• 5th: deep coma, sharp increase in muscle tone.

Fisher scale, classifies the patient’s condition according to the amount of hemorrhage shown on the results of computed tomography or MRI:

• hemorrhage is not detected;
• lesion size 1 mm;
• lesion more than 1 mm;
• intraventricular hemorrhage or damage to the brain parenchyma (the magnitude does not matter).

Glasgow Coma Scale (GCS), determines the severity of the disease by neurological deficit (the condition is assessed by points, where 15 is clear consciousness and 3 is deep coma):

• GCS 15 - absence of neurological deficit;
• 13-14 GCS - moderate or deep stunning;
• 8-10 GCS - stupor (numbness, lethargy);
• 6-7 GCS - moderate coma;
• 4-5 GCS - thermal coma;
• GCS 3 - deep coma.

There is also a classification that combines some factors from the above methods of assessing the patient’s condition. The Ogilvy and Carter scale takes into account the age of the patient, the severity of the patient according to the Hunt-Hess and Fisher scales and the size of the aneurysm. Severity is assessed by the number of signs present and absent.

Symptoms

Signs of SAH occur suddenly. The clinical picture of the disease is characterized by a sharp and acute headache that cannot be tolerated. For a large number of people, headache is the only symptom of the disease. But pain can also appear with other brain diseases.

The remaining signs are divided as follows:

Most often, subarachnoid hemorrhage occurs against the background of physical or emotional outbursts.

Differential diagnosis

The most effective method is a computed tomography (CT) scan.

It is used to determine:

• site of hemorrhage;
• data on the liquor system;
• presence of cerebral edema.

In addition, in order to detect hemorrhage, the following methods can be used, both partially and in combination (in each specific clinical case, the methods used may differ):

How is the treatment carried out?

Emergency care for a person with such bleeding can only be provided by doctors using intravenous injections to reduce agitation and headaches. Self-administration of any medications can aggravate the situation (for example, aspirin is contraindicated in patients).

If bleeding is suspected, the patient must be taken to the hospital. Therapeutic actions should begin to be carried out by the ambulance team at prehospital stage. Subarachnoid hemorrhage is fatal in 50% of cases, and a third of patients die in the ambulance.

The patient is taken to the neurological, neurosurgical department or intensive care unit.

After the diagnosis is established or confirmed, the patient is prescribed drugs that increase blood clotting and drugs that lower blood pressure.

Drug therapy

Drug treatment includes the primary stage (stopping bleeding) and eliminating headaches.

If the course of the disease is accompanied by convulsions or seizures, medications can be used to reduce these manifestations of the disease.

During drug treatment drugs prescribed:

• reducing arterial spasms;
• laxatives and diuretics (help reduce edema of the brain);
• painkillers;
• reducing cramps;
• antiemetics;
• tranquilizers.

Surgical intervention

Brain surgeries are performed in cases where intracerebral hemorrhage is caused by an aneurysm, as well as in case of massive hemorrhage in the brain, characterized by impaired consciousness, loss of speech and motor function (in this case, the hematoma is removed).

There are two types of surgery:

• Neurosurgical clipping. The operation involves placing a metal clip on the aneurysm, which will prevent growth and rupture. The operation is performed on the open brain under general anesthesia, in the case of an aneurysm of the middle cerebral artery (occlusion has great risks, since access to the artery is difficult).
• Endovascular occlusion. The operation involves inserting a coil into the aneurysm, which, like a staple, prevents growth and rupture. The operation is performed on a closed brain (a coil is inserted through a catheter, which is led from the femoral artery through the carotid and vertebral arteries to the aneurysm) and under general anesthesia. This type Surgery is performed more often, especially in cases where the patient's condition is unstable and open-brain surgery may worsen it. Also, preference is given to occlusion in case of aneurysm of the basilar artery and posterior cerebral artery, since clipping in this case is impossible.

In case of aneurysm of the anterior cerebral and anterior communicating artery, both operations can be performed.

Surgery can also be called removal of a hematoma through holes in the skull. The operation is performed only if the blood clot is on the surface.

Rehabilitation period

Recovery time after subarachnoid hemorrhage depends on the severity of its occurrence, but takes at least 6 months.

Rehabilitation is carried out under the supervision of doctors in a hospital and directly depends on drug therapy, as well as on:

• patient hygiene;
• therapeutic exercises and physical education;
• classes with a speech therapist.

