Statin Risks May Outweigh Benefits for Patients With a History of Brain Hemorrhage

8/3/2019 Statin Risks May Outweigh Benefits for Patients With a History of Brain Hemorrhage

1/17

Statin Risks May Outweigh Benefits for Patients with a History of Brain HemorrhageScienceDaily (Jan. 10, 2011) A computer decision model suggests that for patients with a history of bleeding within the brain, the risk of recurrenceassociated with statin treatment may outweigh the benefit of the drug inpreventing cardiovascular disease, according to a report posted online thatwill appear in the May print issue of Archives of Neurology , one of theJAMA/Archives journals.

The benefits of statins for reducing the risk of heart disease and stroke are well established, but morewidespread use of statin therapy remains controversial, according to background information in thearticle. "A particular subgroup of patients for whom the advisability of statin use is unclear are those athigh risk for intracerebral hemorrhage," or a stroke caused by bleeding within the brain, the authors write."The reason for added concern is the increased incidence of intracerebral hemorrhage observed amongsubjects randomized to statin therapy in a clinical trial of secondary stroke prevention.""Because intracerebral hemorrhage sufferers commonly have co-morbid [co-occurring] cardiovascular risk factors that would otherwise warrant cholesterol-lowering medication, it is important to weigh the risks

and benefits of statin therapy in this population," write M. Brandon Westover, M.D., Ph.D., of Massachusetts General Hospital and Harvard Medical School, Boston, and colleagues. The researchersused a Markov decision model to evaluate these benefits and risks. Based on prior research, simulatedpatients were assigned to states that correspond to disease risk and could then experience anycombination of events which may lead to the increased risk of stroke or heart disease, change in qualityof life or death."Our analysis indicates that in settings of high recurrent intracerebral hemorrhage risk, avoiding statintherapy may be preferred," the authors write. "For lobar intracerebral hemorrhage [bleeding in thecerebrum] in particular, which has a substantially higher recurrence rate than does deep intracerebralhemorrhage, statin therapy is predicted to increase the baseline annual probability of recurrence fromapproximately 14 percent to approximately 22 percent, offsetting the cardiovascular benefits for bothprimary and secondary cardiovascular prevention."In the case of deep intracerebral hemorrhage, a type of stroke due to bleeding deep within the brain thathas a lower risk of recurrence, the benefits and risks of statin use were more evenly balanced.

"Consequently, the optimal treatment option may vary with specific circumstances," the authors write.The mechanism by which statins might increase the risk of hemorrhagic stroke are unknown, the authorsnote. The association may be due to an increased risk of brain bleeding among those with lower cholesterol levels, or potential anti-clotting properties of statins."In summary, mathematical decision analysis of the available data suggests that, because of the high riskof recurrent intracerebral hemorrhage in survivors of prior hemorrhagic stroke, even a small amplificationof this risk by use of statins suffices to recommend that they should be avoided after intracerebralhemorrhage," the authors conclude. "In the absence of data from a randomized clinical trial (ideallycomparing various agents and doses), the current model provides some guidance for clinicians facing thisdifficult decision."Editorial: Do No Harm With Statin Treatment"The question prompting the decision analysis model reported by Westover et al epitomizes a commonconundrum faced by clinicians -- the need to make a therapeutic decision for a given patient in theabsence of guidance from specific, high-quality clinical trial data," writes Larry B. Goldstein, M.D., of DukeUniversity and Durham VA Medical Center, Durham, N.C., in an accompanying editorial."In this case, exploratory data from two clinical trials (Heart Protection Study and SPARCL) suggest, butdo not prove, a statin-associated increased risk of brain hemorrhage that may reduce the overall benefitof treatment in patients with a history of cerebrovascular disease."The available data are "generally consistent with the conclusion of the decision analysis -- the risk of statin therapy likely outweighs any potential benefit in patients with (at least recent) brain hemorrhage andshould generally be avoided in this setting," Dr. Goldstein writes. "Until and unless there are data to thecontrary, or warranted by specific clinical circumstances, the use of statins in patients with hemorrhagicstroke should be guided by the maxim of nonmaleficence -- Primum non nocere."Editor's Note: This work was supported by a grant from the National Institutes of Health.


2/17

Recommend this story on Facebook , Twitter ,and Google +1 :Other bookmarking and sharing tools:| More

Story Source:The above story is reprinted from materials provided by JAMA and Archives Journals .Note: Materials may be edited for content and length. For further information, please contact the sourcecited above.

Journal References :

1. M. Brandon Westover; Matt T. Bianchi; Mark H. Eckman; Steven M. Greenberg. Statin UseFollowing Intracerebral Hemorrhage: A Decision Analysis . Archives of Neurology , 2011; DOI:10.1001/archneurol.2010.356

2. Larry B. Goldstein. Statins After Intracerebral Hemorrhage: To Treat or Not to Treat . Archives of Neurology , 2011; DOI: 10.1001/archneurol.2010.349

Despite Benefits, Few Brain Aneurysm Patients ReceiveSpecialized CareScienceDaily (Sep. 19, 2011) The Neurocritical Care Society is releasing acomprehensive set of guidelines this week to guide physicians and hospitalson how to optimally care for patient's ruptured brain aneurysms. One of thestrongest recommendations is that all patients receive specialized care athigh-volume stroke centers that treat at least 60 cases per year.

See Also:Health & Medicine

1. Today's Healthcare

2. Health Policy

3. Elder CareMind & Brain

1. Caregiving

2. Brain Injury

3. NeuroscienceReference

1. Physical trauma

2. Stroke

3. Palliative care

4. Brain damageSubarachnoid hemorrhage strikes without warning and results from rupture of an artery supplying thebrain. Thirty percent do not survive, and half of those who do are permanently disabled.The recommendation that patients receive care at high-volume centers is based on a comprehensiveanalysis of medical outcomes research conducted by an international panel of experts. The report foundthat relatively fewer patients are treated at high-volume centers, despite overwhelming evidence that carein more experienced centers will most likely result in definitive repair of the aneurysm and a goodrecovery.
http://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.jamamedia.org/http://dx.doi.org/10.1001/archneurol.2010.356http://dx.doi.org/10.1001/archneurol.2010.349http://www.sciencedaily.com/news/health_medicine/http://www.sciencedaily.com/news/health_medicine/today's_healthcare/http://www.sciencedaily.com/news/health_medicine/health_policy/http://www.sciencedaily.com/news/health_medicine/caregiving/http://www.sciencedaily.com/news/mind_brain/http://www.sciencedaily.com/news/mind_brain/caregiving/http://www.sciencedaily.com/news/mind_brain/brain_injury/http://www.sciencedaily.com/news/mind_brain/neuroscience/http://www.sciencedaily.com/articles/http://www.sciencedaily.com/articles/p/physical_trauma.htmhttp://www.sciencedaily.com/articles/s/stroke.htmhttp://www.sciencedaily.com/articles/p/palliative_care.htmhttp://www.sciencedaily.com/articles/b/brain_damage.htmhttp://www.jamamedia.org/http://dx.doi.org/10.1001/archneurol.2010.356http://dx.doi.org/10.1001/archneurol.2010.349http://www.sciencedaily.com/news/health_medicine/http://www.sciencedaily.com/news/health_medicine/today's_healthcare/http://www.sciencedaily.com/news/health_medicine/health_policy/http://www.sciencedaily.com/news/health_medicine/caregiving/http://www.sciencedaily.com/news/mind_brain/http://www.sciencedaily.com/news/mind_brain/caregiving/http://www.sciencedaily.com/news/mind_brain/brain_injury/http://www.sciencedaily.com/news/mind_brain/neuroscience/http://www.sciencedaily.com/articles/http://www.sciencedaily.com/articles/p/physical_trauma.htmhttp://www.sciencedaily.com/articles/s/stroke.htmhttp://www.sciencedaily.com/articles/p/palliative_care.htmhttp://www.sciencedaily.com/articles/b/brain_damage.htmhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedaily


