More common in patients over 50 years old; the incidence rate is higher in cold seasons; many have a history of hypertension, which often occurs during emotional excitement/activity, and the condition reaches its peak within minutes to hours after the onset.

After the onset of the disease, the blood pressure is often obvious↑; there may be signs of increased intracranial pressure

Hemorrhage in the basal ganglia (70%): often leads to "triple deviation"; both eyes stare toward the affected side, and there may be focal twitching and aphasia (dominant hemisphere); when the amount of bleeding is large, the disorder of consciousness worsens, and symptoms of increased intracranial pressure occur. , even cerebral herniation

Lobar hemorrhage: most common in the parietal lobe; manifests as headache, vomiting, meningeal irritation, and focal localization signs

Thalamus hemorrhage: Similar to hemorrhage in the basal ganglia, there may be vertical movement disorders of both eyes/eyes staring up/down. Pontine hemorrhage: often caused by rupture of the pontine branch of the basilar artery; massive bleeding can often rupture into the fourth ventricle, causing corresponding symptoms. A small amount of bleeding may lead to unconsciousness, and the symptoms include cross paralysis (hemorrhagic facial paralysis, slow limb hemiplegia), ataxic hemiplegia, paralysis of both eyes staring to the affected side/internuclear ophthalmoplegia, and the pupils can Needle-like shape, slow/disappearance of light reflex

Cerebellar hemorrhage: often caused by dentate nucleus artery rupture; manifests as headache, vomiting, dizziness, ataxia, and occipital pain, but no paralysis; severe cerebellar hemorrhage can still cause acute foramen magnum hernia

Intraventricular hemorrhage: A small amount of bleeding is usually primary, and can easily be misdiagnosed as subarachnoid hemorrhage (with similar symptoms); a large amount of bleeding is usually secondary, with rapid onset of coma, pinpoint pupils, vomiting of coffee-like contents, central hyperthermia, and central nervous system hemorrhage. Respiratory failure, floating eyeballs, quadriplegia, decerebrate ankylosis

Cerebrospinal fluid examination: generally not used when the clinical diagnosis is clear (especially in those with obvious intracranial hypertension and cerebellar hemorrhage); however, it can be performed with caution when intracranial infection and SAH need to be ruled out.

Others: blood routine, blood biochemistry, coagulation function

CT: preferred diagnostic method; shows high-density lesions after bleeding

MRI and MRA: helpful in detecting structural abnormalities and clarifying the cause of cerebral hemorrhage; MRI is better than CT in diagnosing subacute and chronic cerebral hemorrhage, brainstem and posterior fossa hematoma

DSA: Generally not required, unless vascular malformation or vasculitis is suspected and surgical/interventional treatment is required

General processing

Adjust blood pressure

Adjust blood sugar

Cerebrospinal fluid drainage and intracranial pressure monitoring

Reduce intracranial pressure: ① 20% mannitol; ② Short-term use of dexamethasone when conditions permit; ③ Hyperventilation; ④ High-dose barbiturates

Indications: ① Cerebral hemorrhage accompanied by neurological deterioration, brainstem compression/ventricular obstruction causing hydrocephalus requires surgical removal of hematoma as soon as possible; ② Cerebral lobar hemorrhage exceeds 30ml, and the hematoma is within 1cm from the cortical surface; ③ Cerebral hemorrhage originates from aneurysm , AVM, cavernous hemangioma

Surgical procedures: decompressive craniectomy, small bone window craniotomy for hematoma evacuation, drilling and hematoma aspiration, ventricular puncture

Temperature management, DVT and pulmonary embolism, seizures and epilepsy

It can be started when the acute phase is over, consciousness is clear, vital signs are stable, and local symptoms begin to improve.

More common in young and middle-aged people, the onset is sudden; most cases have obvious triggers before the onset (such as strenuous exercise, excessive fatigue, straining to defecate, and emotional excitement)

Headache: Sudden, extremely severe, full-body headache, which cannot be relieved and worsens (gradually reduces after 2 weeks). The headache may not be obvious in the elderly; accompanied by transient disturbance of consciousness, nausea and vomiting, pale complexion, and cold sweat all over the body.

