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Subarachnoid hemorrhages and intracranial aneurysms. Why does it appear and what are the consequences of subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a form of hemorrhagic stroke.

With it, blood enters the subarachnoid space of the brain.

This condition occurs spontaneously or as a result of traumatic injury.

Hemorrhage in the subarachnoid space (the gap between the meninges) in most cases occur spontaneously. At the same time, the person feels a sudden headache and nausea. Some people start vomiting, others faint.

Subarachnoid hemorrhage occurs due to complete rupture of blood vessels or partial rupture of the cerebral artery... This is caused by various pathological processes, most often - aneurysms () and traumatic lesions.

Blood accumulates in the region of the basal cisterns, so the disease can be called basal subarachnoid hemorrhage. The ruptured aneurysm causes blood begins to flow into the cerebrospinal fluid... In this case, a pronounced spasm of the arteries of the brain is observed, its edema develops, and neurons begin to die.

The prevalence of the disease and the stages of its development

Among all forms of circulatory disorders in the brain, SAH occurs in 1-7% of cases... Spontaneous subarachnoid hemorrhage occurs in 8-12 people out of 100 thousand annually. Its traumatic form is more common. Depending on the situation, the incidence of subarachnoid hemorrhage in traumatic brain injury varies from 8 to 59%.

Older patients are more likely to develop this condition. Also a risk factor is the state of alcohol intoxication.

Almost 85% of cases occur due to rupture of the cerebral arteries, which are located in the circle of Willis. About half of subarachnoid hemorrhages are fatal. Of them 15% of patients do not have time to get to the hospitalhospitals.

Allocate 3 stages of development traumatic subarachnoid hemorrhage.

  1. The blood that has entered the subarachnoid space begins to spread through the cerebrospinal fluid canals. In this case, the volume of cerebrospinal fluid increases and intracranial hypertension develops.
  2. In the cerebrospinal fluid, blood begins to coagulate, clots are formed. They block the cerebrospinal fluid pathways. As a result of this condition, cerebrospinal fluid circulation is disturbed, and intracranial hypertension begins to increase.
  3. Dissolution of blood, which is clotted, is accompanied by the appearance of a meningeal syndrome and signs of the onset of aseptic inflammation.

Classification of severity of conditions

Doctors use three methods to assess the severity of a lesion. When classified according to Hess and Hunt, 5 levels are distinguished:

  • Asymptomatic or minor manifestations in the form of mild headache and stiff neck. The survival rate in this condition is 70%.
  • Moderate or severe pain, severe stiffness of the muscles of the back of the head, paresis of the nerves of the skull. The chances of survival do not exceed 60%.
  • Neurological deficit in minimal manifestations, stunning. Only 50% of patients survive.
  • Soporous state, manifestations of moderate or severe hemiparesis, autonomic disturbances, signs of decerebration rigidity. The probability of surviving does not exceed 20%.
  • Agony, deep coma, decerebral rigidity. In this condition, 90% of patients die.

Fisher scale, modified by Klaassen et al., is based on the results of computed tomography. On it, 4 degrees of damage are distinguished:

  • The first level is assigned when the hemorrhage is not visualized.
  • The second level is when the thickness of the lesion is less than 1 mm.
  • At the third level, the thickness exceeds 1 mm.
  • The fourth level of SAH is diagnosed in cases when intraventricular hemorrhages are visualized or their spread to the brain parenchyma, regardless of thickness.

The World Federation of Neurosurgeons uses the Glasgow Coma Scale and evaluates focal neurological deficits:

  • At the 1st level, there is no neurological deficit, according to the GCS 15 points.
  • For the assignment of level 2 according to the GCS, there must be from 13 to 14 points and the absence of neurological deficits.
  • With signs of damage to the central or peripheral nervous system and 13-14 points on the GCS, level 3 is established.
  • The GCS was 7-12 points, the presence of focal neurological deficit is not important.
  • Less than 7 points were assigned for the GCS.

Causes and risk factors

SAH occurs due to violations of the integrity of the walls of the arteries, which pass inside the skull. They are located on top of the cerebral hemispheres or at its base. There are such causes of damage to the arteries:

  • traumatic injuries: craniocerebral trauma, in which a contusion of the brain and damage to the arteries are diagnosed;
  • spontaneous violations of the integrity of the walls;
  • ruptured aneurysms;
  • ruptures of arteriovenous malformations.

In most cases, non-traumatic subarachnoid hemorrhage occurs due to a sudden rupture of an aneurysm in the arteries of the brain.

Specialists include the following risk factors:

  • the use of alcoholic and narcotic drugs;
  • high;
  • infections in which the arteries in the brain are damaged (syphilis).

Clinic: symptoms and signs

Calling an ambulance for subarachnoid hemorrhage is necessary if, against the background of normal health, a person has:

  • headache that worsens with any activity;
  • nausea and vomiting;
  • the appearance of psycho-emotional disorders: fear, drowsiness, increased excitability;
  • convulsions;
  • disorder of consciousness: stunning, fainting or coma appears;
  • the temperature rose to febrile and subfebrile values;
  • photophobia.

The symptoms persist for several days.

Separately, there are signs that arise in violation of the functioning of the cortex and nerves of the brain... This is evidenced by:

  • loss of sensitivity of the skin;
  • speech problems;
  • the appearance of strabismus.

A few hours after the outpouring of blood, symptoms of meningitis appear:

  • kernig's sign (a person cannot straighten a leg that was bent at the same time at the knee and hip joints);
  • stiff neck muscles (the patient does not reach the neck with the chin).