3/17

"One important reason for better outcomes in large volume centers is that care is provided by specializedneurocritical care teams," said Dr. Paul Vespa, Director of Neurocritical Care at UCLA Medical Center and lead author of the report. "Once bleeding from the aneurysm is controlled, highly-specialized ICUcare is required to detect and treat secondary complications. These complications are often just asdeadly, if not more so, than the bleeding event."Studies indicate that patients who come to a hospital with little experience in managing subarachnoidhemorrhage are rarely transferred to high-volume centers. "The main reason that patients are nottransferred is that stroke care is not regionalized in the same way that it is for trauma. It is a patchworksystem; sometimes it works, but more often it does not," says Dr. Stephan A. Mayer, Director of Neurocritical Care at Columbia University Medical Center and President of the Neurocritical Care Society.Medical guidelines play an important role in guiding doctors, hospitals, and public policy as it relates tohealthcare. According to Michael N. Diringer, Professor of Neurology and Neurosurgery at WashingtonUniversity and Director of the Neurology/Neurosurgery Intensive Care Unit at Barnes-Jewish Hospital inSt Louis, who chaired the consensus conference and co-authored the report, "None of the specificmedications or treatments that we analyzed made nearly as much difference as where the patient isinitially taken for treatment. These guidelines will hopefully alert patients, doctors, and hospital systems tothe importance of regionalized care for brain aneurysm victims."Recommend this story on Facebook , Twitter ,and Google +1 :Other bookmarking and sharing tools:

| More Story Source:The above story is reprinted from materials provided by Neurocritical Care Society , via EurekAlert !, aservice of AAAS.Note: Materials may be edited for content and length. For further information, please contact the sourcecited above.

Journal Reference :

1. Michael N. Diringer, Thomas P. Bleck, J. Claude Hemphill, David Menon, Lori Shutter, Paul Vespa,Nicolas Bruder, E. Sander Connolly, Giuseppe Citerio, Daryl Gress, Daniel Hnggi, Brian L. Hoh,Giuseppe Lanzino, Peter Roux, Alejandro Rabinstein, Erich Schmutzhard, Nino Stocchetti, Jose I.Suarez, Miriam Treggiari, Ming-Yuan Tseng, Mervyn D. I. Vergouwen, Stefan Wolf, Gregory Zipfel.Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage:Recommendations from the Neurocritical Care Societys Multidisciplinary ConsensusConference . Neurocritical Care , 2011; 15 (2): 211 DOI: 10.1007/s12028-011-9605-9

Science NewsBlog Cite

Save Email Print Share

Drinking Coffee, Having Sex Are Triggers That Raise RuptureRisks for Brain Aneurysm, Study FindsScienceDaily (May 5, 2011) From drinking coffee to having sex to blowingyour nose, you could temporarily raise your risk of rupturing a brain aneurysm-- and suffering a stroke, according to a study published in Stroke: Journal of the American Heart Association .

Dutch researchers identified eight main triggers that appear to increase the risk of intracranial aneurysm(IA), a weakness in the wall of a brain blood vessel that often causes it to balloon. If it ruptures, it canresult in a subarachnoid hemorrhage which is a stroke caused by bleeding at the base of the brain. Anestimated 2 percent of the general population have IAs, but few rupture.
http://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.eurekalert.org/pub_releases/2011-09/ncs-dpb091911.phphttp://www.eurekalert.org/pub_releases/2011-09/ncs-dpb091911.phphttp://www.neurocriticalcare.org/http://www.neurocriticalcare.org/http://www.eurekalert.org/http://www.eurekalert.org/http://www.eurekalert.org/http://dx.doi.org/10.1007/s12028-011-9605-9http://dx.doi.org/10.1007/s12028-011-9605-9http://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.eurekalert.org/pub_releases/2011-09/ncs-dpb091911.phphttp://www.neurocriticalcare.org/http://www.eurekalert.org/http://dx.doi.org/10.1007/s12028-011-9605-9http://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htmhttp://www.sciencedaily.com/releases/2011/05/110505102550.htm


4/17

Calculating population attributable risk -- the fraction of subarachnoid hemorrhages that can be attributedto a particular trigger factor -- the researchers identified the eight factors and their contribution to the riskas:

1. Coffee consumption (10.6 percent)

2. Vigorous physical exercise (7.9 percent)

3. Nose blowing (5.4 percent)4. Sexual intercourse (4.3 percent)

5. Straining to defecate (3.6 percent)

6. Cola consumption (3.5 percent)

7. Being startled (2.7 percent)

8. Being angry (1.3 percent)

"All of the triggers induce a sudden and short increase in blood pressure, which seems a possiblecommon cause for aneurysmal rupture," said Monique H.M. Vlak, M.D., lead author of the study and aneurologist at the University Medical Center in Utrecht, the Netherlands.Risk was higher shortly after drinking alcohol, but decreased quickly, researchers said."Subarachnoid hemorrhage caused by the rupture of an intracranial aneurysm is a devastating event that

often affects young adults," Vlak said. "These trigger factors we found are superimposed on known riskfactors, including female gender, age and hypertension."Few people with IAs have symptoms before such a rupture, such as vomiting, vision problems, loss of consciousness, and especially severe headaches. Many have none. With the increasing use of neuroimaging techniques, more incidental aneurysms are being detected, researchers said.The researchers sought to identify potential triggers and their level of risk. They asked 250 patients withaneurysmal subarachnoid hemorrhage to complete a questionnaire about exposure to 30 potential trigger factors in the period shortly before their event and their usual frequency and intensity of exposure to thesetriggers. They then assessed relative risk using a case-crossover design that determines if a specificevent was triggered by something that happened just before it.Although physical activity had triggering potential, researchers don't advise refraining from it because it'salso an important factor in lowering risk of other cardiovascular diseases."Reducing caffeine consumption or treating constipated patients with unruptured IAs with laxatives maylower the risk of subarachnoid hemorrhage," Vlak said. "Whether prescribing antihypertensive drugs to

patients with unruptured IAs is beneficial in terms of preventing aneurysmal rupture still needs to befurther investigated."The findings were limited by the retrospective design of the study and the average three weeks betweensubarachnoid hemorrhage and completion of the questionnaire, researchers said. Moreover, specificallyasking for exposure in a particular time frame may have been limited by recall bias and including patientsin a relatively good clinical condition could have led to survival bias.Co-authors are Ale Algra, M.D., Ph.D.; Gabriel J.E. Rinkel, M.D., Ph.D.; Paut Greebe, R.N., Ph.D.; andJohanna van der Bom, M.D., Ph.D. Author disclosures are on the manuscript.The Julius Center for General Health and Primary Care and the Department of Neurology of theUniversity Medical Center in Utrecht, the Netherlands funded the study.Recommend this story on Facebook , Twitter ,and Google +1 :Other bookmarking and sharing tools:| More

Story Source:The above story is reprinted from materials provided by American Heart Association , via EurekAlert !, aservice of AAAS.Note: Materials may be edited for content and length. For further information, please contact the sourcecited above.

Journal Reference :
http://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.eurekalert.org/pub_releases/2011-05/aha-dch050211.phphttp://www.eurekalert.org/pub_releases/2011-05/aha-dch050211.phphttp://www.americanheart.org/http://www.eurekalert.org/http://www.eurekalert.org/http://www.eurekalert.org/http://www.addthis.com/bookmark.php?v=250&pubid=sciencedailyhttp://www.eurekalert.org/pub_releases/2011-05/aha-dch050211.phphttp://www.americanheart.org/http://www.eurekalert.org/


5/17

1. Monique H.M. Vlak, Gabriel J.E. Rinkel, Paut Greebe, Johanna G. van der Bom, and Ale Algra.Trigger Factors and Their Attributable Risk for Rupture of Intracranial Aneurysms: A Case-Crossover Study . Stroke , 2011; DOI: 10.1161/STROKEAHA.110.606558

2. Penelope McNulty, neurologist from Neuroscience Research Australia, says that strokes caused byintracranial aneurysm rupture can occur at any age and without warning. But the researcher saysthat patients suffering from this type of stroke can make progress using an unconventional type of

therapy.3. It was often thought that patients with this kind of stroke do not recover as well as those whose

stroke was caused by a blockage in a blood vessel of the brain said McNulty.4. But we have shown this is not the case. Even many years after an aneurysm rupture, patients

can benefit from Wii-based movement therapy, recovering functional use of their arm and handvia an intensive two-week program.

