Subarachnoidal hemorrhage

Description:

Subarachnoidal hemorrhage - suddenly arising bleeding in a subarachnoid space.

Symptoms of Subarachnoidal hemorrhage:

In the clinical course of aneurism of a brain allocate three periods: dogemorragichesky, hemorrhagic, posthemorrhagic. In the dogemorragichesky period at a half of patients with brain aneurisms the disease is not shown. At other patients in this period the local headache in a forehead, eye-sockets can be noted (as migraine). Headache episodes with meningeal symptoms are possible (on an extent of several hours to 1 — 2 days). These symptoms appear at people more often 40 years are more senior. Epileptic seizures of not clear genesis, and also passing dysfunctions of nerves, adjacent to aneurism, can be other manifestations: a diplopia, squint, an anisocoria (at a prelum III, IV, VI pairs of cranial nerves), a prozopalgiya (a prelum of the V couple), a front hemispasm (a prelum of the VII couple). Decrease in visual acuity and bitemporal defects of fields of vision happen result of pressure upon a hiazma, passing gomonimny hemianopsias - at a prelum of a visual tract. Such patient quite often make the diagnosis to ophthalmic migraine.

The hemorrhagic period lasts 3-5 weeks after a gap. The rupture of aneurism usually is followed by an acute intensive headache, is frequent with feeling of heat ("as boiled water spread under a skull"). At the time of a gap or right after it often there is a short-term loss of consciousness (a total spasm of superficial vessels of a brain to switching off of function of a reticular formation of a brainstem and hypothalamus). Sometimes the brain coma develops, however more often the patient is in a condition of devocalization. The blood which streamed in cerebrospinal liquid irritates a meninx and increases intracranial pressure that is shown by a headache, nausea, vomiting, dizziness, bradycardia, breath delay. Epileptic attacks are possible. Muscle tension of a neck and a Kernig's sign begin to come to light days later from the moment of subarachnoidal hemorrhage. During the first 5-10 days body temperature increases. Approximately a quarter of patients has focal and conduction symptoms (paresis, pathological-foot signs), alalias, memories, etc. that is connected or with a spasm of the corresponding brain artery, or with penetration of blood into marrow (a subarachnoidal and parenchymatous hemorrhage). The patients with the diagnosed aneurisms who were not exposed to surgical treatment often have repeated bleedings, especially at non-compliance with a bed rest in the first 3-4 weeks after subarachnoidal hemorrhage.

Depending on localization of the become torn aneurism the characteristic clinical picture appears.

At a rupture of supraklinoidny aneurism there is a fissura orbitalis superior syndrome. His clinical picture is connected with defeat of a third cranial nerve (the III couple): a ptosis, a mydriasis, disturbance of movements of an eyeglobe up, knutr, from top to bottom, local pains in frontal and orbital area (the I branch of the V nerve), the central scotoma under review, sometimes a blindness.

At a rupture of the aneurism which is localized in a lobby brain - a lobby connecting arteries, there are disorders of consciousness, disturbance of mentality, motor aphasia, paresis of distal departments of the lower extremity on the one hand with Babinsky's symptom.

The rupture of aneurism of an average brain artery is followed by a hemiparesis (hemiplegia), a hemianaesthesia, a hemianopsia and aphasia.

The rupture of aneurism of vertebralno-basilar system is characterized by emergence of all-brain symptoms, defeat of caudal group of cranial nerves, cerebellar, trunk symptoms with breath disturbance, up to its stop.

The posthemorrhagic period includes residual neurologic manifestations after the postponed hemorrhage. During this period at the patients who had inside brain hemorrhage danger of emergence repeated hemorrhages, proceeding more hard is big.

Reasons of Subarachnoidal hemorrhage:

Spontaneous, or primary, subarachnoidal hemorrhage (SAKY) usually comes from a rupture of aneurism of superficial vessels of a brain. More rare it happens is connected with atherosclerotic or mycotic aneurism, an arteriovenous malformation or hemorrhagic diathesis. At a craniocereberal injury subarachnoidal hemorrhage meets often, at the same time it concedes on the clinical value to other effects of a bruise of a brain.

Approximately in half of observations aneurisms of vessels of a brain are the reason of intracraneal hemorrhage. They are inborn and acquired. Externally aneurism often has a meshotchaty appearance in which distinguish a neck, a body and a bottom. Usually diameter of a vascular bag fluctuates from several millimeters to 2 cm. Aneurysms more than 2 cm in the diameter are considered as huge. Occur equally often at men and women.

Ruptures of aneurisms usually occur aged from 25 up to 50 years (approximately in 91% of observations). Unexploded aneurisms occur at 7-8%, and asymptomatic - at 0,5% of people. The rupture of aneurism almost always occurs in the field of its bottom where under increase it is quite often possible to see the dot openings covered with trombotichesky masses. Favourite localization of aneurisms - places of division of vessels of I and II orders into branches. The most frequent localization of aneurisms - supraklinoidny department of an internal carotid artery (30-34%), a lobby brain, front connecting arteries - 28-30%, an average brain artery of-16-20%, vertebralno-basilar system – 5-15%. Multiple aneurisms meet in 20% of observations.

At subarachnoidal hemorrhage for the 3-4th days owing to a long spasm of large arteries of the basis of a brain rather diffusion ischemia of a brain develops that leads to posthemorrhagic disturbances of cognitive functions (block, dementia). Secondary increase in intracranial pressure and strengthening of a headache are often noted.

Treatment of Subarachnoidal hemorrhage:

To the patient appoint a high bed rest with an exception of any physical and emotional tension. It is necessary to provide sufficient intake of liquid and nutrients. At excitement appoint diazepam, for reduction of a headache - non-narcotic analgesics, codeine.
Repeated lumbar punctures for cerebral decompression carry out at those patients to whom the first diagnostic lumbar puncture gave relief of a headache. At development of acute hydrocephaly administer the dehydrating drugs, sometimes drain ventricles, up to imposing of the ventrikuloperitonealny shunt.

Coagulants enter only in the first 2 days. Then their introduction is inexpedient because of development of disturbances of microcirculation in a head brain owing to a long spasm of large arteries of the basis of a brain. In deterioration cases - increase of all-brain and focal symptoms for the 3-5th day from the moment of subarachnoidal hemorrhage and absence in liquor of symptoms of repeated subarachnoidal hemorrhage - it is possible to enter small doses of heparin (on 5000 PIECES under stomach skin 2 times into days) or a fraksiparina.