Traumatic subarachnoid hemorrhage in traumatic brain injury requires monitoring the appearance of signs of damage to different brain areas.

About problems with frontal lobe will testify:

  • speech disorder;
  • cramps in the fingers;
  • wobbly gait;
  • speech disorders;
  • changes in behavior.

On defeat temporal lobe hearing loss, memory impairments, auditory hallucinations and tinnitus appear.

Impaired reading ability, loss of tactile sensations, the ability to navigate indicates problems in parietal lobe.

Damage occipital lobe manifested by visual impairment and the appearance of visual hallucinations.

Diagnostics and first aid

The doctor evaluates the patient's condition and prescribes computed tomography. With CT:

  • the area where the outpouring of blood occurred;
  • data on the cerebrospinal fluid system is obtained;
  • it is checked whether there is cerebral edema.

High precision allows you to find out where source of bleeding... Negative CT results are associated with insignificant hemorrhage volumes. They also happen when diagnostics are carried out at a later date.

When negative results are obtained, appoint lumbar punctureand examination of cerebrospinal fluid. An increasing concentration of erythrocytes testifies to SAH.

If the disease has arisen due to aneurysm, then angiography of vessels... A radiopaque substance is injected into them and X-rays are taken. Endovascular surgery is performed on the damaged areas.

First aid is aimed at stabilizing the patient's condition. You need it take to the hospital at the first symptoms.

Treatment is carried out to stop bleeding and eliminate its source. It is important to prevent the development of complications and the occurrence of relapses.

Treatment tactics

Patients with SAH are immediately prescribed drugs that normalize intracranial and arterial pressure ... If the patient is unconscious, the trachea is intubated and a ventilator is connected.

People with massive hemorrhages are given emergency operations to extract hemorrhagic contents... The rest are treated with therapy, which should reduce the risk of re-bleeding.

The doctor has the following tasks:

  • achieve state stabilization;
  • prevent relapses;
  • normalize homeostasis;
  • minimize the manifestations of the disease that led to the defeat;
  • to treat and prevent vascular spasms and cerebral ischemia.

Anesthesia to patients is carried out with such means that give minimal sedation. This allows them to control their minds.

Checking the water balance and assessing kidney function are carried out using a urinary catheter. People with SAH are fed using a nasogastric tube or parenterally. Compression garments help prevent venous thrombosis.

If the cause of the disease is aneurysm, then during angiography can clip a problem vessel or clog it.

Also spend symptomatic treatment:

  • patients who develop seizures are prescribed anticonvulsants;
  • people with cerebral edema are given diuretics;
  • with repeated vomiting, give antiemetics.

Rehabilitation procedures

With the help of timely and adequate treatment, many seek to normalize the condition after cerebral hemorrhage. Recovery lasts at least 6 months.

Full rehabilitation is impossible without daily medication, monitoring of the condition in dynamics and constant visits to a neurologist.

The patient should completely stop smoking, alcohol, drugs, try to minimize stress and start a quiet life.

Expected prognosis and possible complications

The consequences of subarachnoid hemorrhage in the brain depend on the reasons that caused it, and how quickly the patient was hospitalized, how adequate the treatment was. The age of patients and the profusion of bleeding affects the prognosis.

The most serious complication of subarachnoid cerebral hemorrhage is vasospasm. This vasospasm leads to ischemic brain damage. In severe cases, death is possible. Delayed ischemia manifests itself in 1/3 of patients, half of them develop irreversible neurological deficits.

Prevent the development of vasospasmallows the introduction of calcium channel blockers. But for traumatic injuries, such drugs are not used.

Other consequences also arise:

  • Relapse. It happens both in the early period and after a certain period of time.
  • Hydrocephalus - Cerebrospinal fluid accumulates in the ventricles of the brain. It occurs in the early and remote periods.
  • Pulmonary edema, ulcerative bleeding, myocardium. These complications are rare.

Among the long-term consequences are called:

  • violation of attention;
  • memory problems;
  • fatigue;
  • psycho-emotional disorders.

People after SAH often complain of headaches, sometimes pituitary and hypothalamic hormonal regulation is impaired.

Preventive measures to prevent relapse

To minimize the negative consequences, it is necessary to remember how the prevention of subarachnoid hemorrhages is carried out:

  • Good nutrition, in which large quantities of fruits and vegetables enter the body, reduces the amount of fatty and fried foods.
  • Refusal from drugs, alcohol, cigarettes.
  • Gradually entering a moderate load (swimming, walking, jogging).
  • Regular walks.
  • Monitoring blood pressure (find out) and blood glucose concentration.

These preventive measures reduce the risk subarachnoid hemorrhage.

Timely diagnosis and treatment allow patients to recover... But the negative consequences of subarachnoid hemorrhage, which are life-threatening, occur in 80% of patients. The use of preventive measures will help prevent this.

This video presents a lecture on the treatment of subarachnoid hemorrhage:

Subarachnoid hemorrhage is a diagnosis that shocks both the patient suffering from such an ailment and his friends and relatives. Like any pathological process in the brain, the disease has a dangerous etiology for human health, can threaten not only loss of capacity, but also death.

In this article, we will talk about the features of the disease, its root causes and symptoms, the knowledge of which will help to seek medical help in time, and also consider the specifics of diagnosis, therapy and rehabilitation of the disease, effective ways to prevent it.

