Subarachnoid Hemorrhage

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Subarachnoid Hemorrhage

Definition

A subarachnoid hemorrhage is an abnormal and very dangerous condition in which blood collects beneath the arachnoid mater, a membrane that covers the brain. This area, called the subarachnoid space, normally contains cerebrospinal fluid. The accumulation of blood in the subarachnoid space can lead to stroke, seizures, and other complications. Additionally, subarachnoid hemorrhages may cause permanent brain damage and a number of harmful biochemical events in the brain. A subarachnoid hemorrhage and the related problems are frequently fatal.

Description

Subarachnoid hemorrhages are classified into two general categories: traumatic and spontaneous. Traumatic refers to brain injury that might be sustained in an accident or a fall. Spontaneous subarachnoid hemorrhages occur with little or no warning and are frequently caused by ruptured aneurysms or blood vessel abnormalities in the brain.

Traumatic brain injury is a critical problem in the United States. According to annual figures compiled by the Brain Injury Association, approximately 373,000 people are hospitalized, more than 56,000 people die, and 99,000 survive with permanent disabilities due to traumatic brain injuries. The leading causes of injury are bicycle, motorcycle, and automobile accidents, with a significant minority due to accidental falls, and sports and recreation mishaps.

Exact statistics are not available on traumatic subarachnoid hemorrhages, but several large clinical studies have found an incidence of 23-39% in relation to severe head injury. Furthermore, subarachnoid hemorrhages have been described in the medical literature as the most common brain injury found during autopsy investigations of head trauma.

Spontaneous subarachnoid hemorrhages are often due to an aneurysm (a bulge or sac-like projection from a blood vessel) which bursts. Arteriovenous malformations (AVMs), which are abnormal interfaces between arteries and veins, may also rupture and release blood into the subarachnoid space. Both aneurysms and AVMs are associated with weak spots in the walls of blood vessels and account for approximately 60% of all spontaneous subarachnoid hemorrhages. The rest may be attributed to other causes, such as cancer or infection, or are of unknown origin.

In industrialized countries, it is estimated that there are 6.5-26.4 cases of spontaneous subarachnoid hemorrhage per 100,000 people annually. Certain factors raise the risk of suffering a hemorrhage. Aneurysms are acquired over a person's lifetime and are rarely a factor in subarachnoid hemorrhage before age 20. Conversely, AVMs are present at birth. In some cases, there may be a genetic predisposition for aneurysms or AVMs. Other factors that have been implicated, but not definitively linked to spontaneous subarachnoid hemorrhages, include atherosclerosis, cigarette use, extreme alcohol consumption, and the use of illegal drugs, such as cocaine. The exact role of high blood pressure is somewhat unclear, but since it does seem linked to the formation of aneurysms, it may be considered an indirect risk factor.

The immediate danger due to subarachnoid hemorrhage, whether traumatic or spontaneous, is ischemia. Ischemia refers to tissue damage caused by restricted or blocked blood flow. The areas of the brain that do not receive adequate blood and oxygen can suffer irreparable injury, leading to permanent brain damage or death. An individual who survives the initial hemorrhage is susceptible to a number of complications in the following hours, days, and weeks.

The most common complications are intracranial hypertension, vasospasm, and hydrocephalus. Intracranial hypertension, or high pressure within the brain, can lead to further bleeding from damaged blood vessels; a complication associated with a 70% fatality rate. Vasospasm, or blood vessel constriction, is a principal cause of secondary ischemia. The blood vessels in the brain constrict in reaction to chemicals released by blood breaking down within the subarachnoid space. As the blood vessels become narrower, blood flow in the brain becomes increasingly restricted. Approximately one third of spontaneous subarachnoid hemorrhages and 30-60% of traumatic bleeds are followed by vasospasm. Hydrocephalus, an accumulation of fluid in the chambers of the brain (ventricles) due to restricted circulation of cerebrospinal fluid, follows approximately 15% of subarachnoid hemorrhages. Because cerebrospinal fluid cannot drain properly, pressure accumulates on the brain, possibly prompting further ischemic complications.

Causes and symptoms

Whether through trauma or disease, subarachnoid hemorrhages are caused by blood being released by a damaged blood vessel and accumulating in the subarachnoid space. Symptoms associated with traumatic subarachnoid hemorrhage may or may not resemble those associated with spontaneous hemorrhage, as trauma can involve multiple injuries with overlapping symptoms.

Typically, a spontaneous subarachnoid hemorrhage is indicated by a sudden, severe headache. Nausea, vomiting, and dizziness frequently accompany the pain. Loss of consciousness occurs in about half the cases of spontaneous hemorrhage. A coma, usually brief, may occur. A stiff neck, fever, and aversion to light may appear following the hemorrhage. Neurologic symptoms may include partial paralysis, loss of vision, seizures, and speech difficulties.

Spontaneous subarachnoid hemorrhages may be preceded by warning signs prior to the initial bleed. Sentinel, or warning, headaches may be present in the days or weeks before an aneurysm or AVM ruptures. These headaches can be accompanied by dizziness, nausea, and vomiting, and possibly neurologic symptoms. Approximately 50% of AVMs are discovered before they bleed significantly; however, most aneurysms are not diagnosed before they rupture.

Diagnosis

To make a diagnosis, a health-care provider takes a detailed history of the symptoms and does a physical examination. The symptoms may mimic other disorders and diagnosis can be complicated, especially if the individual is unconscious. The sudden, severe headache can fuel suspicion of a subarachnoid hemorrhage or similar event, and a computed tomography scan (CT scan) or magnetic resonance imaging (MRI) scan is considered essential to a quick diagnosis. The MRI is less sensitive than the CT in detecting acute subarachnoid bleeding, but more sensitive in diagnosing AVM or aneurysm.

