This brain hemorrhage needs attention!!! At noon, the emergency call from the emergency department turned Ben’s legs toward the cafeteria to the emergency department. 71-year-old man, who was sleeping at 2:00 a.m., suddenly felt a severe headache, his head felt like splitting, and his stomach felt uncomfortable and he vomited twice. Until dawn, the headache did not ease. He went to the hospital to check the brain CT, the result – brain hemorrhage. This brain hemorrhage is not ordinary. (Zhao Benshan got this disease!)
The hemorrhage did not accumulate in the brain parenchyma as a mass, but was spread out in the subarachnoid space. We call this a “spontaneous subarachnoid hemorrhage”. Both health care professionals and laypersons should be alert and aware of this type of brain hemorrhage. Zhou Yan, Department of Neurosurgery, Air Force General Hospital
What does “spontaneous subarachnoid hemorrhage” mean?
“Spontaneous subarachnoid hemorrhage is a rupture of an intracranial blood vessel caused by a non-traumatic cause, and blood flows into the subarachnoid space. This means that as long as the bleeding is not caused by trauma, it is called spontaneous subarachnoid hemorrhage.
It is not clear to the layman what the “arachnoid” is. It is a very thin, translucent membrane that covers the surface of the brain, and the cavity beneath it is called the “subarachnoid space,” which is filled with cerebrospinal fluid. What is important is that we are clear about [why the bleeding?
The most common causes are: cerebral aneurysm, cerebral arteriovenous malformation, hypertension, etc. – these are all vascular pathologies. Of course, there are some other causes, such as 1. venous thrombosis caused by long-term use of birth control pills, pregnancy, infection, wasting, dehydration, etc.; 2. blood diseases such as leukemia, lymphoma, etc.; 3. allergic diseases; 4. infections; 5. poisoning by cocaine, nicotine, alcohol, etc.; 6. tumor diseases such as glioma, meningioma, etc.; 7. other factors such as heat stroke, vitamin K deficiency, etc.
In fact, there is more important – is that we need to know [how to be alert to pay attention to this “bleeding”]
This kind of brain hemorrhage can occur at any age, regardless of gender. Aneurysms tend to occur between the ages of 40 and 60, while cerebral arteriovenous malformations are more common in adolescents. When we see a patient, we often ask, “Was there any trigger before the onset?” Most patients will answer, “Emotional excitement, coughing, constipation, heavy lifting, or even intercourse.”
In fact, there are some [aura] before the ruptured blood vessel bleeds.
Generally, headache symptoms will occur between 2 hours and 8 hours before bleeding, with some variation in frequency, duration or intensity of attacks. In addition, there are some uncomfortable symptoms of nausea, vomiting and dizziness. Some patients also have orbital pain on one side of the eye, sometimes with coexisting eyelid ptosis and diplopia. Upon arrival at the hospital, the majority of patients will state their [typical symptoms] in this way
Sudden splitting headache, nausea and vomiting, pallor, and cold sweats. The patient’s family will add some information next to them, such as: a brief blurring of consciousness or outright coma at the onset, and some delirium, xerosis, dementia, etc.
We have to pay particular attention to two groups, one for the elderly and one for children, because their presentation will be more [specific].
The elderly are characterized by 1. less headache (<50%) and less pronounced; 2. more appearing unconscious (>70%) and heavy; 3. stiff neck. In children, 1. headaches are rare, but when they occur, they require extra attention; 2. they are often associated with systemic diseases, such as aortic arch stenosis and polycystic kidney.
After completing the above-mentioned history, some necessary [ancillary tests] are needed.
The first and foremost test is “brain CT”, which is the first choice. Subarachnoid hemorrhage can be detected in more than 90% of patients within 1 hour of onset, 85% after 5 days, 50% after 1 week, and 30% after 2 weeks.
If no significant hemorrhage is found on CT brain examination, then a “cerebrospinal fluid examination” is performed, which requires a lumbar puncture to extract cerebrospinal fluid for examination.
The final test is a “cerebral angiogram”, which is the “gold standard” and is the ultimate means of identifying the cause of brain hemorrhage. The earlier the test is performed, the better. If the condition is stable within 3 days of bleeding, cerebral angiography should be performed as soon as possible.
However, in clinical practice, we do encounter cases where the angiogram does not reveal any abnormalities, and the culprit is cerebral vasospasm. What can be done? Usually after 2 weeks, the vasospasm has almost subsided, or after 6-8 weeks, when the blood clot has almost been absorbed, another angiogram is performed.
Although cerebral angiography is the “gold standard”, it is after all an invasive test. Some patients are unable to undergo this test due to poor physical condition. We have other non-invasive tests, such as head and neck CT angiography (CTA) and magnetic resonance angiography (MRA), which have certain reference value to clarify the cause.
In addition, transcranial Doppler ultrasound (TCD) can detect the blood flow velocity of the large cranial vessels non-invasively and has been used as a routine monitoring method for “vasospasm”. After the patient is admitted to the hospital, the treating physician will explain in detail to the patient and his family the seriousness and [complications] of the disease.
In general, we are very careful to explain two things: 1. rebleeding and 2. cerebral vasospasm. The occurrence of both of these conditions can directly pull up the mortality rate. The peak time period for rebleeding is within 3 weeks after the first bleeding, especially within 48 hours. In contrast, vasospasm occurs 3-6 days after bleeding, with 7-10 days being its peak time period.
In addition, other common complications are: increased intracranial pressure, hyponatremia, hyperglycemia, cardiac arrhythmia, and gastrointestinal bleeding. Finally, the most important thing is [how to cure?
The preferred treatment is of course “root cause treatment”. This is the fundamental treatment. Take the common aneurysm as an example, the method of eliminating the root cause is either open aneurysm clamping or endovascular interventional embolization.
For poor systemic conditions (difficult to tolerate surgery) or in the perioperative preparation phase, [drug therapy] is important. Both the health care provider and the patient’s family should be aware of the need for absolute bed rest with the head elevated 30°. Absolute bed rest means that both urine and stool should be settled in bed. It is also necessary to keep the airway open and prevent constipation. At the doctor’s discretion, treatment will be given to stop bleeding, control cranial pressure, and prevent cerebrovascular spasm.