Features of the disease

To understand what a subarachnoid cerebral hemorrhage is, a small excursion into physiology, namely, into the structure of the hemisphere cover, will help. Physiologically meninges consists of three balls:

  • external, solid configuration;
  • medium, spider type;
  • internal, which is a vascular cover.

There is space between all the balls: the zone between the first two balls is called subdural, and the area between the vascular and middle membrane is called subarachnoid.

In a normal state, all membranes have an integral structure, which provides protection for the hemispheres and normal brain activity. A precedent in which, due to difficulties in blood circulation, vascular spasms or traumatic events, an outpouring of blood into the subarachnoid zone occurs, is identified as subarachnoid. Subarachnoid hemorrhage, abbreviated as SAH, can also be referred to as intracranial bleeding or stroke.

Hemorrhage of the subarachnoid type is often characterized by spontaneity, occurs against the background of a segmental or large-scale rupture of the cerebral blood vessels, accompanied by sharp and intense headaches, bouts of vomiting, and loss of consciousness. This is a very dangerous condition, often causing a sudden death for a patient, and the chances of saving a person directly depend on the promptness of first aid and the intensity of filling the subarachnoid zone with blood.


Causes of the outpouring

Help for the progression of pathology is the violation of the tightness of the walls of the vascular lines of the hemispheres. The causes of subarachnoid hemorrhage can have different etiologies, mainly as follows:

  1. Complex head injuries, which are accompanied by craniocerebral trauma, brain contusions, or direct rupture of arteries in the hemispheres.
  2. An unexpected rupture of the artery wall, which can be triggered by infectious diseases, a rapid increase in pressure, and also occur as a result of the use of alcoholic beverages or drugs.
  3. Deformation of vascular malformation.

Symptoms of pathology

Often, the progression of pathology begins to make itself felt to a person with unpleasant symptoms with its etiology of a neuralgic nature a few days before the start of a massive effusion. During this period, thinning of the vessel wall is characteristic, through which blood begins to seep in small volumes. This condition is accompanied by nausea and dizziness, visual impairment. In the absence of timely diagnosis and adequate treatment, the disease progresses, one or more vessels rupture, blood begins to intensively fill the subarachnoid segments of the brain. Traumatic subarachnoid hemorrhage may be accompanied by similar symptoms, if the head contusion is not characterized by particular intensity.

Symptoms for extensive bleeding are pronounced, accompanied by sharp, explosive pains of a diffuse type in the head region, followed by irradiation to the shoulders, neck and occipital region. Subarachnoid brain hemorrhage of a progressive type is often accompanied by nausea with bouts of vomiting, photophobia, impaired consciousness, often with fainting precedents and coma. The period from the beginning of a massive effusion to coma can range from several minutes to half a day.

In newborns, subarachnoid hemorrhage is mainly a consequence of traumatism during childbirth, characterized by the formation of hematomas in the hemispheres. Cerebral effusion of blood in newborns is accompanied by the following symptoms:

  • shrill, intense crying of the child against the background of increased physical activity;
  • convulsive attacks;
  • lack of sleep;
  • involuntary eye movement, visual squint;
  • extreme severity of congenital reflexes;
  • increased muscle tone;
  • bulging fontanelle with intense pulsation;
  • jaundiced body shade.


Symptoms of pathology in a newborn can appear both immediately after birth and within several days, depending on the scale of the outpouring into the hemispheres. With timely identification of the problem, modern medicine allows you to reanimate a child, in most cases without negative consequences for his later life.

The prevalence of the disease and the stages of its progression

Precedents associated with SAH of the brain are quite common. According to statistics, the most common are the cases of subarachnoid effusion against the background of injuries, accounting for about sixty percent of all cases.

Less common are precedents of the development of pathology due to changes in blood circulation in the cerebral vessels, diagnosed in seven percent of patients with this pathology. Most often these are patients of solid and retirement age, as well as people with alcohol or drug addiction. The most rare are the precedents of spontaneous progression of the disease, their prevalence is less than one percent.

As for the etiology of the disease, the most common situations in medical practice are the occurrence of SAH due to rupture of arteries located in the vizillian circle. About eighty-five percent of all registered cases fall to the share of such precedents, half of them are fatal, while fifteen percent of patients do not even have time to get to a medical facility.

Cerebral hemorrhage is a disease that most often affects the adult population, however, the children's category is no exception. In children, this pathology often occurs against the background of trauma. Subarachnoid hemorrhage in newborns can be the result of protracted or too rapid natural childbirth, with a discrepancy between the birth canal of the mother and the head of the child, as well as a consequence of a long stay of the baby without oxygen. Infectious diseases of the mother, pathologies of brain activity in the baby of the congenital category, and fetal hypoxia can provoke the progression of pathology in a child.


Medicine classifies SAH of traumatic origin into three stages of development:

  1. The progression of intracranial hypertension against the background of mixing the outflowing blood with the cerebrospinal fluid, increasing the latter in volume.
  2. Increase in hypertension of the hemispheres to maximum maxima, due to the formation of blood clots in the cerebrospinal fluid canals, their blockage and impaired circulation of cerebrospinal fluid.
  3. Dissolution of blood clots, with the subsequent intensification of inflammatory processes in the hemispheres.

Disease severity classification

To assess the severity of a patient's condition, medical specialists use three methodologies for ranking the course of pathology.