Patients who have suffered a hemorrhage may encounter several problems that can significantly lengthen the recovery period:

• constant fatigue (solved by walking, with a gradual increase in time);
• insomnia (sleep and rest schedule);
• constant headaches (they can only be treated with medication);
• problems with sensitivity and motor function (physiotherapy and physical therapy help);
• vision problems (requires a visit to an ophthalmologist);
• partial or complete memory loss (its restoration is carried out with medication).

All problems that arise are resolved with the attending physician, who will refer the patient to other specialists (for example, an ophthalmologist). As a preventative measure for both the first and subsequent hemorrhage, it is recommended to eat well, quit smoking/alcohol/drugs, and exercise physical therapy and monitor your blood pressure levels.

Possible complications and consequences

The possibility of complications and their severity depends on the causes of intracerebral hemorrhage and the timeliness of medical care. The faster the patient is taken to the hospital, the greater his chances of survival and successful treatment.

The most severe consequence is cerebral vasospasm (vascular spasm leading to). This complication develops in a third of patients and can lead to cerebral infarction and death.

And also subarachnoid hemorrhage can provoke the development of:

• epilepsy (occurs in 5%);
• neurological defects (problems with speech/motor function)
  hydrocephalus;
• depression/anxiety and other mental problems.

Forecast

Subarachnoid hemorrhage is extremely dangerous disease, the mortality rate of which is 50%.

Most patients die during the first month in hospital, a little less on the first day and before medical care is provided.

The prognosis for the occurrence of complications and consequences is very unfavorable - most of the patients have disabilities and only 25% of all those who have suffered this condition fully recover.

Subarachnoid hemorrhage is a pathological condition characterized by the development of bleeding flowing into the area of ​​the subarachnoid space, that is, into the cavity that is located between the pia mater and the arachnoid mater. There are 2 main types of development of subarachnoid hemorrhage. In one case, there is a traumatic subarachnoid hemorrhage, which is a consequence of severe traumatic brain injury.

In another case, subarachnoid hemorrhage is a consequence of sudden hemorrhage due to an acute circulatory disorder of the hemorrhagic type. It is worth noting that subarachnoid hemorrhage accounts for only 5% of all cases of cerebral circulatory disorders, and such a pathological condition occurs, as a rule, in people aged 40 to 70 years, but there are known cases of the development of a similar pathology in newborns.

The main reasons for the development of subarachnoid hemorrhage

Traumatic subarachnoid hemorrhage is of least interest when considering the etiology of this condition, since it is always a consequence of severe traumatic brain injury. Primary or, as it is also called, spontaneous subarachnoid hemorrhage, as a rule, develops as a result of a violation of the integrity of blood vessel in the brain, and in the vast majority of cases when a vessel aneurysm ruptures.

Cerebral aneurysms are abnormal thickenings of the sac-like type, in which the walls forming the aneurysm are reinforced by fibrous tissue, which further leads to a decrease in their ability to resist the existing pressure. Tissue in the area of ​​blood vessel aneurysms is prone to rupture, so the presence of such an anomaly can provoke extensive hemorrhage at any time, even without the influence of obvious external or internal factors.

In approximately 50% of cases, it is the aneurysm that provokes the appearance of subarachnoid hemorrhage. An aneurysm of the blood vessels of the brain can reach sizes from 2-3 mm to 2 cm, therefore, the larger such formations, the higher the risk of extensive hemorrhage in the brain. To others common reasons Development of subarachnoid hemorrhage refers to:

• cavernomas;
• arteriovenous fistulas;
• arteriovenous malformations;
• blood diseases;
• vascular tumors;
• systemic vasculitis;
• toxic damage to arterial walls;
• fungal infection of arteries;
• atherosclerosis of the blood vessels of the brain;
• thrombosis.

Most often, the development of subarachnoid hemorrhage is associated with a sharp increase in blood pressure, for example, with a strong cough, heavy lifting, and even against the background of strong emotional experiences. Often, spontaneous bleeding into the subarachnoid space can develop due to bleeding in the pituitary gland, myxoma of the heart, penetration of malignant tumor metastases into the brain, as well as rupture of the artery that goes around the brain stem.

Predisposing risk factors for the development of subarachnoid hemorrhage include hypertension, frequent use alcoholic drinks, active and passive smoking, uncontrolled use of contraceptives, as well as the use of certain hormonal drugs, including hormone replacement therapy for thyroid diseases.

Symptoms of subarachnoid hemorrhage and possible consequences

As a rule, the pre-hemorrhagic period of development of subarachnoid hemorrhage does not have pronounced manifestations that can make the patient aware of the imminent onset of cerebral hemorrhage. A similar asymptomatic course of the pre-hemorrhagic period is observed in more than 50% of patients, but in the rest, signs of approaching problems can be painful sensations in the head, spreading to the forehead and eye sockets.

