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Subarachnoid Hemorrhage

Subarachnoid Hemorrhage

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Subarachnoid Hemorrhage
Definition
A subarachnoid hemorrhage is an abnormal and very dangerous condition in which blood collects beneaththe arachnoid mater, a membrane that covers the brain. This area, called the subarachnoid space, normallycontains cerebrospinal fluid. The accumulation of blood in the subarachnoid space can lead tostroke, seizures, and other complications. Additionally, subarachnoid hemorrhages may cause permanent braindamage and a number of harmful biochemical events in the brain. A subarachnoid hemorrhage and therelated problems are frequently fatal.
Description
Subarachnoid hemorrhages are classified into two general categories: traumatic and spontaneous.Traumatic refers to brain injury that might be sustained in an accident or a fall. Spontaneous subarachnoidhemorrhages occur with little or no warning and are frequently caused by ruptured aneurysms or bloodvessel abnormalities in the brain.Traumatic brain injury is a critical problem in the United States. According to annual figures compiled bythe Brain Injury Association, approximately 373,000 people are hospitalized, more than 56,000 peopledie, and 99,000 survive with permanent disabilities due to traumatic brain injuries. The leading causes of injury are bicycle, motorcycle, and automobile accidents, with a significant minority due to accidentalfalls, and sports and recreation mishaps.Exact statistics are not available on traumatic subarachnoid hemorrhages, but several large clinical studieshave found an incidence of 23-39% in relation to severehead injury. Furthermore, subarachnoidhemorrhages have been described in the medical literature as the most common brain injury foundduringautopsyinvestigations of head trauma.Spontaneous subarachnoid hemorrhages are often due to an aneurysm (a bulge or sac-like projection froma blood vessel) which bursts.Arteriovenous malformations(AVMs), which are abnormal interfaces between arteries and veins, may also rupture and release blood into the subarachnoid space. Bothaneurysms and AVMs are associated with weak spots in the walls of blood vessels and account for approximately 60% of all spontaneous subarachnoid hemorrhages. The rest may be attributed to othecauses, such ascancer or infection, or are of unknown origin.In industrialized countries, it is estimated that there are 6.5-26.4 cases of spontaneous subarachnoidhemorrhage per 100,000 people annually. Certain factors raise the risk of suffering a hemorrhage.Aneurysms are acquired over a person's lifetime and are rarely a factor in subarachnoid hemorrhage before age 20. Conversely, AVMs are present at birth. In some cases, there may be a genetic predisposition for aneurysms or AVMs. Other factors that have been implicated, but not definitivelylinked to spontaneous subarachnoid hemorrhages, includeatherosclerosis,cigarette use, extreme alcoholconsumption, and the use of illegal drugs, such ascocaine. The exact role of high blood pressure issomewhat unclear, but since it does seem linked to the formation of aneurysms, it may be considered anindirect risk factor.The immediate danger due to subarachnoid hemorrhage, whether traumatic or spontaneous, isischemia. Ischemia refers to tissue damage caused by restricted or blocked blood flow. The areas of the brain thatdo not receive adequate blood and oxygen can suffer irreparable injury, leading to permanent braindamage or death.An individual who survives the initial hemorrhage is susceptible to a number of complications in the following hours, days, and weeks.The most common complications are intracranialhypertension, vasospasm, andhydrocephalus.  Intracranial hypertension, or high pressure within the brain, can lead to further bleeding from damaged blood vessels; a complication associated with a 70% fatality rate. Vasospasm, or blood vesselconstriction, is a principal cause of secondary ischemia. The blood vessels in the brain constrict inreaction to chemicals released by blood breaking down within the subarachnoid space. As the bloodvessels become narrower, blood flow in the brain becomes increasingly restricted. Approximately onethird of spontaneous subarachnoid hemorrhages and 30-60% of traumatic bleeds are followed byvasospasm. Hydrocephalus, an accumulation of fluid in the chambers of the brain (ventricles) due to
 