The Hunt-Hess scale for categorizing the patient's condition is most often used in practice, which has five degrees of human brain damage:

  1. The first degree of the disease is considered the least life-threatening with the timely initiation of therapy, is characterized by a high percentage of patient survival. At this stage, the disease has an asymptomatic course with minor headaches and the onset of stiff neck muscles.
  2. The second degree of the disease is characterized by a distinct loss of mobility of the occipital muscles, intense headaches, paresis of the nerves of the hemispheres. The prospects for a favorable outcome do not exceed sixty percent.
  3. The third degree of the disease is manifested for a person by a moderate deficiency of the neuralgic category, stunning. The patient's chances of survival do not exceed fifty percent.
  4. The fourth level of pathology is characterized by a stopping state of the patient; a first degree coma may occur. Disruptions of the autonomic system, severe hemiparesis are typical for this stage. The chances of life are about twenty percent.
  5. The last degree of progression: coma of the second or third level. The forecasts for the patient are disappointing, the survival rate is no more than ten percent.

The second, no less popular in medical practice for assessing the patient's condition, is the Fisher gradation, which is based on the results of computed tomography:

  1. If during the examination by the CT method, the effusion of blood is not visually determined, the disease is assigned the first degree of severity.
  2. The second stage is assigned to pathology if the scale of the effusion does not exceed one millimeter in thickness.
  3. With a lesion size of more than one millimeter, the third level of pathology progression is diagnosed.
  4. With the spread of blood inside the ventricles and in the parenchyma, the fourth degree of SAH progression is diagnosed.


The SAH severity scale according to the World Federation of Neurosurgeons ranks the disease as follows:

  1. The first stage - fifteen points on the GCS, no neurological deficit.
  2. The second level is from thirteen to fourteen points, with no neurological impairment.
  3. The third level - the scores are similar to the previous version, with signs of disorders from the nervous and peripheral systems.
  4. The fourth stage of progression - on the Glasgow coma scale, was assigned from seven to twelve points.
  5. The last stage of the disease: the GCS was diagnosed with less than seven points.

Diagnosis of pathology

Subarachnoid hemorrhage belongs to the category of the most difficult and life-threatening precedents. Its diagnosis involves a complex of hardware examinations of the patient in order to confirm the diagnosis, as well as determine the stage of development, localization of hemorrhage, the degree of disorders in the vascular system and hemispheres.

The main examination procedures include:

  1. Initial examination of the patient, analysis of his complaints.
  2. Visual assessment of a person's condition, monitoring of his consciousness and the presence of neurological abnormalities.
  3. A laboratory blood test, with which you can determine the criteria for its coagulation.
  4. Puncture of the cerebrospinal fluid. If about twelve hours have passed since the beginning of the hemorrhage, according to its results, namely the presence of blood in the cerebrospinal fluid, it is possible to confirm the progression of SAH.
  5. or cT scan allows you to identify the presence and localization of effusion, as well as assess the general state of the brain. CT is more informative in the situation with SAH, therefore this type of study is often prescribed to patients.
  6. If there is a suspicion of displacement of the brain as a result of trauma, an echoencephalography is prescribed, which allows you to confirm or deny this fact.
  7. Doppler ultrasonography of the transcranial type is performed to monitor the quality of blood flow in the cerebral arteries, its deterioration as a result of narrowing of the bloodstream.
  8. Magnetic resonance angiography of the arteries helps to assess their integrity and patency.

Based on the results of the study, the patient will be diagnosed in accordance with the International Classification of Diseases of the tenth revision. SAH is included in the section "Diseases of the circulatory system", a subgroup of cerebrovascular ailments, may have an ICD-10 code from I160.0 to I160.9, depending on the localization of the source of the effusion.

Treatment methods

The methodology of pathology therapy provides for both drug treatment and surgical intervention, depending on the stage of the disease and its complexity. The expediency of the therapy and its direction can be determined only by a qualified specialist solely on the basis of the diagnostic results. Primary measures should be focused on stopping bleeding, stabilizing, preventing or reducing the volume of cerebral edema.

First aid

First aid for subarachnoid hemorrhage does not provide for any specific procedures, it consists in calling an "ambulance" without delay. It is strictly forbidden to give the patient any medications to eliminate symptoms, as this can cause unpredictable consequences.

If a sick person has an epileptic seizure, it is necessary to try to create comfortable conditions for him by placing soft things under his head and other parts of the body. After the end of the seizure, you need to put the sick person on one side, try to fix the limbs and wait for the ambulance to arrive.

When a person is unconscious as a result of cardiac arrest, it is necessary to resuscitate the cardiopulmonary type, with the proportion of pressing on the thoracic region to breaths of thirty to two.

When pouring out into the hemispheres, the only rational help to the patient is his hospitalization as soon as possible. All restorative and therapeutic procedures are subsequently carried out exclusively under the guidance of specialists, based on the results of diagnosing the patient's condition.

Drug treatment

Conservative therapy can be applied in situations where there are no indicators for surgical intervention, as well as to normalize the patient's condition in the preoperative and postoperative period.

The main objectives of the drug treatment of subarachnoid hemorrhage are:

  • achieving stability of the patient's condition;
  • avoidance of relapses;
  • stabilization of homeostasis;
  • elimination of the original source of the outpouring;
  • carrying out medical and preventive measures focused on prevention.

Depending on the complexity of the disease and its manifestations, the patient may be prescribed the following drugs:


The feasibility, dosage and duration of taking drugs are determined exclusively by the attending doctor, based on medical indicators. In the course of treatment, the doctor monitors the dynamics, can change the quantitative and qualitative composition of drugs in the absence of positive results.

