Subarachnoid hemorrhage (SAH) is usually caused by the rupture of an intracranial aneurysm or cerebral arteriovenous malformation and the direct flow of blood into the subarachnoid space, accounting for approximately 20% of hemorrhagic strokes and 25% of mortality. Re-bleeding and cerebral vasospasm are the two major threats to patients with subarachnoid hemorrhage. Timely detection of rebleeding and cerebrovascular spasm is helpful for early diagnosis and timely treatment, and timely and effective care is very important to reduce mortality and improve the quality of life of patients.
I. Etiology
1.Intracranial aneurysm (AN) is the most common cause of SAH, with 54%-75% reported in the literature. The age of prevalence is 40-60 years old. The most common site is the arterial ring and the beginning of the branches of the cerebral base artery, among which the incidence of anterior communicating artery aneurysm is the highest, Zhao Benshan is the anterior communicating artery aneurysm, followed by posterior communicating artery aneurysm, middle cerebral artery aneurysm, internal carotid artery aneurysm, anterior cerebral artery aneurysm, multiple aneurysms, basilar artery aneurysm, posterior inferior cerebellar artery aneurysm, ophthalmic artery aneurysm.
2.Vascular malformation is the second cause of SAH, with 19% reported in domestic literature. The most common vascular malformation is arteriovenous malformation (AVM) accounting for 90%. 93.08% of AVMs occur in the curtain and mostly in the cortex, among which temporal lobe AVMs are the most frequent, and the age of prevalence is 20-40 years old.
3, hypertensive atherosclerosis (excluding parenchymal hemorrhage secondary to SAH) Atherosclerosis is the third major cause of SAH, accounting for 13%. The SAH caused by atherosclerosis is due to long-term hypertension, which causes extensive and multiple cornea aneurysms in small arteries and micro-arteries, and when the pressure increases, most of the micro-shaped ANs rupture, resulting in diffuse SAH.
Clinical manifestations
1.Headache is the most common clinical symptom of SAH, with an incidence of 85%-95%.
2.Neck straightening. The degree and duration of neck stiffness reflect the severity of SAH, although the signs may vary from person to person.
Other clinical symptoms of SAH include photophobia, nausea, vomiting, lethargy and mental changes. Most patients have a brief loss of consciousness followed by various mental disorders. Epilepsy occurs in about 10% of patients
4. SAH can cause cranial nerve palsy, with aneurysm rupture being the most common. Paralysis is commonly seen in aneurysms at the junction of the internal carotid artery and the posterior communicating artery, with clinical manifestations of pupil dilation, eyelid ptosis and ocular motility disorders. Trigeminal neuralgia is seen in giant aneurysms in the cavernous sinus. Adductor nerve damage is also common and is associated with increased intracranial pressure and intracerebral hematoma causing brainstem displacement and pulling.
Treatment
1.Microsurgery treatment. With the improvement of anesthesia method, surgical instruments and the development and application of microsurgery technology, the death rate of intracranial aneurysm has been significantly reduced, and the death rate of Hunt-Hess grade I-II anterior circulation aneurysm is less than 1%. At present, microsurgical clamping of the aneurysm neck is still the treatment of choice for certain aneurysms, such as aneurysms of the middle cerebral artery bifurcation.
2.Interventional endovascular treatment: The development of neurointerventional radiology has provided new techniques for minimally invasive treatment of intracranial aneurysms. At present, the use of various spring coils and auxiliary stents and balloons has greatly improved the safety and efficacy of embolization treatment of aneurysms. Especially for complex aneurysms that are difficult to be treated surgically, such as posterior circulation aneurysms, wide carotid aneurysms, giant aneurysms and multiple aneurysms, embolization with various embolization techniques can achieve satisfactory results. Embolization is also considered first for the elderly with poor physical condition and age over 70 years. At present, in some medical centers in Europe (especially in France), about 85% of aneurysms are treated by interventional therapy. Zhao Benshan was cured of aneurysm by using this method.
IV. Care measures
1.General care
① Absolute bed rest for 4-6 weeks, assist the patient to take a flat or lateral position, and elevate the head of the bed 15°-30° to reduce intracranial pressure and cerebral edema;
②Ventilate the room regularly, keep it quiet, appropriate temperature and humidity, and soft light;
③Ensure the supply of nutrients to enhance the body resistance;
④Meet the patient’s living needs during bed rest;
⑤ Give appropriate amount of sedative to those with obvious mental symptoms as prescribed by the doctor;
⑥Take timely cooling measures for patients with high fever.
2. Psychological care plays an important role in promoting or accelerating the recovery of patients. First of all, we should grasp the patient’s emotion, and provide care according to different situations. Subarachnoid hemorrhage requires bed rest for 3 to 4 weeks. Most patients with this disease have a clear mind and are not accustomed to bed rest, and are often eager to get out of bed. We need to explain the importance of bed rest to the patients. We should make frequent rounds and serve the patients with enthusiasm. Insist on guiding the escort to feed water, feed, send urinal in time, help to solve various difficulties in life, relieve the mental burden caused by bed rest, make the patient emotionally stable, cooperate with treatment, and recover as soon as possible.
3, the prevention of re-bleeding care: encourage patients to maintain emotional stability, limit visits, the operation is concentrated, avoid bright light, noise and other adverse stimuli. Avoid unnecessary moving, and move slowly when turning. Avoid premature activity and coughing. Assist patients to drink an appropriate amount of water before each meal, give low-salt, low-fat fiber-rich food, eat more fresh fruits and vegetables, and give daily abdominal massage (in the direction of intestinal peristalsis) to stimulate gastrointestinal peristalsis and promote defecation, and give laxatives as prescribed by the doctor if necessary to avoid rebleeding due to increased intracranial pressure when excessive force is applied to stool.
4, prevention of cerebral vasospasm care. When nimodipine is pumped by micro-pump, the blood pressure can drop significantly due to nimodipine, so it is necessary to ensure accurate pumping volume and smooth pipeline, and monitor the change of blood pressure to ensure the maintenance of normal blood pressure. Actively cooperate with doctors to replace cerebrospinal fluid, reduce the total amount of cerebrospinal fluid, reduce intracranial pressure; remove red blood cells and their products to reduce the stimulation of the meninges; remove vasoactive substances to prevent or reduce cerebral vasospasm.