10/24/2014 Subarachnoid Hemorrhage: Stroke (CVA): Merck Manual Home Edition

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Subarachnoid Hemorrhage
A subarachnoid hemorrhage is bleeding into the space (subarachnoid
space) between the inner layer (pia mater) and middle layer (arachnoid
mater) of the tissue covering the brain (meninges).
The most common cause is rupture of a bulge (aneurysm) in an artery.
Usually, rupture of an artery causes a sudden, severe headache, often
followed by a brief loss of consciousness.
Computed tomography, sometimes a spinal tap, and angiography are done
to confirm the diagnosis.
Drugs are used to relieve the headache and to control blood pressure, and
surgery is done to stop the bleeding.
A subarachnoid hemorrhage is a life-threatening disorder that can rapidly
result in serious, permanent disabilities. It is the only type of stroke more
common among women than among men.
Bursts and Breaks: Causes of Hemorrhagic Stroke
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When blood vessels of the brain are weak, abnormal, or under unusual pressure, a hemorrhagic
stroke can occur. In hemorrhagic strokes, bleeding may occur within the brain, as an intracerebral
hemorrhage. Or bleeding may occur between the inner and middle layer of tissue covering the
brain (in the subarachnoid space), as a subarachnoid hemorrhage.
Causes
Subarachnoid hemorrhage usually results from head injuries. However,
hemorrhage due to a head injury causes different symptoms, is diagnosed
and treated differently, and is not considered a stroke.
Subarachnoid hemorrhage is considered a stroke only when it occurs
spontaneouslythat is, when the hemorrhage does not result from
external forces, such as an accident or a fall. A spontaneous hemorrhage
usually results from the sudden rupture of an aneurysm in an artery in the
brain. Aneurysms are bulges in a weakened area of an artery's wall.
Aneurysms typically occur where an artery branches. Aneurysms may be
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Did You Know...
Almost half of people with a subarachnoid hemorrhage die
before reaching the hospital.
present at birth (congenital), or they may develop later, after years of high
blood pressure weaken the walls of arteries. Most spontaneous
subarachnoid hemorrhages result from congenital aneurysms.
Less commonly, subarachnoid hemorrhage results from rupture of an
abnormal connection between arteries and veins (arteriovenous
malformation) in or around the brain. An arteriovenous malformation may
be present at birth, but it is usually identified only if symptoms develop.
Rarely, a blood clot forms on an infected heart valve, travels (becoming
an embolus) to an artery that supplies the brain, and causes the artery to
become inflamed. The artery may then weaken and rupture.
Symptoms
Before rupturing, an aneurysm usually
causes no symptoms unless it presses
on a nerve or leaks small amounts of
blood, usually before a large rupture (which causes a severe headache).
Then it produces warning signs, such as the following:
Headache, which may be unusually sudden and severe (sometimes called
a thunderclap headache)
Facial or eye pain
Double vision
Loss of peripheral vision
The warning signs can occur minutes to weeks before the rupture. People
should report any unusual headaches to a doctor immediately.
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A rupture usually causes a sudden, severe headache that peaks within
seconds. It is often followed by a brief loss of consciousness. Almost half
of affected people die before reaching a hospital. Some people remain in
a coma or unconscious. Others wake up, feeling confused and sleepy.
They may also feel restless. Within hours or even minutes, people may
again become sleepy and confused. They may become unresponsive and
difficult to arouse. Within 24 hours, blood and cerebrospinal fluid around
the brain irritate the layers of tissue covering the brain (meninges),
causing a stiff neck as well as continuing headaches, often with vomiting,
dizziness, and low back pain. Frequent fluctuations in the heart rate and in
the breathing rate often occur, sometimes accompanied by seizures.
Severe impairments may develop and become permanent within minutes
or hours. Fever, continued headaches, and confusion are common during
the first 5 to 10 days.
A subarachnoid hemorrhage can lead to several other serious problems:
Hydrocephalus: Within 24 hours, the blood from a subarachnoid
hemorrhage may clot. The clotted blood may prevent the fluid surrounding
the brain (cerebrospinal fluid) from draining as it normally does. As a result,
blood accumulates within the brain, increasing pressure within the skull.
Hydrocephalus may contribute to symptoms such as headaches,
sleepiness, confusion, nausea, and vomiting and may increase the risk of
coma and death.
Vasospasm: Vasospasm is sudden contraction (spasm) of blood vessels.