Surgery

Surgical intervention is often provided for by medicine if there are significant intracranial hematomas or if SAH occurs as a result of a serious head injury. In a situation where the patient has massive bleeding, emergency surgical procedures are performed. In other cases, the timing of the operation may vary and depend on the condition and age of the patient, the amount of effusion and the complexity of the symptoms.

Medicine provides the following types surgical intervention with subarachnoid effusion:

  1. Removal of hemorrhagic contents by inserting a syringe or a specific needle.
  2. Elimination of hematoma with opening of the cranium.
  3. Laser coagulation of blood vessels, if the effusion cannot be stopped with medications, sometimes with the imposition of specific clips on the damaged areas of the artery.

After the surgical intervention, the patient will have to undergo a compulsory course of drug therapy.

Rehabilitation procedures

Measures to restore the patient after subarachnoid hemorrhage are a mandatory continuation of therapy in the postoperative period. Depending on the complexity of the illness suffered, rehabilitation can last from six months to several years, has a complex structure.

It is important for a patient after a precedent to completely abandon bad habits, try to avoid stressful situations and maintain a healthy lifestyle. In addition, during the rehabilitation period, medicine provides for the intake of medications, the action of which is aimed at preventing relapse.

Rehabilitation of a patient, depending on the severity of the experienced illness, may include the following areas:

  • specific massages and hardware procedures to restore the patient's muscle and motor activity;
  • wellness procedures in special centers;
  • remedial gymnastics to restore walking and coordination skills;
  • classes with a psychologist to restore the patient's psycho-emotional state.


In the process of recovery at home, the patient will need proper care, as well as the support of relatives and friends.

Prognosis and possible complications

Subarachnoid hemorrhage of the brain is an insidious ailment that very rarely passes without a trace for a person. The most harmless are complications in the form of frequent migraines and disorders of hormonal regulation of the body. In addition, after a past illness, the patient may experience a deterioration in brain activity, manifested in the form of psychoemotional disorders, impairment of attention and memory. However, such manifestations of the body after SAH are not considered particularly dangerous. Dangerous consequences include:

  • vasospasm, which often provokes ischemic processes in the hemispheres;
  • delayed ischemia, which affects more than a third of all patients, entails irreversible starvation of the brain with all the ensuing consequences;
  • recurrent exacerbation of pathology;
  • hydrocephalus;
  • rare complications include pulmonary edema and heart attacks.

The chances of a patient recovering after SAH depend on many factors, such as the general physical health of a person, his age, the stage of the disease and the extent of the effusion, and the promptness of providing first aid.

Often, it is the belated appeal to a medical facility against the background of a profuse outpouring that causes death for the patient or serious complications that prevent a person from returning his life to his usual course.

Preventive measures

Prevention of SAH, like many other diseases of the cardiovascular system, is not particularly difficult. The main rule, the observance of which helps to prevent cerebral hemorrhage, in addition to precedents with injuries, is a healthy lifestyle. Rational nutrition, rejection of bad habits, regular walks in the fresh air and moderate physical activity to maintain the body in excellent condition, timely treatment of vascular and heart problems under the supervision of doctors are the primary and effective preventive measures against the development of SAH and other complex ailments.

If a person has the prerequisites for the development of SAH caused by cardiac problems, it is worthwhile to undergo regular examinations, take prophylactic drugs prescribed by doctors to normalize blood pressure and heart rate, if necessary, and monitor your health.

In this case, it is the attentive attitude to your body and the correct way of life that are the most important preventive measures that help to avoid a complex and life-threatening precedent.

Let's sum up

Hemorrhage of the subarachnoid type belongs to the category of the most dangerous diseases, which are very often the cause of death. Of course, it is better to prevent such situations, however, if such a precedent takes place, it is worth urgently delivering the patient to a medical facility: a person's life depends on the promptness of the diagnosis and the provision of correct assistance.

Lead a full, healthy and correct lifestyle - this will help you avoid many health problems, is the key to the proper functioning of the body, and reduces the risk of developing not only SAH, but also other diseases.

  • Psychomotor agitation.

    With psychomotor agitation, diazepam 10-20 mg IM or IV is prescribed, or sodium oxybutyrate 30-50 mg / kg IV, or magnesium sulfate (Magnesium sulfate) 2-4 mg / hour IV, or haloperidol 5 - 10 mg IV or IV. In severe cases, barbiturates.

    For short-term sedation, it is preferable to use fentanyl 50-100 μg, or sodium thiopental 100-200 mg, or propofol 10-20 mg. For medium-duration procedures and transportation on MRI, morphine 2-7 mg, or droperidol 1-5 mg are recommended. For long-term sedation, along with opiates, sodium thiopental (bolus 0.75-1.5 mg / kg and infusion 2-3 mg / kg / hour), or diazepam, or droperidol (boluses 0.01-0.1 mg / kg), or propofol (bolus 0.1-0.3 mg / kg; infusion 0.6-6 mg / kg / h), to which analgesics are usually added.

  • Adequate nutrition of the patient

    Should be started no later than 2 days from the onset of the disease. Self-feeding is prescribed in the absence of impaired consciousness and the ability to swallow. In case of suppression of consciousness or violation of the act of swallowing, tube feeding is carried out with special nutritional mixtures, the total energy value of which should be 1800-2400 kcal / day, the daily amount of protein 1.5 g / kg, fat 1 g / kg, carbohydrates 2-3 g / kg , water 35 ml / kg, the daily amount of injected liquid is not less than 1800-2000 ml. Tube feeding is performed if the patient has indomitable vomiting, shock, intestinal obstruction or intestinal ischemia.

