A subarachnoid hemorrhage is an acute intracranial hemorrhage (into the interior of the skull) that is most commonly due to an aneurysm rupture and has an unfavorable prognosis. Subarachnoid hemorrhage affects approximately 15 per 100,000 people each year.
What is a subarachnoid hemorrhage?
Subarachnoid hemorrhage refers to acute intracranial bleeding into the subarachnoid space, which is located between the arachnoid (cobweb) membrane and the pia mater (vascular part of the meninges), which together form the soft meninges (leptomeninx). Symptoms characteristic of subarachnoid hemorrhage include sudden, very severe headache in the back of the head (“annihilation headache“), nausea and vomiting, meningismus (neck stiffness, sensitivity to light), and initial clouding of consciousness. Later, as a result of rising intracranial pressure, unconsciousness, coma, and circulatory and respiratory arrest are also characteristic of subarachnoid hemorrhage.
Causes
In most cases, subarachnoid hemorrhage is due to rupture of a cerebral artery aneurysm. A cerebral aneurysm is generally caused by a genetic weakness of the vessel wall at the base of the brain, as a result of which bulges develop on the vessels (aneurysmata) that can burst (rupture) and lead to a subarachnoid hemorrhage. Aneurysm rupture is favored by physical exertion such as lifting heavy objects or sexual intercourse. In addition, in rarer cases, craniocerebral trauma, sinus vein thrombosis (occlusion of the large blood vessels of the brain), angiomas (vascular malformations), coagulation disorders as well as vascular inflammations can cause a subarachnoid hemorrhage. Hypertension (high blood pressure), nicotine use in hypercholesterolemia (elevated blood cholesterol levels), and drug use (heroin, amphetamines) are factors that promote the manifestation of an aneurysm and thus subarachnoid hemorrhage.
Symptoms, complaints, and signs
The first symptom of subarachnoid hemorrhage is usually a sudden and extremely severe headache called an annihilation headache. Patients describe it as unbearable and never experienced before in a similar way. The pain usually starts from the forehead or neck and extends all over the head, sometimes to the back. However, this symptom can also be absent. In addition, sufferers experience a stiff neck, nausea, vomiting, and increased sensitivity to light. Blood pressure may increase or decrease, breathing rate changes, and body temperature fluctuates frequently. The pulse may beat irregularly and paralysis may occur. Rather rarely, epileptic seizures occur. Symptoms are divided into five grades, according to which the severity of the hemorrhage can be judged. Grade I shows only mild headache. Grade II shows more severe headaches and the neck is stiff. Once grade III is reached, drowsiness is added and milder neurological disturbances such as paralysis or reduced sensitivity. Grade IV subarachnoid hemorrhage is manifested by coma-like sleep. In addition, there are disturbances in breathing and hemiplegia. In grade V, severe hemorrhage is present and the patient falls into a coma. The pupils no longer respond to light stimuli, and marked neurologic disturbances occur.
Diagnosis and course
Subarachnoid hemorrhage is diagnosed on the basis of characteristic symptoms, with the specific presenting complaints providing information about the stage of the disease. Thus, mild headache and neck stiffness are associated with an early stage (grade I). These intensify as the disease progresses and may be accompanied by cranial nerve deficits (grade II). Additional clouding of consciousness and neurologic focal symptoms indicate grade III disease. Subsequently, symptoms such as somnolence or sopor (deep sleep), hemiparesis (hemiplegia), circulatory and respiratory disturbances (grade IV), and coma, extensor spasms, and impaired vital functions (grade V) may manifest. The diagnosis is confirmed by imaging techniques such as computed tomography (first week after a subarachnoid hemorrhage), magnetic resonance imaging, or lumbar puncture (from day 8). Doppler sonography is used to exclude possible vasospasm (vascular spasm), while angiography provides information about the exact location of the aneurysm.The prognosis is unfavorable in subarachnoid hemorrhage. About half of those affected die within the first 30 days after a subarachnoid hemorrhage. In addition, there is an increased risk of impaired brain function despite successful surgery.
Complications
In the worst case, subarachnoid hemorrhage can lead to the death of the affected person. However, this occurs only if the condition is not treated. In this case, the affected person primarily suffers from very severe headaches. These can also spread to the neighboring regions of the body and lead to pain there as well. Furthermore, the affected persons experience vomiting and also nausea. These complaints also have a very negative effect on the patient’s quality of life. A high sensitivity to light and noise can also occur with subarachnoid hemorrhage and make the daily life of the affected person more difficult. Many patients also suffer from a very stiff neck, possibly including pain in this region. As the subarachnoid hemorrhage progresses, unconsciousness may occur, during which the affected person may possibly injure himself in a fall. Treatment of the hemorrhage is usually by surgical intervention. No particular complications occur and the symptoms can be alleviated. However, due to the bleeding, the risk of stroke increases significantly, so that the affected person also continues to rely on various therapies and examinations. It may also reduce the patient’s life expectancy.
