What happens in the brain
When a vessel ruptures, blood under pressure fills the subarachnoid space and mixes with the cerebrospinal fluid. Intracranial pressure increases sharply, which explains instant pain and often loss of consciousness. Then the blood begins to break down, and its breakdown products cause a spasm of the cerebral arteries, which develops on days 3–14 and can lead to a secondary cerebral infarction. Another late complication is a violation of the outflow of cerebrospinal fluid with the development of hydrocephalus. Therefore, treatment does not end with stopping the bleeding: the patient needs observation in the hospital for several weeks.
- A sharp rise in intracranial pressure
- Irritation of the membranes of the brain by blood
- Delayed spasm of cerebral arteries
- Impaired outflow of cerebrospinal fluid and hydrocephalus
- Risk of rebleeding on the first day
Causes and risk factors
In approximately the majority of non-traumatic cases, the source is a ruptured saccular aneurysm of the artery of the base of the brain. Other causes include arteriovenous malformation, arterial dissection, inflammatory vascular lesions, blood thinning medications, and clotting diseases. A separate group is traumatic hemorrhages after a blow to the head. Provoking moments are often a sharp rise in pressure during straining, intense exercise, or strong emotional stress.
- Rupture of a cerebral aneurysm
- Arteriovenous malformation
- Traumatic brain injury
- Taking anticoagulants, coagulation disorders
- Smoking and hypertension
- Alcohol and stimulant abuse
- Familial cases of hemorrhage
Symptoms
The key symptom is a headache that begins instantly and reaches a maximum within seconds; patients describe it as a blow to the back of the head or the worst pain of their life. Nausea and vomiting, intolerance to bright light and sound, pain and stiffness in the neck are almost always associated. About half of patients experience a brief loss of consciousness at the time of rupture. Convulsions, confusion, weakness in the limbs, double vision, and drooping eyelids may occur. Sometimes, a few days before a disaster, there is a warning headache that is important to pay attention to.
- Instant severe headache
- Nausea and repeated vomiting
- Photophobia and noise intolerance
- Neck stiffness, inability to tilt head
- Loss of consciousness, convulsions
- Confusion and agitation
- Focal symptoms: weakness, speech impairment, double vision
Diagnostics
The first study is a computed tomography of the brain without contrast: in the first hours it detects blood in the subarachnoid space in the vast majority of patients. If the picture is questionable, but the clinical picture is typical, a lumbar puncture is performed to look for blood and its breakdown products in the cerebrospinal fluid. After confirming the diagnosis, they immediately look for the source: CT angiography of the intracranial arteries is performed, and, if necessary, direct cerebral angiography, which most accurately describes the aneurysm before intervention.
- MSCT of the brain on an emergency basis
- Lumbar puncture with negative CT and typical clinical picture
- MSCT of intracranial arteries to search for an aneurysm
- Cerebral angiography before surgery
- MRI of the brain and blood vessels in the delayed period
- Coagulogram, complete blood count, electrolytes, ECG
Treatment and recovery
Treatment is carried out only in a hospital, often in an intensive care unit. The first task is to prevent re-bleeding: the aneurysm is switched off from the bloodstream in the next few hours or days by endovascular embolization or surgical clipping. At the same time, they maintain stable blood pressure, relieve pain, prevent convulsions and delayed spasm of the arteries with special medications. The condition is monitored through repeated studies. After discharge, long-term rehabilitation is required - restoration of movements, speech, memory and performance, as well as lifelong cessation of smoking and blood pressure control.
- Emergency hospitalization and bed rest
- Aneurysm shutdown: embolization or clipping
- Blood pressure control and pain management
- Prevention of spasm of cerebral arteries
- Monitoring the development of hydrocephalus
- Rehabilitation: physical therapy, speech therapist, neuropsychologist
- Complete smoking cessation and blood pressure control after discharge