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.
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.
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.