It occurs in about 25% of people, usually about 3 to 10 days after the
hemorrhage. Vasospasm limits blood flow to the brain. Then, brain tissues
may not get enough oxygen and may die, as in ischemic stroke.
Vasospasm may cause symptoms similar to those of ischemic stroke, such
as weakness or loss of sensation on one side of the body, difficulty using
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or understanding language, vertigo, and impaired coordination.
A second rupture: Sometimes a second aneurysm ruptures, usually
within a week.
Diagnosis
If people have a sudden, severe headache that peaks within seconds or
that is accompanied by loss of consciousness, confusion, or any
symptoms suggesting a stroke, they should go immediately to the
hospital.
Computed tomography (CT) is done as soon as possible to check for
bleeding. Magnetic resonance imaging (MRI) can also detect bleeding but
may not be available immediately.
A spinal tap (lumbar puncture) is done if CT is inconclusive or unavailable.
It can detect any blood in the cerebrospinal fluid. A spinal tap is not done
if doctors suspect that pressure within the skull is increased enough to
make doing a spinal tap risky.
Cerebral angiography (see Table 2: Common Types of Angiography ) is
done as soon as possible to confirm the diagnosis and to identify the site
of the aneurysm or arteriovenous malformation causing the bleeding.
Magnetic resonance angiography or CT angiography may be used
instead.
Prognosis
About 35% of people who reach the hospital alive die soon after. Some
die because the subarachnoid hemorrhage resulted in extensive brain
damage. Others die within a few weeks because a second aneurysm
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ruptures, causing more bleeding. People who survive for 6 months but
who do not have surgery for the aneurysm have a 3% chance of another
rupture each year. The outlook is better when the cause is an
arteriovenous malformation. Occasionally, the hemorrhage is caused by a
small defect that is not detected by cerebral angiography because the
defect has already sealed itself off. In such cases, the outlook is very
good.
Some people recover most or all mental and physical function after a
subarachnoid hemorrhage. However, many people continue to have
symptoms such as weakness, paralysis, or loss of sensation on one side
of the body or aphasia.
Treatment
People who may have had a subarachnoid hemorrhage are hospitalized
immediately. When possible, they are transported to a center that
specializes in treating stroke. Bed rest with no exertion is essential.
Analgesics such as opioids (but not or other nonsteroidal anti-
inflammatory drugs, which can worsen the bleeding) are given to control
the severe headaches. Stool softeners are given to prevent straining
during bowel movements. Nimodipine, a calcium channel blocker, is
usually given by mouth to prevent vasospasm and subsequent ischemic
stroke. Doctors take measures (such as giving drugs and adjusting the
amount of intravenous fluid given) to keep blood pressure at levels low
enough to avoid further hemorrhage and high enough to maintain blood
flow to the damaged parts of the brain. Occasionally, a piece of plastic
tubing (shunt) may be placed in the brain to drain cerebrospinal fluid away
from the brain. This procedure relieves pressure and prevents
hydrocephalus.
aspirin
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For people who have an aneurysm, a surgical procedure is done to
isolate, block off, or support the walls of the weak artery and thus reduce
the risk of fatal bleeding later. These procedures are difficult, and
regardless of which one is used, the risk of death is high, especially for
people who are in a stupor or coma. The best time for surgery is
controversial and must be decided based on the person's situation. Most
neurosurgeons recommend operating within 24 hours of the start of
symptoms, before hydrocephalus and vasospasm develop. If surgery
cannot be done this quickly, the procedure may be delayed 10 days to
reduce the risks of surgery, but then bleeding is more likely to recur
because the waiting period is longer.
A commonly used procedure, called endovascular coiling, involves
inserting coiled wires into the aneurysm. The coils are placed using a
catheter that is inserted into an artery and threaded to the aneurysm.
Thus, this procedure does not require that the skull be opened. By slowing
blood flow through the aneurysm, the coils promote clot formation, which
seals off the aneurysm and prevents it from rupturing. Endovascular coils
can be placed at the same time as cerebral angiography, when the
aneurysm is diagnosed.
Less commonly, a metal clip is placed across the aneurysm. This
procedure prevents blood from entering the aneurysm and eliminates the
risk of rupture. The clip remains in place permanently. Most clips that
were placed 15 to 20 years ago are affected by the magnetic forces and
can be displaced during magnetic resonance imaging (MRI). People who
have these clips should inform their doctor if MRI is being considered.
Newer clips are not affected by the magnetic forces.
Last full review/revision March 2014 by Elias A. Giraldo, MD, MS
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