A CT scan reveals blood that has escaped into the subarachnoid space. For the best results, the scan should be done within 12 hours of the hemorrhage. If this is not possible, lumbar puncture and examination of the cerebrospinal fluid is advised. Lumbar puncture is also done in cases in which the CT scan doesn't reveal a hemorrhage, but there is a high suspicion that one has occurred. In subarachnoid hemorrhage, cerebrospinal fluid shows red blood cells and/or xanthochromia, a yellowish tinge caused by blood breakdown products. Xanthochromia first appears six to 12 hours after subarachnoid hemorrhage, making it advisable to delay lumbar puncture until at least 12 hours after the onset of symptoms for a more definite diagnosis.

Once a hemorrhage, AVM, or aneurysm has been diagnosed, further tests are done to pinpoint the damage. The CT scan may be useful in giving the general location, but cerebral angiography maps out the exact details. This procedure involves injecting a special dye into the blood stream. This dye makes blood vessels visible in x rays of the area.

Treatment

The initial course of treatment focuses on stabilizing the hemorrhage victim. Depending on the individual's condition, this may involve intubation and mechanical ventilation, supplemental oxygen, intravenous fluids, and close monitoring of vital signs. If the person suffers seizures, an anticonvulsant, such as phenytoin (Dilantin), is administered. Nimodipine, a calcium channel blocker, may be given to prevent vasospasm and its complications. Sedatives and medications for pain, nausea, and vomiting are administered as needed.

Once the individual is stabilized, cerebral angiography is done to locate the damaged blood vessel. This information and the individual's condition are considered before attempting surgical treatment. Surgery is necessary to remove the damaged area of the blood vessel and prevent a second hemorrhage. The specific neurosurgical procedures depend on the location and type of blood vessel damage. Typically, clip ligation is the preferred means of treating an aneurysm, and surgical excision, radiosurgery, or endovascular embolization are used to manage an AVM.

Prognosis

Individuals who are conscious and demonstrate few neurologic symptoms when they reach medical help have the best prognosis. However, the overall prospects for subarachnoid hemorrhage patients are generally not good. Of the individuals who suffer an aneurysmal hemorrhage, approximately 15% do not live long enough to get medical treatment. Another 20-40% will not survive the complications caused by the hemorrhage, and approximately 12% of the survivors will experience permanent neurologic disability. Neurologic disabilities may include partial paralysis, weakened or numbed areas of the body, cognitive or speech difficulties, and vision problems. Individuals whose subarachnoid hemorrhages occur as a result of AVMs have a slightly better prognosis, although the risk of death is approximately 10-15% for each hemorrhage.

Subarachnoid hemorrhage associated with traumatic brain injury has a poor prognosis. In clinical studies, 46-78% of head injury cases involving subarachnoid hemorrhage resulted in severe disability, vegetative survival, or death. Furthermore, it is possible that traumatic subarachnoid hemorrhages are accompanied by additional injuries, which would further diminish survival and recovery rates.

Prevention

Traumatic brain injury is the leading cause of subarachnoid hemorrhages, so it follows that efforts to prevent head injury would prevent these hemorrhages. Since accidents cannot always be prevented, measures to minimize potential damage are always advisable. Use of activity-appropriate protective gear, such as bicycle helmets, motorcycle helmets, and sports head gear, is strongly encouraged and promoted by medical associations, consumer organizations, advocacy groups, and health-care professionals. These same groups also advise using seat belts in automobiles.

Spontaneous subarachnoid hemorrhages are more difficult to prevent. Since there may be a genetic component to aneurysms and AVMs, close relatives to individuals with these conditions may consider being screened to assess their own status. Quitting smoking and keeping blood pressure within normal limits may also reduce the risk of suffering a spontaneous subarachnoid hemorrhage.

KEY TERMS

Aneurysm— A weak point in a blood vessel where the pressure of the blood causes the vessel wall to bulge outwards. An aneurysm may also appear as a sac-like projection from the blood vessel wall.

Arachnoid mater— One of three membranes that encase the brain and spinal cord. The arachnoid mater is the middle membrane.

Arteriovenous malformation— An abnormal tangle of arteries and veins in which the arteries feed directly into the veins without a normal intervening capillary bed.

Atherosclerosis— An abnormal condition in which lipids, or fats, form deposits on the inside walls of blood vessels.

Cerebral angiography— A medical test in which an x-ray visible dye is injected into blood vessels to allow them to be imaged on an x ray.

Cerebrospinal fluid— The clear, normally colorless fluid found within the subarachnoid space.

Computerized tomography (CT) scan— Cross-sectional x rays of the body compiled to create a three-dimensional image of the body's internal structures.

Hemorrhage— The escape of blood from blood vessels.

Hydrocephalus— Englargement of the chambers in the brain (ventricles) caused by an accumulation of cerebrospinal fluid.

Intracranial hypertension— Abnormally high pressure within the brain.

Ischemia— A condition in which blood flow is cut off or restricted from a particular area. The tissue becomes starved of oxygen and nutrients, resulting in tissue death.

Ischemic— Referring to ischemia.

Lumbar puncture— A diagnostic procedure in which a needle is inserted into the lower spine to withdraw a small amount of cerebrospinal fluid. This fluid is examined to assess trauma to the brain.

Subarachnoid— Referring to the space underneath the arachnoid mater.

Vasospasm— The constriction or narrowing of blood vessels. In cases of hemorrhage, the constriction is prompted by chemical signals from the escaped blood as it breaks down.