For someone with a brain aneurysm, having sex or drinking coffee could temporarily

raise the risk of the aneurysm rupturing and causing a stroke, according to a new study.

1. Don't miss these Health stories

1.

Ikophotos / FeaturePics.com

People can smell your neuroticism

Getting to know someone usually requires at least a little conversation. But a new study

suggests you can get a hint of an individual's personality through his or her scent alone.

2. 91-year-old yoga teacher: 'Why should I quit?'

3. Too promiscuous to donate an organ? Maybe

4. Sick'nd by Chik'n? Group warns of fungus meat

5. Clue found to seizures that cause giggles

Researchers identified eight triggers that seem to increase the risk of aneurysm rupture, though the

increased risk only lasts for about an hour after the activity, said study researcher Dr. Monique H.M. Vlak,

a neurologist at the University Medical Center in Utrecht, the Netherlands.

Drinking coffee raises aneurysm rupture risk by 10.6 percent, vigorous exercise increases the risk by 7.9

percent and nose-blowing increases the risk by 5.4 percent, researchers found.

Meanwhile, sexual intercourse increases the risk by 4.3 percent, according to the study.
http://dx.doi.org/10.1161/STROKEAHA.110.606558http://dx.doi.org/10.1161/STROKEAHA.110.606558http://bodyodd.msnbc.msn.com/_news/2011/12/02/9172646-people-can-smell-your-neuroticismhttp://www.msnbc.msn.com/id/45484875/ns/today-today_health/t/-year-old-yoga-teacher-asks-why-should-i-quit/http://vitals.msnbc.msn.com/_news/2011/12/02/9173566-too-promiscuous-to-donate-an-organ-maybe-cdc-sayshttp://vitals.msnbc.msn.com/_news/2011/12/05/9233051-sickened-by-chikn-food-police-take-fun-out-of-fungus-meathttp://bodyodd.msnbc.msn.com/_news/2011/12/04/9209050-a-clue-found-to-seizures-that-cause-helpless-giggleshttp://www.myhealthnewsdaily.com/coffee-protects-against-diabetes-1052/http://bodyodd.msnbc.msn.com/_news/2011/12/02/9172646-people-can-smell-your-neuroticismhttp://dx.doi.org/10.1161/STROKEAHA.110.606558http://bodyodd.msnbc.msn.com/_news/2011/12/02/9172646-people-can-smell-your-neuroticismhttp://www.msnbc.msn.com/id/45484875/ns/today-today_health/t/-year-old-yoga-teacher-asks-why-should-i-quit/http://vitals.msnbc.msn.com/_news/2011/12/02/9173566-too-promiscuous-to-donate-an-organ-maybe-cdc-sayshttp://vitals.msnbc.msn.com/_news/2011/12/05/9233051-sickened-by-chikn-food-police-take-fun-out-of-fungus-meathttp://bodyodd.msnbc.msn.com/_news/2011/12/04/9209050-a-clue-found-to-seizures-that-cause-helpless-giggleshttp://www.myhealthnewsdaily.com/coffee-protects-against-diabetes-1052/


6/17

Brain aneurysms are present in about 2 to 3 percent of the general population, but only 9 in 100,000 of

those people ever experience an aneurysm rupture, Vlak said. The findings are especially relevant to the

people who do have aneurysms (which are often discovered accidentally via brain scans) and need to be

cautious about their rupture risk.

The study was published today (May 5) in Stroke: Journal of the American Heart Association.

Other triggers

Vlak and her colleagues found the triggers by interviewing 250 people who had suffered an aneurysmal

subarachnoid hemorrhage (a ruptured aneurysm that resulted in stroke). These people were asked to fill

out a questionnaire on 30 potential triggers that may have occurred before the hemorrhage , and the

intensity and frequency of the exposure.Advertise | AdChoices

Advertise | AdChoices

Advertise | AdChoices

In addition to the increased risk from coffee-drinking , physical exercise, nose-blowing and sexual

intercourse, researchers also found that straining to defecate increased rupture risk by 3.6 percent and

consumption of soda increased rupture risk by 3.5 percent.

Researchers also found that being startled increased the risk of rupture by 2.7 percent and being angry

increased the risk by 1.3 percent.

Blood pressure risks

Brain aneurysms are caused by weaknesses in the blood vessel wall that causes the vessel to balloon. If

the blood vessel ruptures, it could result in a subarachnoid hemorrhage, which is a kind of stroke that is

caused by bleeding at the base of the brain.

These triggers likely increase the risk of aneurysm rupture because they increase blood pressure, Vlak

said.

The risks are "minor, but they all have the same temporary elevation of blood pressure," Vlak told

MyHealthNewsDaily. "It seems that's the pathological mechanism."

Pass it on: Drinking coffee, having sex and blowing your nose temporarily increases the risk of aneurysm

rupture, if you have a brain aneurysm. A ruptured aneurysm could lead to a stroke.

10 Medical Myths That Just Wont Go Away

Top 10 Leading Causes of Death

7 Foods You Can Overdose OnSponsored links

Subarachnoid hemorrhageFrom Wikipedia, the free encyclopedia
http://www.myhealthnewsdaily.com/genes-risk-factors-thoracic-aortic-aneurysm-101118-0762/http://www.myhealthnewsdaily.com/ocd-patients-benefit-brain-surgery-1191/http://www.myhealthnewsdaily.com/ocd-patients-benefit-brain-surgery-1191/http://www.msnbc.msn.com/id/31066137/media-kit/http://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://g.msn.com/AIPRIV/en-ushttp://www.msnbc.msn.com/id/31066137/media-kit/http://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://g.msn.com/AIPRIV/en-ushttp://www.msnbc.msn.com/id/31066137/media-kit/http://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://g.msn.com/AIPRIV/en-ushttp://www.myhealthnewsdaily.com/daily-coffee-intake-decreases-stroke-risk-1257/http://www.myhealthnewsdaily.com/daily-coffee-intake-decreases-stroke-risk-1257/http://www.myhealthnewsdaily.com/virtual-reality-games-stroke-recovery-rehabilitation--1360/http://www.myhealthnewsdaily.com/ten-medical-myths-0947/http://www.myhealthnewsdaily.com/top-10-leading-causes-of-death-1056/http://www.myhealthnewsdaily.com/seven-good-foods-you-can-overdose-on-110201-1112/http://www.myhealthnewsdaily.com/genes-risk-factors-thoracic-aortic-aneurysm-101118-0762/http://www.myhealthnewsdaily.com/ocd-patients-benefit-brain-surgery-1191/http://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://www.msnbc.msn.com/id/31066137/media-kit/http://g.msn.com/AIPRIV/en-ushttp://www.myhealthnewsdaily.com/daily-coffee-intake-decreases-stroke-risk-1257/http://www.myhealthnewsdaily.com/virtual-reality-games-stroke-recovery-rehabilitation--1360/http://www.myhealthnewsdaily.com/ten-medical-myths-0947/http://www.myhealthnewsdaily.com/top-10-leading-causes-of-death-1056/http://www.myhealthnewsdaily.com/seven-good-foods-you-can-overdose-on-110201-1112/