restricted circulation of cerebrospinal fluid, follows approximately 15% of subarachnoid hemorrhages.Because cerebrospinal fluid cannot drain properly, pressure accumulates on the brain, possibly promptingfurther ischemic complications.
Causes and symptoms
Whether through trauma or disease, subarachnoid hemorrhages are caused by blood being released by adamaged blood vessel and accumulating in the subarachnoid space. Symptoms associated with traumaticsubarachnoid hemorrhage may or may not resemble those associated with spontaneous hemorrhage, astrauma can involve multiple injuries with overlapping symptoms.Typically, a spontaneous subarachnoidhemorrhage is indicated by a sudden, severe headache. Nausea, vomiting, anddizzinessfrequentlyaccompany thepain.Loss of consciousness occurs in about half the cases of spontaneous hemorrhage.Acoma, usually brief, may occur. A stiff neck,fever , and aversion to light may appear following the hemorrhage. Neurologic symptoms may include partial paralysis, loss of vision, seizures, and speechdifficulties. Spontaneous subarachnoid hemorrhages may be preceded by warning signs prior to the initial bleed. Sentinel, or warning, headaches may be present in the days or weeks before an aneurysm or AVMruptures. These headaches can be accompanied by dizziness, nausea, and vomiting, and possiblyneurologic symptoms. Approximately 50% of AVMs are discovered before they bleed significantly;however, most aneurysms are not diagnosed before they rupture.
Diagnosis
To make a diagnosis, a health-care provider takes a detailed history of the symptoms and does aphysical examination.The symptoms may mimic other disorders and diagnosis can be complicated, especially if the individual is unconscious. The sudden, severe headache can fuel suspicion of a subarachnoidhemorrhage or similar event, and a computed tomography scan (CT scan) or magnetic resonance imaging(MRI) scan is considered essential to a quick diagnosis. The MRI is less sensitive than the CT indetecting acute subarachnoid bleeding, but more sensitive in diagnosing AVM or aneurysm.A CT scan reveals blood that has escaped into the subarachnoid space. For the best results, the scanshould be done within 12 hours of the hemorrhage. If this is not possible, lumbar puncture andexamination of the cerebrospinal fluid is advised. Lumbar puncture is also done in cases in which the CTscan doesn't reveal a hemorrhage, but there is a high suspicion that one has occurred. In subarachnoidhemorrhage, cerebrospinal fluid shows red blood cells and/or xanthochromia, a yellowish tinge caused by blood breakdown products. Xanthochromia first appears six to 12 hours after subarachnoid hemorrhage,making it advisable to delay lumbar puncture until at least 12 hours after the onset of symptoms for amore definite diagnosis.Once a hemorrhage, AVM, or aneurysm has been diagnosed, further tests are done to pinpoint thedamage. The CT scan may be useful in giving the general location, but cerebralangiographymaps out theexact details. This procedure involves injecting a special dye into the blood stream. This dye makes bloodvessels visible in x rays of the area.
Treatment
The initial course of treatment focuses on stabilizing the hemorrhage victim. Depending on theindividual's condition, this may involve intubation and mechanical ventilation, supplemental oxygen,intravenous fluids, and close monitoring of vital signs. If the person suffers seizures, an anticonvulsant,such as phenytoin (Dilantin), is administered. Nimodipine, a calcium channel blocker, may be given to prevent vasospasm and its complications. Sedatives and medications for pain, nausea, and vomiting areadministered as needed.Once the individual is stabilized, cerebral angiography is done to locate the damaged blood vessel. Thisinformation and the individual's condition are considered before attempting surgical treatment. Surgery isnecessary to remove the damaged area of the blood vessel and prevent a second hemorrhage. The specificneurosurgical procedures depend on the location and type of blood vessel damage. Typically, clip ligationis the preferred means of treating an aneurysm, and surgical excision, radiosurgery, or endovascular embolization are used to manage an AVM.
Prognosis

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