THE CLINICAL SYNDROME

• Subarachnoid hemorrhage (SAH) is one of the most damaging cerebrovascular accidents.

• Fewer than 60% of patients will recover cognitive and functional abilities.

• 65–70% of SAH patients result from intracranial berry aneurysm rupture.

• Neoplasms, angiomas, and arteriovenous malformations account for the rest.

• Berry aneurysms are more likely to rupture due to their incomplete muscular media and collagen-elastic layer.

• Marfan's syndrome, Ehlers-Danlos syndrome, sickle cell disease, coarctation of the aorta, alpha 1-antitrypsin deficiency, polycystic kidney disease, fibromuscular vascular dysplasia, and pseudoxanthoma elasticum are associated with berry aneurysms.

• Cerebral atherosclerosis and modifiable risk factors like hypertension, alcohol, caffeine, smoking, and cocaine usage enhance SAH risk.

• Blacks have twice the risk of SAH as whites. SAH affects more women than men, and its average age is 50. Even with modern therapy, severe SAH kills 25%.

SIGNS AND SYMPTOMS

• A sentinel headache or thunderclap headache often precedes a major subarachnoid hemorrhage.

  • This headache may be caused by a bursting aneurysm.

  • The sentinel headache is immediate and intense.

  • Sentinel headache victims may feel photophobia, nausea, and vomiting.

  • Nine out of 10 people will get a sentinel headache three months after a major subarachnoid hemorrhage.

• Major SAH patients often experience the worst headache of their lives.

  • This headache usually comes with nausea, vomiting, light sensitivity, vertigo, fatigue, confusion, nuchal stiffness, and back and neck pain.

• Acute subarachnoid hemorrhage (SAH) patients look very sick, and up to 50% will lose consciousness due to the rapidly rising intracranial pressure caused by the uncontrolled hemorrhage.

  • High intracranial pressure may cause abducens nerve palsy.

  • Paresis, seizures, subretinal hemorrhages, and papilledema are often found on physical examination.

TESTING

• Subarachnoid hemorrhage (SAH) testing has two immediate goals: (1) to find an occult intracranial pathologic process or other diseases that may mimic SAH and be more curable; and (2) to identify SAH.

• Diagnostics should achieve these goals.

• All patients with severe SAH-related headaches should get brain CT scans immediately.

• Modern multidetector CT scanners can accurately diagnose subarachnoid hemorrhage (SAH) via CT angiography of the brain arteries.

• Cerebral angiography may be needed before surgery if the bleeding location is unknown.

• If CT scans do not show an aneurysm, brain MRI and angiography may help diagnose arteriovenous malformations. These imaging methods may be more accurate than CT scans.

• SAH patients should have screening lab tests. Erythrocyte sedimentation rate, complete blood count, coagulation studies, and automated blood chemistry are recommended.

• Surgery or pre-existing anemia patients should consider blood typing and crossmatching.

• Every SAH patient should undergo repeated ophthalmologic exams to monitor papilledema progression.

• The lumbar puncture can show blood in the spinal fluid, but rising intracranial pressure makes it dangerous.

• SAH patients often have electrocardiographic abnormalities.

• Catecholamine excess and hypothalamic dysfunction may cause these anomalies.

DIFFERENTIAL DIAGNOSIS

• The differential diagnosis of subarachnoid hemorrhage (SAH) can, for the most part, be thought of as the diagnosis of the lesser of two evils.

• This is due to the fact that the majority of the disorders that mimic SAH are also linked with high mortality and morbidity.

• Stroke, collagen vascular disease, infection, neoplasm, hypertensive crisis, spinal fluid leaks, and other types of headaches can all be caused by a variety of conditions.

TREATMENT

Medical Management

• The therapy of SAH begins with cautious acute medical management, with the goal of limiting the long-term effects of both the cerebral insult and the morbidity that is associated with a severe disease.

• A suitable first step in the treatment of a patient suffering from SAH is to have the patient take bed rest with the head of the bed elevated to between 30 and 35 degrees in order to promote excellent venous drainage.

• During the initial therapy of SAH, accurate measurements of intake and output, as well as cautious management of hypertension and hypotension, are also crucial.

• In addition, invasive cardiovascular monitoring should be undertaken sooner rather than later in this situation.

• There is a possibility that dexamethasone, the osmotic agent mannitol, and furosemide will be necessary in order to treat the raised intracranial pressure.

• Blockers of calcium channels and magnesium may be helpful in lowering the risk of cerebrovascular spasm and reducing the size of the ischemic zone.

• According to studies, statins may also be helpful in a situation like this one.

• Antifibrinolytic drugs like epsilonaminocaproic acid, for example, have shown promise in reducing the risk of rebleeding in some individuals.

Surgical Treatment

• The surgical treatment of hydrocephalus with ventricular drainage may be required to treat highly elevated intracranial pressure.

• However, it is important to keep in mind that a too rapid a decrease in intracranial pressure in this setting may result in an increased incidence of rebleeding.

• Surgical treatment of hydrocephalus with ventricular drainage may be required.

• Surgical treatment with clipping of the aneurysm or interventional radiologic endovascular occlusive coil treatment of continued bleeding or rebleeding carries a high risk of morbidity and mortality, but it may be necessary if more conservative treatments fail.

• Surgical treatment with clipping of the aneurysm or interventional radiologic endovascular occlusive coil treatment of continued bleeding or rebleeding.

COMPLICATIONS AND PITFALLS

• In most cases, there are three different types of complications and hazards that might occur during the diagnosis and treatment of SAH.

• In the first group, there is a failure to notice a sentinel hemorrhage, as well as an evaluation and treatment of the patient, before a substantial subarachnoid hemorrhage occurs.

• The second type of problem is an incorrect diagnosis, which causes a delay in treatment and ultimately contributes to an increase in morbidity and mortality rates.

• The third type of situation involves medical administration that is subpar, leading to unnecessary deaths and illnesses that could have been prevented.

• For instance, pulmonary embolus can result from thrombophlebitis, and aspiration pneumonia can occur when the patient's airway is not adequately protected.