When should you go to the doctor?
Treatment by a physician should always be sought for this condition. The earlier the subarachnoid hemorrhage is detected and treated, the better the further course of the disease in most cases. Only early diagnosis with subsequent treatment can prevent further complications or discomfort. If the subarachnoid hemorrhage is left untreated, the worst case scenario can be death of the affected person. A doctor should be consulted if the affected person suffers from very severe headaches. In most cases, the affected person is also no longer able to concentrate or go about his or her usual daily routine. A stiff neck and severe nausea associated with vomiting may also indicate a subarachnoid hemorrhage. Some affected individuals are very sensitive to light or even prone to an epileptic seizure. If such a seizure occurs, go to the hospital or call an emergency physician immediately. Usually, subarachnoid hemorrhage can be recognized by a general practitioner. However, further treatment requires a specialist and usually surgical intervention. No general prediction can be made about the further course and life expectancy of the patient.
Treatment and therapy
In cases of subarachnoid hemorrhage, therapeutic measures are aimed at stabilizing the general condition of the affected person by providing intensive medical care. In the presence of an aneurysm rupture, surgical intervention is used to separate the vascular outpouching from the blood circulation and stop the subarachnoid hemorrhage. Two surgical procedures are used for this purpose. In the so-called clipping procedure, the aneurysm is isolated from the blood circulation with the help of special clips at the vessel outlet in order to exclude further intracranial bleeding. In addition to this procedure, which is performed directly on the brain, the now more frequently used coiling procedure involves inserting a platinum microcoil (platinum coil) into the aneurysm with the aid of a catheter passing through the inguinal artery. After the platinum coil is placed, the coil unwinds and, as a result of the subsequent thrombosis, the meshes of the coil and thus the aneurysm are closed. Because of the increased risk of vascular occlusion, appropriate thrombosis prophylaxis should be used postoperatively. If vasospasms (vascular spasms) are already present or if the patient’s poor condition precludes surgical intervention, conservative treatment is usually used until the spasms subside (at least 10-12 days) in an attempt to maintain blood flow as far as possible because of the increased risk of stroke.Preferably, calcium antagonists such as nimodipine and infusions to dilute the blood with a simultaneous increase in blood volume (hypervolemic hemodilution) are used for this purpose. Intubation and ventilation may be required. If an angioma underlies the subarachnoid hemorrhage, it is embolized in many cases for prophylaxis of recurrent hemorrhage. In addition, absolute bed rest is indicated after both conservative and surgical therapy to minimize the risk of rebleeding.
Prevention
Only limited prevention of subarachnoid hemorrhage is possible. Measures against hypertension, refraining from nicotine and excessive alcohol consumption, and avoiding obesity through a healthy diet and regular exercise prevent an aneurysm and thus indirectly a subarachnoid hemorrhage.
Follow-up
Affected patients usually have few and also limited measures of follow-up care available for subarachnoid hemorrhage. For this reason, patients should seek medical attention at the first symptoms and signs of the disease to prevent further complications. As a rule, there is no independent cure, so that the affected person is dependent on medical examination and treatment. The sooner a doctor is consulted, the better the further course of the disease usually is. Most of the affected persons are dependent on a surgical intervention, whereby usually also the measures of a radiation therapy or a chemotherapy are necessary. Regular check-ups by a physician are also very important after removal in order to detect and treat further tumors at an early stage. Those affected by this disease should generally rest and take it easy, and in severe cases, strict bed rest should also be observed. In general, this disease does not reduce the patient’s life expectancy, although a general course cannot be predicted.
What you can do yourself
In most cases, the daily life of the affected person is characterized by heteronomy. This is because the damage is almost always accompanied by permanent disturbances. Everyday life should be adapted to the severity and complexity of the impairments, with self-help always at the forefront. Relatives and caregivers can support affected persons in everyday life by working according to the Bobath concept. The regulation of muscle tone, the initiation of normal movement sequences and the promotion of body awareness are the three basic aspects. This results in a daily routine in which feeding, mobility, elimination, dressing and washing are supported. However, it is always necessary beforehand to relieve spastic paralysis through movement and to avoid negative stimuli, such as cold hands. In particular, physiological movements can be supported during activities of daily living such as brushing teeth, combing or eating, always focusing on bilateral arm control. People after a subarachnoid hemorrhage often suffer from reduced attention. Therefore, the living situation must be redesigned accordingly and distractions must be eliminated. This is because the brain can only adapt over time with a few stimuli. Due to anosognosia, neglect or pusher syndrome, the risk of falls is greatly increased. Avoidance of falls during positioning or mobilization must therefore always be considered, as these result in further immobility and dependence.
