It is the rupture of vascular lesions at the base of the brain or on the surface of the brain (such as congenital aneurysms, cerebrovascular malformations, microaneurysms caused by hypertensive cerebral arteriosclerosis, etc.) and blood flows into the subarachnoid space, accounting for about 10% of acute strokes. ;

The intracerebral hematoma penetrates the brain tissue and blood flows into the subarachnoid space.

It is the most common cause (accounting for about 75% to 80%). Among them, congenital miliary aneurysms account for about 75%, and fusiform aneurysms caused by hypertension, atherosclerosis, and fungal aneurysms caused by infection can also be seen.

It accounts for about 10% of the causes of SAH, of which arteriovenous malformations (AVMs) account for 80% of vascular malformations. More common in young people, more than 90% are located in the supratentorial area, often in the distribution area of ​​the middle cerebral artery.

Such as moyamoya disease (accounting for 20% of SAH in children), intracranial tumors, pituitary apoplexy, blood system diseases, intracranial venous system thrombosis and complications of anticoagulation therapy, etc. In addition, about 10% of patients have unknown causes

stimulate pain sensitive structures

Intracranial pressure (↑)

Blood clot blocks cerebrospinal fluid circulation pathway

inflammatory mediators

vasoactive substances

hypothalamus

The typical manifestation of aneurysmal SAH is a sudden, extremely severe, full-body headache. Patients often describe the headache as "the worst headache they have ever experienced in their life." The headache cannot be relieved or is progressively worsening.

It is often accompanied by transient disturbance of consciousness, nausea and vomiting.

Localized headaches often indicate the location of a ruptured aneurysm

The headache of aneurysmal SAH lasts for several days and gradually decreases after 2 weeks. If the headache worsens again, it often indicates that the aneurysm is bleeding again. However, SAH headaches caused by arteriovenous malformation rupture are often not severe.

Cervical ankylosis, Kernig's sign, Brudzinski sign and other meningeal irritation signs, with cervical ankylosis being the most common

Subvitreous patchy hemorrhage can be seen in the fundus of 20% of patients, which is caused by acute increase in intracranial pressure and obstruction of ophthalmic vein return.

Some patients may develop symptoms such as cerebral heart syndrome, gastrointestinal bleeding, acute pulmonary edema, and localized neurological deficits.

Patients have forehead and eye pain, vascular murmurs, exophthalmos, and eye movement disorders caused by damage to cranial nerves III, IV, VI, and V1, and their rupture can cause internal carotid artery cavernous sinus fistula.

Patients presenting with oculomotor nerve compression often suggest posterior communicating artery aneurysm

Symptoms such as hemiplegia, aphasia, and convulsions in patients often indicate that the aneurysm is located at the first branch of the middle cerebral artery.

The patient's symptoms such as psychiatric symptoms, unilateral or bilateral lower limb paralysis, and disturbance of consciousness suggest that the aneurysm is located in the anterior cerebral artery or anterior communicating artery.

The patient presented with homonymous hemianopsia, Weber syndrome, and III cranial nerve palsy.

Patients may experience symptoms such as occipital and facial pain, hemifacial spasm, facial paralysis, and brainstem compression.

It refers to the recurrence of severe headache, vomiting, epileptic seizures, coma or even decerebrate tonic attacks after the condition has stabilized. Cervical ankylosis and Kernig's sign are aggravated. The cerebrospinal fluid is bright red upon review. 20% of patients with aneurysms may experience rebleeding 10 to 14 days after the disease, approximately doubling the mortality rate

Delayed vasospasm begins to occur 3 to 5 days after illness, peaks at 5 to 14 days, and gradually disappears in 2 to 4 weeks. TCD or DSA can help confirm the diagnosis.

Caused by blood entering the ventricular system and subarachnoid space to form blood clots that block the cerebrospinal fluid circulation pathway.

In mild cases, signs such as drowsiness, slow thinking, impaired short-term memory, limited upward vision, abducens nerve paralysis, and hyperreflexia of lower limb tendons may occur.

Severe cases can cause intracranial hypertension and even cerebral herniation.

Subacute hydrocephalus occurs weeks after onset and is characterized by insidious dementia, gait abnormalities, and urinary incontinence

Sudden severe headache

Vomit

disorder of consciousness

Positive meningeal irritation sign

No focal neurological signs

CT confirms cisterns and cobwebs

Submembranous space hyperdensity sign

lumbar puncture bloody cerebrospinal fluid

★Key points in identifying subarachnoid hemorrhage and cerebral hemorrhage

Dehydrating agents are mainly used, such as mannitol, furosemide, glyceryl fructose or glycerol sodium chloride. Albumin can also be used as appropriate.

Those who are irritable are given sedatives, and those who have headaches are given analgesics. Be careful when using aspirin and other non-steroidal anti-inflammatory analgesics that may affect coagulation function, or morphine, pethidine and other drugs that may affect respiratory function.

This includes maintaining water and electrolyte balance, providing high-fiber and high-energy diets, strengthening nursing care, and paying attention to preventing urinary tract infections and aspiration pneumonia, etc.

Prevent excessive blood pressure from causing further bleeding, and pay attention to maintaining cerebral perfusion pressure.

Generally, systolic blood pressure should be controlled below 160mmHg.

SAH does not have the hemostatic effect of compressing brain tissue, so hemostatic drugs can be used appropriately.

Clamping or endovascular treatment are the most effective treatments for preventing rebleeding in SAH.

nimodipine

is cerebral angioplasty and/or selective intra-arterial vasodilator therapy, Especially if you haven’t seen quick results after treatment to raise your blood pressure.

cerebrospinal fluid shunt treatment

A permanent cerebrospinal fluid shunt was performed.