7/17

Jump to: navigation , search

Subarachnoid hemorrhage

Classification and external resources

CT scan of the brain showing subarachnoid

hemorrhage as a white area in the center and

stretching into the sulci to either side (marked

by the arrow)

ICD -10 I60 , P10.3 , S06.6

ICD -9 430 , 852.0 -852.1

OMIM 105800

DiseasesDB 12602

MedlinePlus 000701

eMedicine med/2883 neuro/357

emerg/559

MeSH D013345

A subarachnoid hemorrhage (SAH , /s b r k n d h m r d /), or subarachnoid haemorrhage in BritishEnglish , is bleeding into the subarachnoid space the area between the arachnoid membrane and the pia mater surrounding the brain . This may occur spontaneously, usually from a ruptured cerebral aneurysm , or may resultfrom head injury .Symptoms of SAH include a severe headache with a rapid onset (" thunderclap headache "), vomiting , confusion or alowered level of consciousness , and sometimes seizures .[1] The diagnosis is generally confirmed with a CT scan of

the head, or occasionally by lumbar puncture . Treatment is by prompt neurosurgery or radiologically guidedinterventions with medications and other treatments to help prevent recurrence of the bleeding and complications.Surgery for aneurysms was introduced in the 1930s, but since the 1990s many aneurysms are treated by a lessinvasive procedure called " coiling ", which is carried out by instrumentation through large blood vessels .[1]

SAH is a form of stroke and comprises 17% of all strokes .[2] It is a medical emergency and can lead to death or severe disability even when recognized and treated at an early stage. Up to half of all cases of SAH are fatal and1015% of casualties die before reaching a hospital, [1] and those who survive often have neurological or cognitiveimpairment .[3]

Contents
http://en.wikipedia.org/wiki/Sulcus_(neuroanatomy)http://en.wikipedia.org/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problemshttp://en.wikipedia.org/wiki/ICD-10http://en.wikipedia.org/wiki/ICD-10_Chapter_Ihttp://en.wikipedia.org/wiki/ICD-10_Chapter_Phttp://en.wikipedia.org/wiki/ICD-10_Chapter_Shttp://en.wikipedia.org/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problemshttp://en.wikipedia.org/wiki/List_of_ICD-9_codeshttp://www.icd9data.com/getICD9Code.ashx?icd9=430http://www.icd9data.com/getICD9Code.ashx?icd9=852.0http://www.icd9data.com/getICD9Code.ashx?icd9=852.1http://en.wikipedia.org/wiki/OMIMhttp://omim.org/entry/105800http://en.wikipedia.org/wiki/Diseases_Databasehttp://www.diseasesdatabase.com/ddb12602.htmhttp://en.wikipedia.org/wiki/MedlinePlushttp://www.nlm.nih.gov/medlineplus/ency/article/000701.htmhttp://en.wikipedia.org/wiki/EMedicinehttp://www.emedicine.com/med/topic2883.htmhttp://www.emedicine.com/neuro/topic357.htmhttp://www.emedicine.com/emerg/topic559.htmhttp://en.wikipedia.org/wiki/Medical_Subject_Headingshttp://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?field=uid&term=D013345http://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/American_and_British_English_spelling_differenceshttp://en.wikipedia.org/wiki/American_and_British_English_spelling_differenceshttp://en.wikipedia.org/wiki/American_and_British_English_spelling_differenceshttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Subarachnoid_spacehttp://en.wikipedia.org/wiki/Subarachnoid_spacehttp://en.wikipedia.org/wiki/Arachnoid_(brain)http://en.wikipedia.org/wiki/Pia_materhttp://en.wikipedia.org/wiki/Pia_materhttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Head_injuryhttp://en.wikipedia.org/wiki/Head_injuryhttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Level_of_consciousnesshttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Neurosurgeryhttp://en.wikipedia.org/wiki/Interventional_radiologyhttp://en.wikipedia.org/wiki/Interventional_radiologyhttp://en.wikipedia.org/wiki/Interventional_radiologyhttp://en.wikipedia.org/wiki/Guglielmi_Detachable_Coilhttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Sulcus_(neuroanatomy)http://en.wikipedia.org/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problemshttp://en.wikipedia.org/wiki/ICD-10http://en.wikipedia.org/wiki/ICD-10_Chapter_Ihttp://en.wikipedia.org/wiki/ICD-10_Chapter_Phttp://en.wikipedia.org/wiki/ICD-10_Chapter_Shttp://en.wikipedia.org/wiki/International_Statistical_Classification_of_Diseases_and_Related_Health_Problemshttp://en.wikipedia.org/wiki/List_of_ICD-9_codeshttp://www.icd9data.com/getICD9Code.ashx?icd9=430http://www.icd9data.com/getICD9Code.ashx?icd9=852.0http://www.icd9data.com/getICD9Code.ashx?icd9=852.1http://en.wikipedia.org/wiki/OMIMhttp://omim.org/entry/105800http://en.wikipedia.org/wiki/Diseases_Databasehttp://www.diseasesdatabase.com/ddb12602.htmhttp://en.wikipedia.org/wiki/MedlinePlushttp://www.nlm.nih.gov/medlineplus/ency/article/000701.htmhttp://en.wikipedia.org/wiki/EMedicinehttp://www.emedicine.com/med/topic2883.htmhttp://www.emedicine.com/neuro/topic357.htmhttp://www.emedicine.com/emerg/topic559.htmhttp://en.wikipedia.org/wiki/Medical_Subject_Headingshttp://www.nlm.nih.gov/cgi/mesh/2011/MB_cgi?field=uid&term=D013345http://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/Wikipedia:IPA_for_Englishhttp://en.wikipedia.org/wiki/American_and_British_English_spelling_differenceshttp://en.wikipedia.org/wiki/American_and_British_English_spelling_differenceshttp://en.wikipedia.org/wiki/Bleedinghttp://en.wikipedia.org/wiki/Subarachnoid_spacehttp://en.wikipedia.org/wiki/Arachnoid_(brain)http://en.wikipedia.org/wiki/Pia_materhttp://en.wikipedia.org/wiki/Human_brainhttp://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Head_injuryhttp://en.wikipedia.org/wiki/Symptomhttp://en.wikipedia.org/wiki/Headachehttp://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Level_of_consciousnesshttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Medical_diagnosishttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Neurosurgeryhttp://en.wikipedia.org/wiki/Interventional_radiologyhttp://en.wikipedia.org/wiki/Interventional_radiologyhttp://en.wikipedia.org/wiki/Guglielmi_Detachable_Coilhttp://en.wikipedia.org/wiki/Strokehttp://en.wikipedia.org/wiki/Medical_emergencyhttp://en.wikipedia.org/wiki/Disabilityhttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhage


8/17

[hide ] 1 Signs and symptoms 2 Causes 3 Diagnosis

3.1 Imaging 3.2 Lumbar puncture 3.3 Angiography 3.4 ECG

4 Classification 5 Screening and prevention 6 Treatment

6.1 Prevention of rebleeding

6.2 Vasospasm 6.3 Other complications

7 Prognosis 7.1 Early morbidity and

mortality 7.2 Long-term outcomes

8 Epidemiology 9 History 10 References 11 External links

[ edit ] Signs and symptomsThe classic symptom of subarachnoid hemorrhage is thunderclap headache (a headache described as "like beingkicked in the head" ,[4] or the "worst ever", developing over seconds to minutes). This headache often pulsatestowards the occiput (the back of the head) .[5] About one-third of sufferers have no symptoms apart from thecharacteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosedwith a subarachnoid hemorrhage .[1] Vomiting may be present, and 1 in 14 have seizures .[1] Confusion , decreasedlevel of consciousness or coma may be present, as may neck stiffness and other signs of meningism .[1] Neck stiffnessusually presents six hours after initial onset of SAH. [6] Isolated dilation of a pupil and loss of the pupillary lightreflex may reflect brain herniation as a result of rising intracranial pressure (pressure inside the skull). [1] Intraocular hemorrhage (bleeding into the eyeball) may occur in response to the raised pressure: subhyaloid hemorrhage(bleeding under the hyaloid membrane , which envelops the vitreous body of the eye) and vitreous hemorrhage may

be visible on fundoscopy . This is known as Terson syndrome (occurring in 313% of cases) and is more common inmore severe SAH .[7]

