Subarakhnoidalny hemorrhage — the state caused by brain bleeding at which blood accumulates in subweb space of cerebral covers. It is characterized by an intensive and sharp headache, short-term loss of consciousness and its confusion in combination with a hyperthermia and meningealny simptomokompleks. It is diagnosed according to KT and an angiography of a brain; at their inaccessibility — on availability of blood in tserebrospinalny liquid. The basis of treatment is made by basic therapy, knocking over of an angiospazm and surgical switching off of cerebral aneurism of a blood-groove.
Subarakhnoidalny hemorrhage (SAKY) represents a separate type of a hemorrhagic stroke at which izlity blood occurs in subarakhnoidalny (subweb) space. The last settles down between arakhnoidalny (web) and soft cerebral covers, contains tserebrospinalny liquid. The blood which streamed in subweb space increases the volume of the liquid which is in it that leads to increase in intra cranial pressure. There is an irritation of a soft cerebral cover to development of aseptic meningitis. The angiospasm arising in response to bleeding can become the reason of ischemia of certain sites of a brain with developing of an ischemic stroke or TIA.
Subarakhnoidalny hemorrhage makes about 10% of all ONMK. Frequency of its occurrence in a year varies from 6 to 20 cases on 100 thousand population. As a rule, SAKY it is diagnosed for persons 20 years are more senior, it is the most frequent (to 80% of cases) in an age interval from 40 to 65 years.
Reasons of subarakhnoidalny hemorrhage
In 70-85% of cases subarakhnoidalny hemorrhage is a consequence of a rupture of vascular aneurism. In the presence of aneurism of vessels of a brain the probability of its gap makes from 1% to 5% a year and from 10% to 30% during all life. Treat the diseases which are often followed by existence of cerebral aneurism: Elers's syndrome — Danlosa, fakomatoza, Marfan's syndrome, anomalies of a villiziyev of a circle, an aorta koarktation, a congenital hemorrhagic teleangiektaziya, kidneys, etc. congenital diseases. Arteriovenozny malformation of a brain (cerebral AVM) usually lead to hemorrhage in ventricles of a brain or parenchymatous to bleeding and seldom happen etiofaktory isolated SAKY.
Subarakhnoidalny hemorrhage of traumatic genesis occurs at ChMT and is caused by wound of vessels at a skull fracture, a bruise of a brain or its sdavleniya. The subarakhnoidalny hemorrhage caused by a patrimonial trauma of the newborn can be an example of similar of SAKY. Risk factors of SAKY of the newborn are a narrow basin at the woman in labor, rapid childbirth, perenoshenny pregnancy, pre-natal infections, a large fruit, anomalies of development of a fruit, prematurity.
Subarakhnoidalny hemorrhage can arise owing to stratification vertebral or a carotid. In most cases it is about stratification of ekstrakranialny departments vertebral arteries, extending to its intraduralny site. Act as rare factors of SAKY a miksoma of heart, the cerebral tumor, vaskulit, an angiopatiya at an amiloidoza, crescent and cellular anemia, various koagulopatiya, antikoagulyantny treatment.
Along with immediate causes of emergence of SAKY allocate the promoting factors: arterial hypertension, alcoholism, atherosclerosis and hypercholesterolemia, smoking. To 15-20% of SAKY it is not possible to establish the hemorrhage reason. In such cases speak about cryptogene character of SAKY. Neanevrizmatichesky perimezentsefalichesky benign subarakhnoidalny hemorrhage at which bleeding occurs in the tanks surrounding a midbrain belongs to such options.
Classification of subarakhnoidalny hemorrhage
According to an etiofaktor subarakhnoidalny hemorrhage is classified on post-traumatic and spontaneous. Traumatologists, with the second — experts in the field of neurology often face the first option. Depending on a zone of hemorrhage distinguish isolated and combined SAKY. The last, in turn, is subdivided on subarakhnoidalno-ventrikulyarny, subarakhnoidalno-parenchymatous and - parenchymatous .
In world medicine Fischer's classification based on prevalence of SAKY by results of brain KT is widely applied. According to it allocate: the class 1 — blood is absent, a class 2 — SAKY less than 1 mm thick without clots, a class 3 — SAKY more than 1 mm thick or with existence of clots, a class 4 — mainly parenchymatous or ventricular hemorrhage.
