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Spontaneous subarachnoid (pronounced sub-uh-RACK-noid) hemorrhage is with very good reason the most feared cause of sudden onset headaches. Most often due to rupture of aneurysms (abnormal, balloon-like outpouchings of arteries) situated in the vicinity of the base of the brain, subarachnoid hemorrhages involve bleeding into the space between the brain and its surrounding membrane, called the meninges. A traumatic blow to the head can also cause subarachnoid hemorrhage, but this is a completely unrelated process and is not the topic of this article.

About 10% of men and women with spontaneous subarachnoid hemorrhages die before they even get to a hospital and over a third die within the 1st 4 weeks following the bleed. Survivors can suffer with serious impairments because of resulting brain damage.

And at the same time as the results of the initial bleed are not bad enough, in the following few weeks men and women with subarachnoid hemorrhage can have to bear unpleasantness and additional, serious complications. One complication is that the aneurysm responsible for the initial hemorrhage can bleed a second time and cause even more damage. This occurs in 4% of situations within the 1st 24 hours and there is one other 1.2% chance of re-bleeding every day thereafter for the 1st two weeks. Thus, without cure 20% of instances have a second hemorrhage within the 1st two weeks.

The other serious complication is that the blood deposited in the subarachnoid space can cause otherwise healthy arteries passing through this space to go into spasm. The spasm decreases blood-flow to the parts of the brain ordinarily nourished by these arteries and thereby inflicts additional damage. Or, said one other way, a blocked artery causes a new stroke, this time of the non-bleeding type. For reasons that are not entirely understood, these spasms of the arteries do not happen within the 1st few days after the initial hemorrhage. Instead, they most often develop after a postpone of 4-9 days.

What can be done to decrease these complications? In the case of blood-vessel spasm, the best cure is a preventive one. Administering a drug named nimodipine (prononounced nye-MO-dih-peen) intravenously makes spasming less likely to happen. But in order to prevent the other predominant complication, re-bleeding, the best treatments are those which physically stabilize the aneurysm. In one such procedure, a surgeon places a metal clip across the aneurysm where it joins the otherwise ordinary artery. An alternative surgery is to wrap the outside of the aneurysm with surgical gauze or plastic sheeting. A most recent procedure involves filling the aneurysm with small metal coils inserted via a flexible catheter snaked through the arteries.

How can one tell if a particular headache is brought on by a bleeding aneurysm? It can be a tough call, but certain features make a ruptured aneurysm more likely. First, a headache due to a ruptured aneurysm is usually of extremely hasty onset (often described as a “thunderclap”) and is classically the worst headache of one’s life. In men and women who already have frequent intense and serious headaches from other causes, the headache due to a ruptured aneurysm might feel diverse from the more usual attacks.

Medical evaluation of patients with ruptured aneurysms can turn up additional clues, like a stiffened neck or adjustments in the backs of the eyes made visible through an ophthalmoscope. Of course, if the patient is drowsy or confused, this might recommend that something serious is going on, as would any new impairment in the capacity to shift the eyes, an arm or a leg. A computed tomographic (CT) scan of the head performed within the 1st 24 hours is extremely sensitive in detecting a hemorrhage, but if the scan is delayed it is less capable to become aware of the bleed. A lumbar puncture (also known as a spinal tap) always detects subarachnoid hemorrhage even when it is a few days old, but if the needle causes bleeding by piercing a blood-vessel on its way to the subarachnoid space, the examination might give the false influence that a subarachnoid hemorrhage occurred when it hadn’t.

After discovery of subarachnoid hemorrhage, the next round of testing focuses on where exactly the bleeding occurred. at the same time as in over two-thirds of the instances it originates from ruptured aneurysms, other potential sources include tangles of abnormal blood-vessels known as arteriovenous malformations or from bleeds within the brain tissue that secondarily leak into the subarachnoid space. The managing physician can order any of 3 tests to image the blood vessels themselves and pinpoint the basis of bleeding.

The oldest test–still thought of as the gold-standard–is known as an arteriogram or, alternatively, an angiogram. An arteriogram is thought of as an “invasive” examination because the doctor must slide a long, flexible catheter through the arterial system (which is below much higher pressure than the veins) so that dye infused through the catheter will enter the arteries in question. Two most recent tests are “non-invasive,” though, in truth, they often involve an infusion into a vein. One is magnetic resonance arteriography (MRA) which is performed with the assist of an MRI-scanner. The other is computed tomographic arteriography (CT-A) which is performed with the facilitate of a CT-scanner. at the same time as the non-invasive tests are getting enhanced all the time, they still occasionally miss aneurysms otherwise visible on arteriograms.

Apart from identifying the bleeding aneurysms, these tests can become aware of additional aneurysms, when present. About 20% of individuals experiencing a ruptured aneurysm have one or more co-existing, unruptured aneurysms.

Subarachnoid hemorrhages happen annually in about 10 men and women out of 100,000. This computes to a 0.01% pace of annual occurrence. Contrast this figure with the 12% of the adult population who have migraine (most of whom have at least one intense and serious headache per year) and it is apparent that the large majority of intense and serious headaches are not due to ruptured aneurysms. But the concern about missing a ruptured aneurysm means that many folks without subarachnoid hemorrhage must receive tests in order to diagnose the few who have it.

What causes aneurysms in the 1st place? More than one factor is involved. First, there can be an inborn weakening of the artery’s wall. When the wall subsequently deteriorates in ways that can be accelerated by hypertension and smoking, an aneurysm can form.

Actually, aneurysms affecting the brain’s arteries are fairly common. Autopsy and arteriogram studies signify that about 1-4% of the general population have them. This is many more individuals than have subarachnoid hemorrhages, so a logical conclusion is that most people with aneurysms go through their whole lifetimes without having symptoms. Studies show that aneurysms less than 5 millimeters (0.2 inches) in diameter have a extremely low velocity of rupture, at the same time as aneurysms greater than 10 millimeters (0.4 inches) in diameter have a significant danger of bleeding.

Do ruptured aneurysms run in families? A 2005 report from the Scottish Aneurysm learn about group showed a slight tendency for this trait to be shared by close relatives. The 10-year hazard for subarachnoid hemorrhage in first-degree relatives (parents, siblings and children) was 1.2%. The peril was even lower in more distant relatives. In families with two affected first-degree relatives there was a trend toward higher hazard. The authors felt that most relatives of patients suffering subarachnoid hemorrhages have low danger of future hemorrhages, and that routine screening of family members is inappropriate unless there are multiple affected individuals in the same family.


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