Oculomotor nerve abnormalities (affected eye looking downward and outward and inability to lift the eyelid on thesame side ) or palsy (loss of feeling) may indicate bleeding from the posterior communicating artery .[1][5] Seizures aremore common if the hemorrhage is from an aneurysm; it is otherwise difficult to predict the site and origin of thehemorrhage from the symptoms .[1] SAH in a person known to have seizures is often diagnostic of an arteriovenousmalformation .[5]

The combination of intracerebral hemorrhage and raised intracranial pressure (if present) leads to a "sympatheticsurge", i.e. over-activation of the sympathetic system. This is thought to occur through two mechanisms, a direct
http://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=1http://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Occiputhttp://en.wikipedia.org/wiki/Occiputhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Confusionhttp://en.wikipedia.org/wiki/Confusionhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Meningismhttp://en.wikipedia.org/wiki/Meningismhttp://en.wikipedia.org/wiki/Pupillary_responsehttp://en.wikipedia.org/wiki/Pupillary_responsehttp://en.wikipedia.org/wiki/Pupillary_light_reflexhttp://en.wikipedia.org/wiki/Pupillary_light_reflexhttp://en.wikipedia.org/wiki/Pupillary_light_reflexhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Intraocular_hemorrhagehttp://en.wikipedia.org/wiki/Intraocular_hemorrhagehttp://en.wikipedia.org/wiki/Vitreous_membranehttp://en.wikipedia.org/wiki/Vitreous_membranehttp://en.wikipedia.org/wiki/Vitreous_bodyhttp://en.wikipedia.org/wiki/Vitreous_bodyhttp://en.wikipedia.org/wiki/Fundoscopyhttp://en.wikipedia.org/wiki/Fundoscopyhttp://en.wikipedia.org/wiki/Fundoscopyhttp://en.wikipedia.org/wiki/Terson_syndromehttp://en.wikipedia.org/wiki/Terson_syndromehttp://en.wikipedia.org/wiki/Oculomotor_nervehttp://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Palsyhttp://en.wikipedia.org/wiki/Posterior_communicating_arteryhttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=1http://en.wikipedia.org/wiki/Thunderclap_headachehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Occiputhttp://en.wikipedia.org/wiki/Health_carehttp://en.wikipedia.org/wiki/Vomitinghttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Confusionhttp://en.wikipedia.org/wiki/Comahttp://en.wikipedia.org/wiki/Meningismhttp://en.wikipedia.org/wiki/Pupillary_responsehttp://en.wikipedia.org/wiki/Pupillary_light_reflexhttp://en.wikipedia.org/wiki/Pupillary_light_reflexhttp://en.wikipedia.org/wiki/Brain_herniationhttp://en.wikipedia.org/wiki/Intracranial_pressurehttp://en.wikipedia.org/wiki/Intraocular_hemorrhagehttp://en.wikipedia.org/wiki/Intraocular_hemorrhagehttp://en.wikipedia.org/wiki/Vitreous_membranehttp://en.wikipedia.org/wiki/Vitreous_bodyhttp://en.wikipedia.org/wiki/Fundoscopyhttp://en.wikipedia.org/wiki/Terson_syndromehttp://en.wikipedia.org/wiki/Oculomotor_nervehttp://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Ptosis_(eyelid)http://en.wikipedia.org/wiki/Palsyhttp://en.wikipedia.org/wiki/Posterior_communicating_arteryhttp://en.wikipedia.org/wiki/Arteriovenous_malformationhttp://en.wikipedia.org/wiki/Arteriovenous_malformation


9/17

effect on the medulla which leads to activation of the descending sympathetic nervous system and a local release of inflammatory mediators which circulate to the peripheral circulation where they activate the sympathetic system. Asa consequence of the sympathetic surge there is a sudden increase in blood pressure ; mediated by increasedcontractility of the ventricle and increased vasoconstriction leading to increased systemic vascular resistance . Theconsequences of this sympathetic surge can be sudden, severe, and are frequently life threatening. The high plasmaconcentrations of adrenaline also may cause cardiac arrhythmias (irregularities in the heart rate and rhythm),electrocardiographic changes (in 27% of cases) [8] and cardiac arrest (in 3% of cases) may occur rapidly after theonset of hemorrhage. [1][9] A further consequence of this process is neurogenic pulmonary edema [10] where a processof increased pressure within the pulmonary circulation causes leaking of fluid from the pulmonary capillaries intothe air spaces, the alveoli , of the lung.Subarachnoid hemorrhage may also occur in people who have suffered a head injury. Symptoms may includeheadache, decreased level of consciousness and hemiparesis (weakness of one side of the body). SAH is a frequentoccurrence in traumatic brain injury, and carries a poor prognosis if it is associated with deterioration in the level of consciousness. [11]

[ edit ] CausesIn 85% of cases of spontaneous SAH, the cause is rupture of a cerebral aneurysm a weakness in the wall of one of the arteries in the brain that becomes enlarged. They tend to be located in the circle of Willis and its branches. Whilemost cases of SAH are due to bleeding from small aneurysms, larger aneurysms (which are less common) are morelikely to rupture. [1]

In 1520% of cases of spontaneous SAH, no aneurysm is detected on the first angiogram .[12]

About half of these areattributed to non-aneurysmal perimesencephalic hemorrhage, in which the blood is limited to the subarachnoidspaces around the midbrain (i.e. mesencephalon). In these, the origin of the blood is uncertain .[1] The remainder aredue to other disorders affecting the blood vessels (such as arteriovenous malformations ), disorders of the bloodvessels in the spinal cord , and bleeding into various tumors .[1] Cocaine abuse and sickle cell anemia (usually inchildren) and, rarely, anticoagulant therapy, problems with blood clotting and pituitary apoplexy can also result inSAH .[6][12]

Subarachnoid blood can be detected on CT scanning in as many as 60% of people with traumatic brain injury .[13]

Traumatic SAH (tSAH) usually occurs near the site of a skull fracture or intracerebral contusion .[12] It usuallyhappens in the setting of other forms of traumatic brain injury and has been linked with a poorer prognosis. It isunclear, however, if this is a direct result of the SAH or whether the presence of subarachnoid blood is simply anindicator of severity of the head injury and the prognosis is determined by other associated mechanisms. [13]

[ edit ] Diagnosis

A lumbar puncture in progress. A large area on the back has been washed with aniodine -based disinfectant leaving brown coloration

