General Knowledge
Brain vessels are in the subarachnoid distance, and subarachnoid hemorrhage (SAH) occurs with the bleeding of these vessels or the aneurysms on them.
The most common cause of subarachnoid hemorrhage is head trauma. Apart from trauma, the most common cause of spontaneous SAH is intracranial aneurysms.
Etiology and Clinic
0 Bleeds most commonly from anterior communicating artery aneurysm.
0 Secondly, posterior communicating artery aneurysm is seen (becomes mydriasis).
0 A-V malformations, bleeding diathesis, tumors, hypertension, anticoagulation can also cause SAH.
0 Sudden onset of severe headache.
0 Temporary loss of consciousness and epileptic seizures can follow the headache.
Meningeal irritation signs (nuchal stiffness, Kerning, Brudzinski signs) develop within 3-12 hours.
0 Fever is a common finding after bleeding.
Age, blood amount on CT, loss of consciousness during the event, clinical status at hospitalization, previous hypertension and presence of arterial disease are clinical prognostic factors.
0 The gradual closure of consciousness in the first 2-3 days after SAH suggests intracerebral hematoma and prompts emergency surgical intervention.
Diagnosis
0 Computed tomography (without contrast)
It is the first diagnostic test.
It is positive in more than 90% of cases if withdrawn within the first 72 hours after the event.
0 Lumbar puncture
It is the most sensitive test for SAH.
First erythrochromic CSF
CSF with xanthochromic appearance is typical in the following hours.
0 Angiography
It should be done in the first 3 days. It provides the definitive diagnosis (gold standard) of aneurysm or arterio-venous malformation.
Treatment:
Excessive lowering of blood pressure results in cerebral vasodilation and increases the risk of cerebral ischemia-infarction.
0 Intended for etiology.
0 idiopathic cases (20%) and those awaiting surgery; taken to conservative treatment.
Complications after SAH:
0 The most important cause of mortality and morbidity is Vasospasm occurs after the third day.
0 The most common problems after SAH are hyponatremia and hypovolemia.
0 Cardiac arrhythmias are seen in 50% of SAH cases.
0 Rebleeding is important because of the increased mortality rate. 50% of untreated patients bleed again in the first 6 months.
0 After the first aneurysm bleeding, the time period with the highest probability of rebleeding is the first 24 hours. The probability of bleeding again in the first 24 hours is 4%.
0 The probability of rebleeding increases with higher clinical grade, large aneurysm size, hypertension, advanced age, and female gender.
0 Acute or chronic hydrocephalus may develop after SAH.
Conservative Treatment Principles
1. Absolutely bed rest: He is taken to a quiet, dim room, watery pulp-free foods are given, and his vital signs are closely monitored.
2. Analgesia and sedation: Usually paracetamol and/or codeine (aspirin should not be used) for headache. Diazepam is used for sedation. In some patients, severe symptoms require IV morphine/midazolam therapy.
3. IV Fluids: Aggressive fluid therapy is given in the early period to prevent cerebral salt loss.
4. Anti-epileptics (phenytoins}
5. Calcium channel blockers: 60 mg nimodipine every 4 hours orally or by NG is started within the first 96 hours of SAH (they were unsuccessful in preventing cerebral vasospasm, given for neuroprotective effect).
6. 3H" therapy (Hypertension, hypervolemia, hemodilution) is applied to prevent the development of vasospasm.