The development of migraine is often observed, which can last from 2-3 hours to several days. Rare manifestations of the pre-hemorrhagic period of development of subarachnoid hemorrhage include epileptic seizures of unknown origin, decreased visual acuity or even loss of individual visual fields, and also dysfunction of nearby nerves, including in the form of diplopia, facial hemispasm, etc.

The hemorrhagic period, that is, the actual development of subarachnoid hemorrhage, has a number of characteristic symptoms. First of all, it should be noted that in approximately 95% of cases, such a violation of the blood supply to the brain develops rapidly. With spontaneous subarachnoid hemorrhage, patients experience:

• sharp intense pain in the head;
• burning sensation in the head;
• nausea;
• vomit;
• epileptic seizures;
• bradycardia;
• slow breathing;
• increased body temperature;
• meningeal symptoms;
• short-term loss of consciousness;
• prolonged loss of consciousness, passing into coma;
• paresis;
• speech disorders;
• memory disorders;
• mental disorders;
• visual impairment.

IN The severity and range of symptomatic manifestations largely depend on the location of the blood vessel rupture. As subarachnoid hemorrhage progresses, in the vast majority of cases there is a release of adrenaline into the blood, which increases blood pressure and can lead to re-bleeding, so people who survive this condition remain at an increased risk of recurrence for the next 2 weeks. The consequences of the development of subarachnoid hemorrhage can be very diverse, and some of them are reversible, while others are irreversible.

The consequences of this pathological condition can have very different intensities and depend on how extensive the bleeding was, how long the ischemia of brain tissue lasted, and in addition, the age of the patient and other factors.

The most unfavorable outcome is the death of the patient due to prolonged oxygen starvation of the brain, and in addition, disruption of the functioning of the separated systems due to the saturation of brain tissue with blood.

Patients often experience a lot of discomfort associated with the loss of certain functions, and in addition, undergoing a long course of rehabilitation.

Diagnosis of subarachnoid hemorrhage

Modern diagnostic methods make it possible to accurately detect cerebral hemorrhage. When the first signs of subarachnoid hemorrhage appear, the patient must be immediately taken to medical institution. To confirm the diagnosis, collecting an anamnesis is not enough, especially since often upon arrival of an ambulance the patient is already in an unconscious state and cannot independently determine the nature of the symptoms present.

First of all, to identify the problem, a lumbar puncture is performed, which involves taking cerebrospinal fluid, that is, cerebrospinal fluid, from the spinal canal. Often, even when collecting cerebrospinal fluid, it is immediately possible to determine that hemorrhage is occurring. The thing is that normally the cerebrospinal fluid is transparent, while with subarachnoid hemorrhage some of the blood cells enter the cerebrospinal fluid, so it becomes pink or red.

Hemorrhagic stroke with subarachnoid bleeding is quite common, so for a full diagnosis, computed tomography should be performed. Computed tomography allows you to assess the prevalence of blood in the subarachnoid space, determine the appearance of parenchymal and ventricular components of hemorrhage, the presence of dislocation and cerebral edema, and others possible pathologies accompanying the development of subarachnoid hemorrhage. An angiographic study allows you to make a more accurate prognosis regarding the possibilities of recovery.

Treatment of subarachnoid hemorrhage

Treatment of patients with severe subarachnoid hemorrhage is carried out in the neurosurgery department or in intensive care, depending on the general condition. Causes of subarachnoid hemorrhage, as well as parameters such as the degree of damage circulatory system and brain tissue, the patient’s age largely determine the strategy for treatment and rehabilitation measures.

First of all, brain shunting may be prescribed to reduce intracranial pressure. Among other things, diuretins and vasodilators are prescribed. Diuretics are an excellent preventative against cerebral edema, while vasodilators help prevent the formation of blood clots. In some cases, patients may undergo therapeutic lumbar punctures, which can reduce intracranial pressure, but this remedy is used only if the first procedure performed has brought the patient significant relief from headaches.

Hemostatic therapy and elimination of the source of bleeding using minimally invasive surgical means allows the restoration of normal blood supply to the brain within 5-7 days. Next, a course of rehabilitation is required, which can take more than 6 months, and it is not always possible to completely restore lost functions. To prevent this from happening, prevention of subarachnoid hemorrhage is necessary.

Subarachnoid hemorrhage is an independent form of hemorrhagic stroke, which affects on average every 15 people out of 100 thousand and accounts for approximately 10% of the total number of all cerebrovascular pathologies. Subarachnoid hemorrhage in the brain is an outpouring of blood into the subarachnoid (subarachnoid) space, which occurs for reasons belonging to two etiological groups. In any case, it is a pathological process, accompanied by sharply negative symptoms and, like any type of hemorrhagic stroke, poses an immediate threat to human life and health.