[edit ] ImagingThe initial steps for evaluating a person with a suspected subarachnoid hemorrhage are obtaining a medical historyand performing a physical examination ; these are aimed at determining whether the symptoms are due to SAH or toanother cause. The diagnosis cannot, however, be made on clinical grounds alone; therefore medical imaging isgenerally required to confirm or exclude bleeding. The modality of choice is computed tomography (CT scan) of the
http://en.wikipedia.org/wiki/Medullahttp://en.wikipedia.org/wiki/Medullahttp://en.wikipedia.org/wiki/Sympathetichttp://en.wikipedia.org/wiki/Sympathetichttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Contractilityhttp://en.wikipedia.org/wiki/Contractilityhttp://en.wikipedia.org/wiki/Ventriclehttp://en.wikipedia.org/wiki/Ventriclehttp://en.wikipedia.org/wiki/Ventriclehttp://en.wikipedia.org/wiki/Vasoconstrictionhttp://en.wikipedia.org/wiki/Vasoconstrictionhttp://en.wikipedia.org/wiki/Systemic_vascular_resistancehttp://en.wikipedia.org/wiki/Systemic_vascular_resistancehttp://en.wikipedia.org/wiki/Systemic_vascular_resistancehttp://en.wikipedia.org/wiki/Plasmahttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Electrocardiogramhttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Neurogenichttp://en.wikipedia.org/wiki/Neurogenichttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Capillarieshttp://en.wikipedia.org/wiki/Capillarieshttp://en.wikipedia.org/wiki/Alveolihttp://en.wikipedia.org/wiki/Alveolihttp://en.wikipedia.org/wiki/Hemiparesishttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=2http://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Angiogramhttp://en.wikipedia.org/wiki/Angiogramhttp://en.wikipedia.org/wiki/Angiogramhttp://en.wikipedia.org/wiki/Midbrainhttp://en.wikipedia.org/wiki/Midbrainhttp://en.wikipedia.org/wiki/Cerebral_arteriovenous_malformationhttp://en.wikipedia.org/wiki/Cerebral_arteriovenous_malformationhttp://en.wikipedia.org/wiki/Spinal_cordhttp://en.wikipedia.org/wiki/Tumorhttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Sickle_cell_anemiahttp://en.wikipedia.org/wiki/Sickle_cell_anemiahttp://en.wikipedia.org/wiki/Anticoagulanthttp://en.wikipedia.org/wiki/Anticoagulanthttp://en.wikipedia.org/wiki/Anticoagulanthttp://en.wikipedia.org/wiki/Coagulopathyhttp://en.wikipedia.org/wiki/Coagulopathyhttp://en.wikipedia.org/wiki/Pituitary_apoplexyhttp://en.wikipedia.org/wiki/Traumatic_brain_injuryhttp://en.wikipedia.org/wiki/Traumatic_brain_injuryhttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Intracerebral_contusionhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=3http://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Povidone-iodinehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=4http://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Medical_imaginghttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/Computed_tomographyhttp://en.wikipedia.org/wiki/File:Thisisspinaltap.jpghttp://en.wikipedia.org/wiki/Medullahttp://en.wikipedia.org/wiki/Sympathetichttp://en.wikipedia.org/wiki/Nervous_systemhttp://en.wikipedia.org/wiki/Blood_pressurehttp://en.wikipedia.org/wiki/Contractilityhttp://en.wikipedia.org/wiki/Ventriclehttp://en.wikipedia.org/wiki/Vasoconstrictionhttp://en.wikipedia.org/wiki/Systemic_vascular_resistancehttp://en.wikipedia.org/wiki/Plasmahttp://en.wikipedia.org/wiki/Cardiac_arrhythmiahttp://en.wikipedia.org/wiki/Electrocardiogramhttp://en.wikipedia.org/wiki/Cardiac_arresthttp://en.wikipedia.org/wiki/Neurogenichttp://en.wikipedia.org/wiki/Pulmonary_edemahttp://en.wikipedia.org/wiki/Capillarieshttp://en.wikipedia.org/wiki/Alveolihttp://en.wikipedia.org/wiki/Hemiparesishttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=2http://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Arteryhttp://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Angiogramhttp://en.wikipedia.org/wiki/Midbrainhttp://en.wikipedia.org/wiki/Cerebral_arteriovenous_malformationhttp://en.wikipedia.org/wiki/Spinal_cordhttp://en.wikipedia.org/wiki/Tumorhttp://en.wikipedia.org/wiki/Cocainehttp://en.wikipedia.org/wiki/Sickle_cell_anemiahttp://en.wikipedia.org/wiki/Anticoagulanthttp://en.wikipedia.org/wiki/Coagulopathyhttp://en.wikipedia.org/wiki/Pituitary_apoplexyhttp://en.wikipedia.org/wiki/Traumatic_brain_injuryhttp://en.wikipedia.org/wiki/Skull_fracturehttp://en.wikipedia.org/wiki/Intracerebral_contusionhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=3http://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Povidone-iodinehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=4http://en.wikipedia.org/wiki/Medical_historyhttp://en.wikipedia.org/wiki/Physical_examinationhttp://en.wikipedia.org/wiki/Medical_imaginghttp://en.wikipedia.org/wiki/Computed_tomography


10/17

brain. This has a high sensitivity and will correctly identify over 95% of casesespecially on the first day after theonset of bleeding. Magnetic resonance imaging (MRI) may be more sensitive than CT after several days. [1] Withinsix hours of the onset of symptoms a single study has reported that CT is 100% sensitive. [14]

[edit ] Lumbar punctureLumbar puncture , in which cerebrospinal fluid (CSF) is removed with a needle from the lumbar sac, will showevidence of hemorrhage in 3% of people in whom CT was found normal; lumbar puncture is therefore regarded asmandatory in people with suspected SAH if imaging is negative .[1] At least three tubes of CSF are collected .[6] If anelevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If thenumber of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the

procedure (known as a "traumatic tap"). [3] While there is no official cutoff for red blood cells in the CSF nodocumented cases have occurred at less than "a few hundred cells" per high-powered field. [15]

The CSF sample is also examined for xanthochromia the yellow appearance of centrifugated fluid. More sensitiveis spectrophotometry (measuring the absorption of particular wavelengths of light) for detection of bilirubin , a

breakdown product of hemoglobin from red blood cells .[1][16] Xanthochromia and spectrophotometry remain reliableways to detect SAH several days after the onset of headache .[16] An interval of at least 12 hours between the onset of the headache and lumbar puncture is required, as it takes several hours for the hemoglobin from the red blood cellsto be metabolized into bilirubin .[1][16]

As only 10% of people admitted to the emergency department with a thunderclap headache are suffering from anSAH, other possible causes are usually considered simultaneously, such as meningitis , migraine , and cerebral

venous sinus thrombosis .[4]

Intracerebral hemorrhage , in which bleeding occurs within the brain itself, is twice ascommon as SAH and is often misdiagnosed as the latter. [17] It is not unusual for SAH to be initially misdiagnosed asa migraine or tension headache , which can lead to a delay in obtaining a CT scan. In a 2004 study, this occurred in12% of all cases and was more likely in people who had smaller hemorrhages and no impairment in their mentalstatus. The delay in diagnosis led to a worse outcome. [18] In some people, the headache resolves by itself, and noother symptoms are present. This type of headache is referred to as "sentinel headache", because it is presumed toresult from a small leak (a "warning leak") from an aneurysm. A sentinel headache still warrants investigations withCT scan and lumbar puncture, as further bleeding may occur in the subsequent three weeks. [3]

[edit ] AngiographyAfter a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to haveoriginated from an aneurysm (as determined by the CT scan appearance), the choice is between cerebralangiography (injecting radiocontrast through a catheter to the brain arteries) and CT angiography (visualizing bloodvessels with radiocontrast on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below) .[1][3]

[edit ] ECG

ECG changes resembling those of an STEMI in a woman who had an acute CNSinjury from a subarachnoid hemorrhage.