  • Prevention and treatment of somatic complications

    Somatic complications occur in 50-70% of patients with stroke and are more often the cause of death in stroke patients than cerebral disorders themselves.

    • Pneumonia

      Pneumonia is the cause of death in 15-25% of stroke patients. Most pneumonias in stroke patients are associated with aspiration. Oral nutrition should not be allowed if there is a violation of consciousness or swallowing, there are no pharyngeal and / or cough reflexes. Hypoventilation in pneumonia (and as a result, hypoxemia) contributes to an increase in cerebral edema and depression of consciousness, as well as an increase in neurological deficit. With pneumonia, as with other infections, antibiotic therapy should be prescribed, taking into account the sensitivity of the causative agents of nosocomial infections.

      • violation of coughing,
      • bladder catheterization,
      • bedsores,
      • an increase in body temperature above 37 degrees.
      Also, for pneumonia, the following can be used:
      • Regular aspiration of the contents of the oropharynx and tracheobroncheal tree by electric suction.
      • Turning the patient from the back to the right and left side every 2-3 hours.
      • Use of anti-decubitus vibrating mattresses.
      • Prescription of expectorants.
      • Breathing exercises.
      • Vibration massage of the chest 2-3 times a day.
      • Early mobilization of the patient.

      In severe and moderate pneumonia with an abundant amount of sputum and increasing respiratory failure, it is effective to conduct sanitation bronchoscopy with washing purulent sputum, as well as to determine the sensitivity of microflora to antibiotics as early as possible in order to prescribe adequate antibiotic therapy as soon as possible. See more article Pneumonia

    • Respiratory distress syndrome

      Complicates severe pneumonia. With it, the permeability of the alveoli increases and pulmonary edema develops. To relieve acute respiratory distress syndrome, oxygen therapy is prescribed through a nasal catheter in combination with intravenous administration of furosemide (Lasix) and / or diazepam.

    • Bedsores To prevent the development of bedsores, it is necessary:
      • From the first day, regular treatment of the skin with disinfectant solutions (camphor alcohol), neutral soap and alcohol, dusting the folds of the skin with talcum powder.
      • Rotate the patient every 3 hours.
      • Place cotton-gauze circles under the bone protrusions.
      • Use anti-decubitus vibrating mattresses.
        • Prevention of phlebothrombosis of the lower extremities and pulmonary embolism (PE)
          • Prevention of phlebothrombosis and pulmonary embolism in stroke begins from the first day of admission of the patient to the hospital, if it is clear that he will be immobilized for a long time (i.e., in the presence of severe paralysis of the limbs, the serious condition of the patient).
          • From the first day it is necessary to carry out bandaging with an elastic bandage of the legs to the middle of the thigh, or the use of periodic pneumatic compression, or the use of stockings with graduated compression, raising the legs by 10-15º.
          • After 3 - 4 days from the onset of cerebral hemorrhage, with confidence that the bleeding has stopped (i.e., with stabilization or regression of symptoms, the absence of data for an increase in hemorrhage in size with repeated CT), patients with hemiplegia and severe patients with depression consciousness is prophylactically prescribed:
          • Patients with cerebral hemorrhage and acute pulmonary vein thrombosis (PE) are potential candidates for a cava filter. When deciding on the need for long-term antifibrinolytic therapy several weeks after the installation of the cava filter, it is necessary to take into account the cause of the hemorrhage (amyloidosis (high risk of repeated hemorrhage) compared with hypertension), the presence of diseases in the patient with a high risk of arterial thrombosis (such as atrial fibrillation) , patient mobility.
          • For prophylactic purposes, passive and, if possible, active "walking in bed" is shown with bending of the legs, emitting walking for 5 minutes 3-5 times a day.
        • Prevention of contractures in the limbs

          Passive movements from the 2nd day (10 - 20 movements in each joint after 3 - 4 hours, rollers under the knees and heels, slightly bent leg position, early mobilization of the patient (in the first days of the disease) in the absence of contraindications, physiotherapy.

  • Specific therapy for cerebral hemorrhage

    Specific pathogenetic therapy (aimed at stopping bleeding and lysis of a thrombus) of cerebral hemorrhage as such is currently absent, with the proviso that maintaining optimal blood pressure (described in basic therapy) and surgical means of evacuating hematomas are pathogenetic methods of treatment. Specific methods also include neuroprotection and reparative therapy.

    Neuroprotection, antioxidant and reparative therapy are promising areas in the treatment of stroke that require development. Drugs with the indicated effects are used in the treatment of strokes, but currently there are practically no drugs with proven efficacy in terms of functional defect and survival, or their effects are under study. The prescription of these drugs is largely determined by the personal experience of the doctor.

    A number of drugs are used for the purpose of neuroprotection and recovery. 200 mg 2 times a day inside.