Symptoms of subarakhnoidalny hemorrhage
Harbingers of SAKY are observed at 10-15% of patients. They are caused by existence of aneurism with the thinned walls through which a liquid part of blood filters. Time of emergence of harbingers varies from days to 2 weeks before SAKY. Some authors allocate it as the dogemorragichesky period. At this time patients note passing tsefalgiya, dizzinesses, nausea, tranzitorny focal symptomatology (damage of a trigeminal nerve, glazodvigatelny frustration, paresis, sight violations, aphasia and so forth). In the presence of huge aneurism the clinic of the dogemorragichesky period has opukholepodobny character in the form of the progressing all-brain and focal symptomatology.
Subarakhnoidalny hemorrhage demonstrates sharply arising intensive headache and disorders of consciousness. At anevrizmatichesky SAKY extraordinary strong, immediately accruing tsefalgiya is observed. At stratification of arteries the headache has two-phase character. Short-term loss of consciousness and the confusion of consciousness remaining up to 5-10 days is typical. Perhaps psychomotor excitement. Long loss of consciousness and development of its heavy violations (coma) testify in favor of heavy bleeding with izlitiy blood in cerebral ventricles.
The meningealny simptomokompleks acts as the Patognomonichny sign of SAKY: vomiting, rigidnost of muscles of a nape, giperesteziya, photophobia, obolochechny symptoms of Kerniga and Brudzinsky. It appears and progresses in the first days of hemorrhage, can have various expressiveness and remain from several days to one month. Accession of focal neurologic symptomatology in the first days speaks well combined parenchymatous for hemorrhage. Later emergence of focal symptoms can be a consequence of secondary ischemic defeat of brain fabrics that is observed to 25% of SAKY.
Usually subarakhnoidalny hemorrhage proceeds with rise in temperature to a febrilitet and vistsero-vegetative frustration: bradycardia, arterial hypertension, in hard cases — disorder of breath and warm activity. The hyperthermia can have the delayed character and arises as a result of chemical action of products of disintegration of blood on cerebral covers and the thermoregulatory center. In 10% of cases there are epipristupa.
Atypical forms of SAKY
At a third of patients subarakhnoidalny hemorrhage has the atypical current masking under a migraine paroxysm, sharp psychosis, meningitis, hypertensive crisis, cervical radiculitis. The Migrenozny form of SAKY proceeds with sudden emergence of a tsefalgiya without consciousness loss. The Meningealny simptomokompleks is shown 3-7 days later against the background of deterioration in a condition of the patient. The Lozhnogipertonichesky form of SAKY is often regarded as hypertensive crisis. As HELL is shown by a tsefalgiya against the background of high figures. Subarakhnoidalny hemorrhage is diagnosed on the patient's additional examination at deterioration in a state or repeated bleeding. The Lozhnovospalitelny form imitates meningitis. The tsefalgiya is noted, febrilitt, the expressed meningealny symptoms. The Lozhnopsikhotichesky form is characterized by prevalence of psychosymptomatology: disorientations, a deliriya, the expressed psychomotor excitement. It is observed at a rupture of aneurism of a forward brain artery, krovosnabzhayushchy frontal lobes.
Complications of SAKY
The analysis of results of transkranialny doppler sonography showed that subarakhnoidalny hemorrhage practically is always complicated by a spasm of cerebral vessels. However clinically significant spasm is noted, according to various data, at 30-60% of patients. Cerebral usually develops on 3-5 days of SAKY and reaches a maximum for 7-14 days. Its degree directly correlates with a volume of the streamed blood. In 20% of cases primary subarakhnoidalny hemorrhage is complicated by an ischemic stroke. At repeated the frequency of a cerebral heart attack is twice higher than SAKY. Also carry the accompanying hemorrhage in a brain parenchyma, break of blood in ventricles to complications of SAKY.
Approximately in 18% of cases subarakhnoidalny hemorrhage is complicated by the sharp hydrocephaly arising at blockade of outflow of tserebrospinalny liquid the formed blood clots. In turn, hydrocephaly can lead to hypostasis of a brain and dislocation of its structures. Among somatic complications dehydration, a giponatriyemiya, neurogenetic hypostasis of lungs, aspiration or stagnant pneumonia, arrhythmia, a myocardial infarction, a decompensation of the available heart failure, TELA, cystitis, pyelonephritis, a stressful ulcer, LCD bleeding are possible.