Meningeal irritation sign: Neck stiffness is common; but it may not be obvious in the elderly, weak, and those with a small amount of bleeding.

Eye symptoms: subvitreous flake hemorrhage, eye movement disorder

Psychiatric symptoms: such as euphoria, delirium, hallucinations

Others: such as cerebral heart syndrome, gastrointestinal bleeding, acute pulmonary edema

Aneurysm of the cavernous sinus segment of the internal carotid artery: forehead/eye pain, vascular murmur, proptosis, eye movement disorder caused by damage to the III/IV/VI/V1 cranial nerves; rupture can cause internal carotid artery cavernous sinus fistula

Internal carotid artery-posterior communicating artery aneurysm: oculomotor nerve compression

MCA tumor: hemiplegia, aphasia, convulsions

ACA-Anterior communicating artery aneurysm: psychiatric symptoms, unilateral/bilateral lower limb paralysis, disturbance of consciousness

PCA tumors: homonymous hemianopia, Weber syndrome, oculomotor nerve palsy

Vertebro-basilar aneurysm: occipital/facial pain, hemifacial spasm, facial paralysis, brainstem compression symptoms

Rebleeding: a major acute complication; common in 3 to 4 days, 7 to 8 days, and 12 to 14 days after onset; manifested by severe headache, vomiting, epileptic seizures, coma, and even decerebrate ankylosis after the condition stabilizes; cervical ankylosis, Kernig's sign worsened; cerebrospinal fluid was reexamined to be bloody.

Cerebral vasospasm (CVS): occurs in blood vessels surrounded by blood clots in the subarachnoid space; the severity of spasm is related to the amount of bleeding; clinical symptoms depend on the blood vessel where spasm occurs, and often manifests as fluctuating hemiparesis and aphasia

hydrocephalus

Other: Seizures, hyponatremia

Cerebrospinal fluid examination: especially when the CT scan result is negative; 3 consecutive tubes of homogeneous bloody cerebrospinal fluid are characteristic findings (and the only way to confirm the diagnosis)

Others: blood routine, coagulation function, liver function

Head CT: the preferred method when clinically suspected SAH; abnormal high signal in the subarachnoid space can be seen

Head MRI: When the sensitivity of CT examination is reduced within a few days after the onset of SAH, it can play a greater role; when no cause of bleeding is found in the brain, spine MRI should be performed to exclude spinal cavernous hemangioma/AVM.

CTA/MRA: Mainly used for screening of those with family history of aneurysm/premonition of rupture, follow-up of aneurysm patients, and alternative method when DSA cannot perform timely examination.

DSA: Whole-brain DSA should be performed as early as possible when conditions permit and the condition permits. It is still the gold standard for clinical diagnosis of aneurysm (but the peak period of cerebral vasospasm and rebleeding should be avoided, and bleeding should generally occur within 3 days or 3 weeks. later)

TCD: a non-invasive technique for monitoring cerebral vasospasm after SAH

Keep quiet: rest in bed for 2 to 4 weeks, try to reduce moving; avoid exertion and mood swings, and keep defecation smooth

Keep vital signs stable: Admit yourself to ICU if possible and monitor closely; maintain smooth respiratory tract and circulatory system function

Maintain water, electrolyte, and acid-base balance, provide nutritional support, and prevent and treat infections.

Reduce intracranial pressure

Prevent further bleeding: ① Absolute bed rest; ② Control blood pressure; ③ Antifibrinolytic drugs: tranexamic acid, tranexamic acid; ④ Surgical and endovascular treatment of ruptured aneurysm (most effective)

Cerebral vasospasm: nimodipine, flunarizine

Hydrocephalus: cerebrospinal fluid shunt

Seizures: Antiepileptic drugs may be used prophylactically early after SAH hemorrhage

Hyponatremia/Hypovolemia: Monitor changes in blood volume; isotonic fluids can be used to correct hypovolemia, and fludrocortisone acetate and hypertonic saline can be used to correct hyponatremia.

Cerebrospinal fluid replacement therapy: can reduce intracranial pressure, reduce the incidence of cerebral vasospasm and hydrocephalus

Surgical and Endovascular Treatment