Irritation of the pia mater, which occurs as a result of hemorrhage into the subarachnoid space, leads to vasospasm, which can cause a transient ischemic attack or ischemic stroke, as a consequence of ischemia of certain areas of the brain. The expansion of the subarachnoid spaces, which occurs due to the effusion of blood, leads to an increase in intracranial pressure, further increasing the manifestation of stroke in subarachnoid hemorrhage. There are high risks of developing a negative scenario, which can lead to death due to cerebral edema or blood flow into the spinal artery, when cerebral vasospasm and neuronal death occurs.

Modern medicine distinguishes two main groups of causes that contribute to the occurrence of damage and the development of the pathological process. Spontaneous subarachnoid hemorrhage occurs as a result of spontaneous hemorrhage into the subarachnoid space, which occurs due to a violation of the integrity of the cerebral vessels or rupture of an aneurysm. Damage to blood vessels or rupture of an aneurysm during subarachnoid hemorrhage usually becomes a natural consequence of chronic or acute pathological lesions human body. The most common causes of spontaneous subarachnoid hemorrhage include:

• cerebral vascular lesions due to atherosclerosis;
• mycotine aneurysm;
• arteriovenous malformation;
• hemorrhagic diathesis;
• rupture of an aneurysm of the superficial vessels of the brain;
• acute leukemia;
• nodular periarthritis;
• vascular damage in hypertension;
• coarctation of the aorta;
• congenital anomalies of the development of vascular complexes of the brain.

The causes of subarachnoid hemorrhage may lie in any pathological process that occurs with disruption of the normal functioning of the circulatory system or metabolic system, leading to vascular damage.

Treatment of subarachnoid hemorrhage caused by pathological processes should be accompanied by the simultaneous elimination of the main agent that provoked the occurrence of the pathology. In approximately 1/5 of all cases, it is not possible to establish the true cause of the lesion, resulting in subarachnoid hemorrhage. But there are risk factors that can trigger its appearance. These usually include alcoholism, smoking, hypercholesterolemia, hypertension and atherosclerosis. Spontaneous lesions of the subarachnoid space in adults almost always arise as a result of hemodynamic influence on the defective aortic wall.

Damage to the aortic wall in an adult can cause any condition that is considered to be the cause of the disease.

In a newborn, the occurrence of pathology is most often associated with birth trauma. Traumatic subarachnoid hemorrhage manifests itself in infants on days 2–3 in the form of meningeal and hypertensive-hydrocephalic syndromes and focal symptoms. Hemorrhage in newborns, not associated with congenital disorders of the structure of the circulatory system, is classified as brain lesions of traumatic etiology and is associated with the consequences of pathological passage through the birth canal. In adults, the second type of subarachnoid cerebral hemorrhage, the causes of which relate to injuries of various types, has a much wider range of causes.

Traumatic SAH is always based on expansion of the subarachnoid space caused by traumatic brain injury, the course of which can be complicated by polytrauma associated with lesions of other organs.

Classifications and symptoms

There are several classifications of SAC, which are based on a distinction based on different characteristics. According to the degree of prevalence of the condition, SAH is usually divided into:

• occurring within one lobe (limited);
• affecting more than one lobe (extensive, massive);
• accompanied by multiple lesions (multiple).

The predicted consequences largely depend on the location or extent of the lesion that occurs. The rate of development determines the differentiation into acute and subacute (the latter develop within 24 hours). The localization of the lesion became the reason for the emergence of a gradation of SAH according to the place of origin of the pathology (convexital, basal and spinal). This division makes it possible to determine the cause of the occurrence. Thus, basal subarachnoid hemorrhage becomes a consequence of bleeding from the basilar artery. Another distinction - into aneurysmal and non-aneurysmal - highlights the presence or absence of one of the most common causes.

Lesions of the subarachnoid space are also differentiated according to the severity of the condition. The Hess and Hunt scale identifies 5 types of severity of the condition. The World Federation of Neurological Surgeons uses the Glasgow Coma Scale and evaluates focal neurological deficits measured in points. In domestic medicine, the Fisher scale is more often used, which grades the diagnosis of subarachnoid hemorrhage based on the results of a CT study. The main thing in this scale is the size of the lesion, in which the first level is not visualized, and the 4th is expressed by intraventricular hemorrhages (or parenchymal hemorrhage was a consequence of their appearance). The Fisher scale, modified by Claassen, which is now based on computer visualization of visible lesions, marks massive parenchymal conditions by extent, regardless of their thickness. And the other two types - 2nd and 3rd - are distinguished by tomography by the thickness of the layer. The size and nature of assistance for subarachnoid hemorrhage is determined by the treatment protocol immediately after assessing the condition and making a diagnosis, taking into account existing boundaries.

