This is the fifth meeting within the neurological diseases course presented by Dr. Fawzi Abu Khalil and interviewed by Prof. Dr. Eyad Qunaibi. You can find the lecture slides here: https://jpuedu-my.sharepoint.com/:b:/g/personal/eyad_aqunaibi_jpu_edu_jo/EXiMOXBISsFChJCYq7Vzpl4BsfB8R3DEw-prUDaw0ZTysw?e=ZNATm9
Peace be upon you and the mercy of God and His blessings. Today, God willing, we will discuss "Subarachnoid Hemorrhage," which is the second part of the hemorrhagic stroke. We will cover the definition, epidemiology, causes, symptoms, diagnosis, treatment, and a case study for discussion.
A quick reminder of the anatomy: the brain is surrounded by three layers:
The space under the arachnoid layer is called the "subarachnoid space," which contains cerebrospinal fluid (CSF) and blood vessels. The bleeding that occurs in this space is the subject of our discussion today.
Generally, there are four types of brain bleeding:
Subarachnoid hemorrhage accounts for approximately 40% of hemorrhagic stroke cases and about 5% of all stroke cases (both ischemic and hemorrhagic). The primary cause in 85% of cases is a ruptured aneurysm.
Statistics indicate that women are more likely to be affected than men, and the average age of onset is 53 years. This disease is characterized by very high mortality and disability rates; 10-15% of patients die before reaching the hospital, and of those who survive, half suffer from permanent disabilities.
An aneurysm is a bulge or dilation in the wall of an artery due to weakness in the wall. Over time and pressure, this bulge may rupture, causing bleeding. Other rare causes include "arteriovenous malformations" (AVM), and in 10% of cases, no clear source of bleeding may be found.
Risk Factors:
The most important symptom that the patient complains of is "the worst headache of their life," which is sudden and very severe (thunderclap headache). This may be accompanied by:
A common mistake is that the patient comes with a severe headache only, and the CT scan is normal, so they are given painkillers and sent home, then return after a few days in a deteriorating condition.
Cases are divided into grades (from 1 to 5) based on symptoms:
The complications resulting from this bleeding are serious and require close monitoring in the intensive care unit (ICU):
Once the aneurysm is diagnosed, there are two main treatment options:
Patient: A 71-year-old woman suffering from irregular blood pressure. Symptoms: Sudden severe headache and change in consciousness (Confusion). Diagnosis:
Treatment Plan:
Why does the pressure increase despite the presence of bleeding? High blood pressure is often the cause (Risk Factor) rather than the result. The patient is originally suffering from high blood pressure, and this chronic increase is what weakened the artery wall and led to the formation and rupture of the aneurysm.
Can a lumbar puncture (LP) be performed with increased intracranial pressure? Lumbar puncture is contraindicated if there is a "mass effect" or obvious hydrocephalus on the CT scan to avoid cerebral herniation (Herniation). However, in cases of mild subarachnoid hemorrhage that does not appear on the CT scan, lumbar puncture is safe and necessary for diagnosis.
Role of Magnetic Resonance Imaging (MRI): Its use is rare in acute cases because CT scans and lumbar puncture are faster and more accurate initially. It may be resorted to in search of rare causes such as arteriovenous malformations (AVM) if the catheter is negative.
Use of aspirin and plavix: They are completely prohibited in the acute phase of bleeding. However, if a stent is placed for the aneurysm, the doctor may have to start them after one or two weeks depending on the stability of the condition and the size of the bleeding, to prevent stent thrombosis.
In conclusion, subarachnoid hemorrhage is an emergency medical condition that requires high coordination between intensive care physicians, neurosurgeons, and interventional radiologists to ensure the best outcomes for the patient.
Peace be upon you and the mercy of Allah and His blessings.