Diagnosis of subarakhnoidalny hemorrhage
The typical clinical picture allows to suspect subarakhnoidalny hemorrhage to the neurologist. In case of atypical forms early diagnostics of SAKY is represented very difficult. Brain KT is shown to all patients with suspicion of subarakhnoidalny hemorrhage. The method allows to establish authentically the diagnosis to 95% of SAKY; to reveal hydrocephaly, bleeding in ventricles, the centers of cerebral ischemia, brain hypostasis.
Detection of blood under a web cover is the indication to a cerebral angiography for the purpose of establishment of a source of bleeding. Modern noninvasive KT or the MRT-angiography is carried out. At patients with the heaviest degree of SAKY the angiography is carried out after stabilization of their state. If the source of bleeding does not manage to be defined, then the repeated angiography in 3-4 weeks is recommended.
The Lyumbalny puncture at suspicion of subarakhnoidalny hemorrhage is made in the absence of KT and in cases when in the presence of classical clinic of SAKY it is not diagnosed during KT. Identification serves as the indication to an angiography in tserebrospinalny liquid of blood or a ksantokhromiya. In the absence of similar changes of a likvor it is necessary to look for other reason of a condition of the patient. Transkranialny UZDG and duplex scanning of cerebral vessels allow to reveal in early terms of SAKY and to observe a condition of brain blood circulation in dynamics.
During diagnostics subarakhnoidalny hemorrhage should be differentiated with the ONMK other forms (a hemorrhagic stroke, TIA), meningitis, an encephalomeningitis, okklyuzionny hydrocephaly, a craniocereberal trauma, a migrenozny paroxysm, feokhromotsitomy.
Treatment of subarakhnoidalny hemorrhage
Basic therapy against the background of which specific treatment is performed is carried out. Basic therapy of SAKY represents actions for normalization of cardiovascular and respiratory functions, corrections of the main biochemical constants. For the purpose of reduction of hydrocephaly at its increase and knockings over of cerebral hypostasis diuretic therapy is appointed ( or ). At inefficiency of conservative therapy and progressing of hypostasis of a brain with threat of a dislocation syndrome decompressive cranial trepanation, external ventrikulyarny drainage is shown.
Basic therapy also includes symptomatic treatment. If subarakhnoidalny hemorrhage is followed by spasms, antikonvulsant include (lorazepam, diazepam, valproyevy to - that); at psychomotor excitement — sedatives (diazepam, , tiopentat sodium); at repeated vomiting — , , . In parallel perform therapy and prevention of somatic complications.
So far subarakhnoidalny hemorrhage has no the effective conservative ways of specific treatment allowing to achieve a stop of bleeding or restriction of amount of the streamed blood. According to pathogenesis specific therapy of SAKY is directed to minimization of an angiospazm, the prevention and therapy of cerebral ischemia. The standard of therapy is application of a nimodipin and ZN-therapy. The last allows to support a gipervolemiya, the operated hypertensia and a gemodilyution therefore rheological properties of blood and microcirculation are optimized.
Specific surgical treatment of SAKY is optimum in the first 72 h. It is carried out by the neurosurgeon and is directed to an exception of the become torn aneurism of a blood-groove. Operation can consist in clipping of a neck of aneurism or endovascular introduction filling her cavity a cylinder catheter. Endovascular occlusion is more preferable at an unstable condition of the patient, high risk of complications of open operation, an early angiospazm. At a decompensation of a cerebral angiospazm stenting or angioplasty of a spazmirovanny vessel is possible.
Forecast of subarakhnoidalny hemorrhage
In 15% subarakhnoidalny hemorrhage comes to an end with death even before rendering medical aid. The lethality in the first month at sick SAKY reaches 30%. At a coma mortality makes about 80%, at repeated SAKY — 70%. At the survived patients residual neurologic deficiency often remains. The forecast in cases when at an angiography it is not possible to establish a bleeding source is optimum. Most likely, in similar cases there is an independent closing of vascular defect owing to its small size.
The probability of repeated hemorrhage every day the first month remains at the level of 1-2%. Subarakhnoidalny hemorrhage of anevrizmatichesky genesis repeats in 17-26% of cases, at AVM — in 5% of cases, at SAKY other etiology — much more rare.