Symptoms of subarachnoid hemorrhage in the early stages are cerebral in nature, regardless of the etiology and location, and represent the presence of a typical pattern for many lesions rather than an atypical one:

• headache;
• nausea, vomiting;
• photophobia;
• convulsions;
• stiff neck;
• often a characteristic pose with the head thrown back;
• increase in temperature;
• presence of blood in the cerebrospinal fluid.

The more the process expands, the more characteristic the symptoms are, and by the presence of certain signs one can judge not only the localization and intensity of the hemorrhage, but also the involvement of other organs and systems in the process. The presence or absence of blood in the cerebrospinal fluid during subarachnoid hemorrhage serves not only as a sign of an existing lesion, but also as a marker by which the course of the extended stage or the absence of relapse in a condition that has already been treated is determined. An increase in the degree of manifestation of previously insignificant signs indicates the development of complications, the transition from the pre-hemorrhoidal stage to the hemorrhoidal stage, and the characteristic clinical picture manifests itself depending on the location of the ruptured aneurysm or due to distinctive features disease that caused SAH.

The consequences depend not only on the localization and extent of the pathological process, but also on how timely it was diagnosed and what treatment was received.

Diagnosis and treatment

Treatment of subarachnoid hemorrhages takes a long and complex period of time. The treatment protocol and individual prescriptions are determined general condition the patient's body. Diagnosis using computed tomography begins after the doctor assesses the patient's condition during a visual examination. A CT study makes it possible to determine several parameters at once:

• the presence or absence of cerebral edema;
• direct localization;
• state of the liquor system.

CT angiography is a highly accurate study that reveals the location where the bleeding occurred. Lack of imaging warrants a lumbar puncture and cerebrospinal fluid examination. Vascular angiography using a contrast agent is performed if it is determined that the cause of SAH is a ruptured aneurysm. It is important to take the patient to the hospital as soon as the first symptoms appear. Rehabilitation and its possible completeness or partiality depend entirely on how early the hemorrhage began to be treated. A complete and professional diagnosis can give an idea of ​​both the intensity of the ongoing process and what the possible consequences will be.

Treatment in the early stages includes measures to normalize and stabilize the condition, surgical intervention to eliminate the consequences of bleeding and possible negative influence consequences of blood breakdown. In parallel with this, therapeutic measures are carried out aimed at eliminating possible consequences, one of which may be a hemorrhagic stroke. The fight against cerebral edema, high intracranial pressure, possible ischemia of nervous tissue is carried out, the state of the cardiovascular and nervous system is stabilized, and biochemical blood parameters and water-electrolyte balance are maintained at the proper level.

Further tactics of treatment and rehabilitation depend on the degree of damage and the stage at which the process of stopping the subarachnoid hemorrhage that occurred began. These same factors determine the possible consequences.

Negative consequences and ways to prevent them

Even if diagnosed at the earliest stage of its course and treated in time, SAH can be extremely negative consequences. The patient has to take antihypertensive drugs to prevent arterial hypertension, antifibrinolytic medications to prevent recurrence of hemorrhage. A quarter of patients become disabled, which is accompanied by loss of intelligible speech functions and control of the musculoskeletal system.

Hemorrhagic stroke, which often results from cerebrovascular accidents, can turn into a brain catastrophe. The reasons that caused subarachnoid bleeding can, in its repeated course, provoke hemorrhage in any other part of the brain, causing a hemorrhagic stroke, which is also accompanied by vascular breakthrough. Only this time the hemorrhage occurs in the brain and causes irreversible damage.

Hemorrhagic stroke, which developed against the background of a complicated course of SAH, its relapse, or the appearance of cerebral bleeding in another area, is one of the most severe possible complications, which only occur in the brain. In 85% of cases, hemorrhagic stroke occurs against the background of the same factors that caused subarachnoid hemorrhage: arterial hypertension, high blood pressure, impaired vascular integrity, atherosclerosis, blood diseases and inflammatory processes in cerebral vessels.

How less attention A person pays attention to his health, the higher his risk of diseases accompanied by cerebrovascular accidents. Only timely examinations preventive measures, proper nutrition And healthy image life can prevent the occurrence chronic diseases, destructuring blood vessels and leading to severe complications.