Electrocardiographic changes are relatively common in subarachnoid hemorrhage, occurring in 4070% of cases.They may include QT prolongation , Q waves , cardiac dysrhythmias and ST elevation that mimics a heart attack .[19]

[ edit ] ClassificationThere are several grading scales available for SAH. The Glasgow Coma Scale is ubiquitously used for assessingconsciousness. Three specialized scores are used to evaluate SAH; in each, a higher number is associated with a
http://en.wikipedia.org/wiki/Sensitivity_(tests)http://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=5http://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Lumbarhttp://en.wikipedia.org/wiki/Lumbarhttp://en.wikipedia.org/wiki/Lumbarhttp://en.wikipedia.org/wiki/Red_blood_cellhttp://en.wikipedia.org/wiki/Red_blood_cellhttp://en.wikipedia.org/wiki/Xanthochromiahttp://en.wikipedia.org/wiki/Xanthochromiahttp://en.wikipedia.org/wiki/Centrifugationhttp://en.wikipedia.org/wiki/Centrifugationhttp://en.wikipedia.org/wiki/Spectrophotometryhttp://en.wikipedia.org/wiki/Spectrophotometryhttp://en.wikipedia.org/wiki/Spectrophotometryhttp://en.wikipedia.org/wiki/Bilirubinhttp://en.wikipedia.org/wiki/Bilirubinhttp://en.wikipedia.org/wiki/Hemoglobinhttp://en.wikipedia.org/wiki/Hemoglobinhttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Migrainehttp://en.wikipedia.org/wiki/Migrainehttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Intracerebral_hemorrhagehttp://en.wikipedia.org/wiki/Intracerebral_hemorrhagehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=6http://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Catheterhttp://en.wikipedia.org/wiki/Catheterhttp://en.wikipedia.org/wiki/Catheterhttp://en.wikipedia.org/wiki/Computed_tomography_angiographyhttp://en.wikipedia.org/wiki/Computed_tomography_angiographyhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=7http://en.wikipedia.org/wiki/Electrocardiographyhttp://en.wikipedia.org/wiki/QT_prolongationhttp://en.wikipedia.org/wiki/Q_waveshttp://en.wikipedia.org/wiki/Q_waveshttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/ST_elevationhttp://en.wikipedia.org/wiki/ST_elevationhttp://en.wikipedia.org/wiki/Heart_attackhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=8http://en.wikipedia.org/wiki/Glasgow_Coma_Scalehttp://en.wikipedia.org/wiki/Glasgow_Coma_Scalehttp://en.wikipedia.org/wiki/File:CNSinjury.JPGhttp://en.wikipedia.org/wiki/Sensitivity_(tests)http://en.wikipedia.org/wiki/Magnetic_resonance_imaginghttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=5http://en.wikipedia.org/wiki/Lumbar_puncturehttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Lumbarhttp://en.wikipedia.org/wiki/Red_blood_cellhttp://en.wikipedia.org/wiki/Xanthochromiahttp://en.wikipedia.org/wiki/Centrifugationhttp://en.wikipedia.org/wiki/Spectrophotometryhttp://en.wikipedia.org/wiki/Bilirubinhttp://en.wikipedia.org/wiki/Hemoglobinhttp://en.wikipedia.org/wiki/Meningitishttp://en.wikipedia.org/wiki/Migrainehttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Cerebral_venous_sinus_thrombosishttp://en.wikipedia.org/wiki/Intracerebral_hemorrhagehttp://en.wikipedia.org/wiki/Tension_headachehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=6http://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Catheterhttp://en.wikipedia.org/wiki/Computed_tomography_angiographyhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Blood_vesselhttp://en.wikipedia.org/wiki/Radiocontrasthttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=7http://en.wikipedia.org/wiki/Electrocardiographyhttp://en.wikipedia.org/wiki/QT_prolongationhttp://en.wikipedia.org/wiki/Q_waveshttp://en.wikipedia.org/wiki/Cardiac_dysrhythmiahttp://en.wikipedia.org/wiki/ST_elevationhttp://en.wikipedia.org/wiki/Heart_attackhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=8http://en.wikipedia.org/wiki/Glasgow_Coma_Scale


11/17

worse outcome .[20] These scales have been derived by retrospectively matching characteristics of patients with their outcomes.The first scale of severity was described by Hunt and Hess in 1968: [21]

Grade Signs and symptomsSurvi

val

1 Asymptomatic or minimal headache and slight neckstiffness 70%

2Moderate to severe headache; neck stiffness; noneurologic deficit except cranial nerve palsy

60%

3 Drowsy ; minimal neurologic deficit 50%

4Stuporous; moderate to severe hemiparesis; possiblyearly decerebrate rigidity and vegetative disturbances

20%

5 Deep coma; decerebrate rigidity ; moribund 10%

The Fisher Grade classifies the appearance of subarachnoid hemorrhage on CT scan. [22]

Grade Appearance of hemorrhage

1 None evident

2 Less than 1 mm thick

3 More than 1 mm thick

4Diffuse or none with intraventricular hemorrhage orparenchymal extension

This scale has been modified by Claassen and coworkers, reflecting the additive risk from SAH size andaccompanying intraventricular hemorrhage (0 - none; 1 - minmimal SAH w/o IVH; 2 - minimal SAH with IVH; 3 -thick SAH w/o IVH; 4 - thick SAH with IVH); .[23]

The World Federation of Neurosurgeons (WFNS) classification uses Glasgow coma score (GCS) and focalneurological deficit to gauge severity of symptoms. [24]

Grade GCS Focal neurological deficit

1 15 Absent

2 1314 Absent

3 1314 Present

4 712 Present or absent

5


12/17

[ edit ] Screening and prevention

The arteries of the brain, viewed from underneath. Image originally from Gray'sAnatomy , 1918.

Screening for aneurysms is not performed on a population level; because they are relatively rare, it would not becost-effective . If someone has two or more first-degree relatives who have suffered an aneurysmal subarachnoidhemorrhage, screening may be worthwhile .[1][26]

Autosomal dominant polycystic kidney disease (ADPKD), a hereditary kidney condition, is known to be associatedwith cerebral aneurysms in 8% of cases, but most such aneurysms are small and therefore unlikely to rupture. As aresult, screening is only recommended in families with ADPKD where one family member has suffered a rupturedaneurysm .[27]

An aneurysm may be detected incidentally on brain imaging; this presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications. The International Study of Unruptured IntracranialAneurysms (ISUIA) provided prognostic data both in people who had previously suffered a subarachnoidhemorrhage and people who had aneurysms detected by other means. Those who had previously suffered SAH weremore likely to bleed from other aneurysms. In contrast, those who had never bled and had small aneurysms (smaller than 10 mm) were very unlikely to suffer SAH and were likely to sustain harm from attempts to repair theseaneurysms .[28] On the basis of the ISUIA and other studies, it is now recommended that people are only consideredfor preventative treatment if they have a reasonable life expectancy and have aneurysms that are highly likely torupture .[26] At the same time, there is only limited evidence that endovascular treatment of unruptured aneurysms isactually beneficial. [29]

[ edit ] Treatment

Arteriogram showing a partially coiled aneurysm ( indicated by yellow arrows ) of theposterior cerebral artery with a residual aneurysmal sac. The patient was a 34-year-old woman initially treated for a subarachnoid hemorrhage.

Management involves general measures to stabilize the patient while also using specific investigations andtreatments. These include the prevention of rebleeding by obliterating the bleeding source, prevention of a

phenomenon known as vasospasm , and prevention and treatment of complications. [1]
http://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=9http://en.wikipedia.org/wiki/Gray's_Anatomyhttp://en.wikipedia.org/wiki/Gray's_Anatomyhttp://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Cost-effectiveness_analysishttp://en.wikipedia.org/wiki/Cost-effectiveness_analysishttp://en.wikipedia.org/wiki/Preventative_medicinehttp://en.wikipedia.org/wiki/Preventative_medicinehttp://en.wikipedia.org/wiki/Life_expectancyhttp://en.wikipedia.org/wiki/Life_expectancyhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=10http://en.wikipedia.org/wiki/Arteriogramhttp://en.wikipedia.org/wiki/Posterior_cerebral_arteryhttp://en.wikipedia.org/wiki/Vasospasmhttp://en.wikipedia.org/wiki/File:Coiled_PCA_residual_aneurysm_arteriogram.JPGhttp://en.wikipedia.org/wiki/File:Arteries_beneath_brain_Gray_closer.jpghttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=9http://en.wikipedia.org/wiki/Gray's_Anatomyhttp://en.wikipedia.org/wiki/Gray's_Anatomyhttp://en.wikipedia.org/wiki/Screening_(medicine)http://en.wikipedia.org/wiki/Cost-effectiveness_analysishttp://en.wikipedia.org/wiki/Preventative_medicinehttp://en.wikipedia.org/wiki/Life_expectancyhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=10http://en.wikipedia.org/wiki/Arteriogramhttp://en.wikipedia.org/wiki/Posterior_cerebral_arteryhttp://en.wikipedia.org/wiki/Vasospasm