  • Features of the treatment of cerebral hemorrhage due to anticoagulant therapy
    • In case of cerebral hemorrhage as a result of heparin therapy, treatment consists in the rapid normalization of APTT (activated partial thromboplastin time) with protamine sulfate, which is administered intravenously slowly (no faster than 5 mg / min), and the total dose of the drug should not exceed 50 mg. The dose of protamine sulfate is calculated based on the time elapsed since the last injection of heparin. If this time is within 30 - 60 minutes after the last injection of heparin, then the dose of protamine sulfate is 0.5 - 0.75 mg per 100 IU of heparin, 60 - 120 min - 0.375 - 0.5 mg of protamine sulfate per 100 IU of heparin and\u003e 120 min - 0.25 - 0.375 mg per 100 IU of heparin.
    • In patients with cerebral hemorrhage associated with warfarin therapy (Warfarex, Warfarin Nycomed), in particular with cardioembolic stroke, the main risk factors are age, arterial hypertension, intensity of therapy, the presence of concomitant cerebral amyloid angiopathy, Binswanger's syndrome. Exceeding the INR of a more therapeutic level of 2.0–3.0 is associated with an increased risk of intracerebral hemorrhage, especially in the 3.5–4.5 range. At an INR of 4.5 or more, the risk of hemorrhage approximately doubles for each increase in INR of 0.5. The first-line drug for the correction of coagulation disorders caused by taking warfarin is vitamin K 1 (Vikasol), which is administered intravenously at a dosage of 10 mg. Since after the introduction of vitamin K 1 it is necessary that at least 6 hours have passed for the INR to normalize, simultaneously with the introduction of vitamin K 1, an intravenous infusion of fresh frozen plasma is performed at a dosage of 15-20 ml / kg of body weight. The negative aspects of the introduction of frozen plasma are a long, several hours, infusion time and the possibility of developing hypervolemia and cardiac dysfunction. As an alternative to the administration of plasma, it is proposed to administer a complex concentrate of prothrombin, a complex concentrate of IX factor, and a recombined activated factor VIIa. These drugs quickly reduce INR and do not have the same hypervolemic effect as plasma. The negative side their use is a high risk of thromboembolic complications.
    • Thrombolysis with tissue plasminogen activator (tPA) in ischemic stroke is complicated by intracerebral hemorrhage in 3-9% of cases. As a rule, these are massive, multifocal hemorrhages, in which the mortality rate in the first 30 days is 60% or more. To date, there is no proven effective specific therapy in such cases. The introduction of platelet mass (6 - 8 doses) and cryoprecipitate is empirically recommended. After sufficient administration of drugs and upon cessation of intracerebral bleeding, the question of surgical removal of the hematoma can be considered, in particular, in the presence of lateral hemorrhage (no deeper than 1 cm from the surface of the cerebral hemisphere) with a volume of more than 30-40 ml in patients in coma.
  • Surgical treatment of intracranial hemorrhage There are a number of surgical approaches to the treatment of intracerebral hemorrhage. Their effectiveness in many cases is in question, and the indications for surgery are under revision and research. Currently, specialized clinics use such surgical methods as:
    • Traditional removal of hematomas by an open method and ventricular drainage (in acute hydrocephalus, it reduces mortality by 30-33%).
    • Hemicraniectomy (with the development of coma due to severe cerebral edema).
    • Stereotaxic and endoscopic removal of hematomas (with the removal of deeply located hemorrhages, mortality is halved compared with conservative management).
    • Stereotactic removal of hematomas by dissolving them with thrombolytics.
    • Local hemostasis with recombinant factor Vila and ventricular thrombolysis ( latest methods are under investigation).

    Methods such as stereotaxic or endoscopic removal of the liquid part of the hemorrhage (with the subsequent possible introduction of urokinase) are theoretically attractive due to the low invasiveness of the access and the possibility of maximum early holding operations. However, there is currently insufficient data to assess the effectiveness of these methods.

    It should be clarified that most surgical techniques the treatment of cerebral hemorrhage is in the research stage, their effectiveness is always obvious and is under periodic revision, and largely depends on the choice of indications, technical capabilities and experience of the surgeons of this clinic.

    Indications for surgery:

    • The earliest possible surgical removal of a hematoma is indicated for patients with cerebellar hemorrhage more than 3 cm in diameter, who have a deterioration of the neurological state or have compression of the brain stem and / or obstructive hydrocephalus.
    • Lobar hemorrhage, located no more than 1 cm from the surface of the cerebral cortex, can be considered for surgical removal through the craniotomy access. The volume of the hematoma should be more than 30-40 ml. At the same time, routine (widespread) removal of supratentorial intracerebral hematomas within 3 days from the onset of stroke through a standard craniotomy approach is not recommended.
    • There is still no sufficient data to formulate recommendations for the use of minimally invasive surgical techniques (in particular endoscopic) to remove blood clot in brain tissue, and the benefits of using such methods are currently unclear.
    • Lateral stroke (according to CT, a hematoma with a volume of more than 40 ml) is considered by some authors as an indication for surgery.
    • Non-traumatic sub- and epidural hemorrhages (stroke-hematomas) with a volume of more than 30 ml are subject to surgical removal.
    • A medial stroke with a breakthrough of blood into the ventricles can serve as an indication for surgery, provided that puncture aspiration of liquid blood is possible and thrombolysis of the remaining clots is performed.
    • Occlusive hydrocephalus is an indication for surgery.
    • Development coma in patients with hemorrhagic stroke. It is a poor prognostic sign and, if coma lasts more than 6-12 hours, it may be (according to some data) an indication for surgery. The operation consists in removing the hematoma and eliminating the effects of compression and dislocation of the brain, in particular by performing hemicraniectomy. At the same time, it was shown that late operation through the craniotomy access in a patient in a coma with deep hemorrhage worsens the outcomes and is not recommended for carrying out.
    • Aneurysms, arteriovenous malformations, arterio-sinus fistulas, cavernous angiomas accompanied by various forms intracranial hemorrhage (verification: angiography, CT, MRI angiography).

    There are no uniform recommendations regarding the timing of the surgery. There is insufficient evidence that the earliest possible (within 6-9 hours from the beginning) intervention improves clinical outcomes, but at the same time it increases the risk of rebleeding. There is still insufficient evidence that surgical removal of hemorrhage within 12 hours from the onset, in particular with the use of minimally invasive methods, gives positive results in functional outcomes and survival.

Spontaneous subarachnoid hemorrhage (SAH) is a spontaneous (not caused by head injury) outflow of blood into the subarachnoid space, between the soft and arachnoid membranes of the brain. SAH is referred to as acute disorders of cerebral circulation, or rather to intracranial hemorrhage.

In about 80% of cases, SAH is caused by rupture of saccular aneurysm or arteriovenous malformation of the cerebral vessels. Aneurysms are located mainly in the area of \u200b\u200bthe bifurcation of the large arteries of the base of the brain. Rarely, the source of the bleeding is in the spinal cord.

The main clinical signs SAK:

  • Sudden intense headache.
  • Meningeal syndrome.
    • Stiff neck and neck muscles.
    • Photophobia.
    • Vomiting.
    • Meningeal symptoms (Kernig, Brudzinsky and others).
    • General hyperesthesia.
    • Soreness on palpation of the exit points of the branches of the trigeminal nerve.
  • Psychomotor agitation or depression of consciousness is often observed.
  • Focal neurological symptoms may be absent, or develop later, as a result of cerebral vasospasm, the effect of outflowing blood on the brain tissue, and cerebral edema.

The methods of reliable diagnosis of SAH are computed tomography and MRI in the FLAIR mode. If it is not possible to carry out these methods on an emergency basis, or they give a negative result, then a lumbar puncture is performed to detect blood in the cerebrospinal fluid. Methods for diagnosing the cause of SAH are cerebral angiography, as well as CT or MRI angiography.

SAH treatment includes basic therapy (normalization of function external respiration, maintenance of optimal blood pressure, regulation of homeostasis, hyperthermia, reduction of cerebral edema, anticonvulsant therapy, etc.), as well as measures aimed at preventing re-hemorrhage, prevention and treatment of angiospasm, treatment of extracerebral complications. Patients with aneurysmal SAH undergo early surgical shutdown of the aneurysm from the arterial bed in order to prevent re-hemorrhage, which develops in about 25% of patients and ends in death in 75 - 80% of cases.

  • Epidemiology

    The incidence of the disease according to various estimates and in different countries the world is from 6 to 30 cases of SAH per 100,000 thousand population per year. Data for Russia for last years absent. The prevalence of SAH is approximately 50 cases per 100,000 population.

    SAHs account for 5-7% of all strokes (the frequency of which in Russia is 100-400 cases per 100,000 population per year). SAH is usually seen over the age of 20, with a slight predominance in the 25-50 age group. The peak incidence occurs at the age of 50. About 15% of SAH occurs between the ages of 20 and 40, and about 80% in the 40-65 age group. Women get sick 1.5-2 times more often than men.

    SAK is characterized by high level mortality and disability. About 15% of patients die before admission to the hospital, 25% die on the first day from the onset of the disease. The mortality rate at the end of the first week reaches 40%, and in the first half of the year, about 50-60% die.

Treatment

  • General principles
    • Treatment of subarachnoid hemorrhage consists of basic and specific therapy. Basic therapy includes such components as normalization of the function of external respiration, regulation of the function of the cardiovascular system, control and regulation of homeostasis and biochemical constants (maintenance of normoglycemia and water-electrolyte balance), reduction of cerebral edema and intracranial hypertension, symptomatic therapy (anticonvulsant, with vomiting and psychomotor agitation ), adequate nutrition, prevention of somatic complications. Specific therapy includes early surgery SAH, prevention and treatment of cerebral ischemia due to angiospasm.
    • The basis treatment tactics in SAH due to rupture of an aneurysm, an early surgical intervention is performed to turn off the aneurysm from the bloodstream (in order to prevent repeated hemorrhages) and remove blood clots from the basal cisterns (in order to prevent angiospasm and cerebral ischemia). The optimal timing is the operation in the first three days (72 hours) from the rupture of the aneurysm, i.e. before the development of vascular spasm and cerebral ischemia.
    • In the presence of spasm and cerebral ischemia, the operation can be performed only under the condition of the compensated state of the patient or with compensated vascular spasm and cerebral ischemia.
    • With the development of decompensated cerebral ischemia due to spasm, which is accompanied by a progressive deterioration in the patient's condition, surgery cannot be performed due to the high risk of developing a heart attack and subsequent unfavorable outcome.
    • Currently no effective methods conservative pathogenetic treatment of SAH, aimed at stopping bleeding from a ruptured aneurysm, limiting the volume of outflowing blood. The basis of SAH therapy is prevention and relief of angiospasm, prevention and treatment of cerebral ischemia. The standard of treatment is the use of nimodipine (nimotope) and 3H therapy (hypervolemia, hypertension (induced controlled arterial hypertension), hemodilution). In case of vasospasm refractory to drug methods of treatment, transluminal angioplasty is performed using a balloon catheter.
    • Σ-aminocaproic acid, previously widely used in CAH, is not currently used. It somewhat reduces the frequency of repeated SAH due to the deterioration of the rheological properties of the blood, but at the same time significantly increases the frequency of ischemic brain damage and arterial embolism fragments of a blood clot.
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