13/17

Stabilizing the patient is the first priority. Those with a depressed level of consciousness may need to be intubatedand mechanically ventilated . Blood pressure, pulse , respiratory rate and Glasgow Coma Scale are monitoredfrequently. Once the diagnosis is confirmed, admission to an intensive care unit may be preferable, especially since15% may have further bleeding soon after admission. Nutrition is an early priority, with oral or nasogastric tube feeding being preferable over parenteral routes. Analgesia (pain control) is generally restricted to less sedatingagents such as codeine , as sedation may impact on the mental status and thus interfere with the ability to monitor thelevel of consciousness. Deep vein thrombosis is prevented with compression stockings , intermittent pneumatic compression of the calves or both .[1] A bladder catheter is usually inserted to monitor fluid balance. Benzodiazepines may be administered to help relieve distress. [6] Antiemetic drugs should be given to awake persons. [5]

[edit ] Prevention of rebleedingPeople whose CT scan shows a large hematoma , depressed level of consciousness or focal neurologic symptomsmay benefit from urgent surgical removal of the blood or occlusion of the bleeding site. The remainder are stabilizedmore extensively and undergo a transfemoral angiogram or CT angiogram later. It is hard to predict who will suffer a rebleed, yet it may happen at any time and carries a dismal prognosis. After the first 24 hours have passed,rebleeding risk remains around 40% over the subsequent four weeks, suggesting that interventions should be aimedat reducing this risk as soon as possible. [1]

If a cerebral aneurysm is identified on angiography, two measures are available to reduce the risk of further bleedingfrom the same aneurysm: clipping [30] and coiling .[31] Clipping requires a craniotomy (opening of the skull) to locatethe aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the

large blood vessels (endovascularly): a catheter is inserted into the femoral artery in the groin and advanced throughthe aorta to the arteries (both carotid arteries and both vertebral arteries ) that supply the brain. When the aneurysmhas been located, platinum coils are deployed that cause a blood clot to form in the aneurysm, obliterating it. Thedecision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of aneurosurgeon , neuroradiologist and often other health professionals. [1]

Generally, the decision between clipping and coiling is made on the basis of the location of the aneurysm, its sizeand the condition of the patient. Aneurysms of the middle cerebral artery and its related vessels are hard to reachwith angiography and tend to be amenable to clipping. Those of the basilar artery and posterior cerebral artery arehard to reach surgically and are more accessible for endovascular management .[32] These approaches are based ongeneral experience, and the only randomized controlled trial directly comparing the different modalities was

performed in relatively well patients with small (less than 10 mm) aneurysms of the anterior cerebral artery andanterior communicating artery (together the "anterior circulation"), who constitute about 20% of all patients withaneurysmal SAH. [32][33] This trial, the International Subarachnoid Aneurysm Trial (ISAT), showed that in this groupthe likelihood of death or being dependent on others for activities of daily living was reduced (7.4% absolute risk

reduction , 23.5% relative risk reduction) if endovascular coiling was used as opposed to surgery. [32] The maindrawback of coiling is the possibility that the aneurysm will recur; this risk is extremely small in the surgicalapproach. In ISAT, 8.3% needed further treatment in the longer term. Hence, people who have undergone coilingare typically followed up for many years afterwards with angiography or other measures to ensure recurrence of aneurysms is identified early. [34] Other trials have also found a higher rate of recurrence necessitating further treatments. [35][36]

[edit ] VasospasmVasospasm, in which the blood vessels constrict and thus restrict blood flow , is a serious complication of SAH. Itcan cause ischemic brain injury (referred to as "delayed ischemia") and permanent brain damage due to lack of oxygen in parts of the brain. It can be fatal if severe. Delayed ischemia is characterized by new neurologicalsymptoms, and can be confirmed by transcranial doppler or cerebral angiography. About one third of all peopleadmitted with subarachnoid hemorrhage will have delayed ischemia, and half of those suffer permanent damage as aresult. [37] It is possible to screen for the development of vasospasm with transcranial doppler every 2448 hours. A

blood flow velocity of more than 120 centimeters per second is suggestive of vasospasm .[3]

The use of calcium channel blockers , thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for the prevention of vasospasm .[13] The oral calcium channel

blocker nimodipine improves outcome if administered between the fourth and twenty-first day after the hemorrhage,even if it does not significantly reduce the amount of vasospasm detected on angiography .[38] In traumaticsubarachnoid hemorrhage, nimodipine does not affect long-term outcome, and is not recommended. [39] Other calcium channel blockers and magnesium sulfate have been studied, but are not presently recommended; neither isthere any evidence that shows benefit if nimodipine is given intravenously .[37]
http://en.wikipedia.org/wiki/Intubationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Mouthhttp://en.wikipedia.org/wiki/Mouthhttp://en.wikipedia.org/wiki/Nasogastric_intubationhttp://en.wikipedia.org/wiki/Nasogastric_intubationhttp://en.wikipedia.org/wiki/Parenteralhttp://en.wikipedia.org/wiki/Parenteralhttp://en.wikipedia.org/wiki/Parenteralhttp://en.wikipedia.org/wiki/Analgesiahttp://en.wikipedia.org/wiki/Analgesiahttp://en.wikipedia.org/wiki/Analgesiahttp://en.wikipedia.org/wiki/Codeinehttp://en.wikipedia.org/wiki/Sedationhttp://en.wikipedia.org/wiki/Deep_vein_thrombosishttp://en.wikipedia.org/wiki/Deep_vein_thrombosishttp://en.wikipedia.org/wiki/Deep_vein_thrombosishttp://en.wikipedia.org/wiki/Compression_stockingshttp://en.wikipedia.org/wiki/Pneumatichttp://en.wikipedia.org/wiki/Calf_(anatomy)http://en.wikipedia.org/wiki/Calf_(anatomy)http://en.wikipedia.org/wiki/Calf_(anatomy)http://en.wikipedia.org/wiki/Urinary_catheterizationhttp://en.wikipedia.org/wiki/Urinary_catheterizationhttp://en.wikipedia.org/wiki/Urinary_catheterizationhttp://en.wikipedia.org/wiki/Benzodiazepinehttp://en.wikipedia.org/wiki/Antiemetichttp://en.wikipedia.org/wiki/Antiemetichttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=11http://en.wikipedia.org/wiki/Hematomahttp://en.wikipedia.org/wiki/Hematomahttp://en.wikipedia.org/wiki/Focal_neurologic_symptomhttp://en.wikipedia.org/wiki/Focal_neurologic_symptomhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Clipping_(medicine)http://en.wikipedia.org/wiki/Clipping_(medicine)http://en.wikipedia.org/wiki/Clipping_(medicine)http://en.wikipedia.org/wiki/Guglielmi_Detachable_Coilhttp://en.wikipedia.org/wiki/Guglielmi_Detachable_Coilhttp://en.wikipedia.org/wiki/Craniotomyhttp://en.wikipedia.org/wiki/Craniotomyhttp://en.wikipedia.org/wiki/Femoral_arteryhttp://en.wikipedia.org/wiki/Femoral_arteryhttp://en.wikipedia.org/wiki/Femoral_arteryhttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Carotid_arteryhttp://en.wikipedia.org/wiki/Carotid_arteryhttp://en.wikipedia.org/wiki/Vertebral_arteryhttp://en.wikipedia.org/wiki/Vertebral_arteryhttp://en.wikipedia.org/wiki/Platinumhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Neurosurgeryhttp://en.wikipedia.org/wiki/Neurosurgeryhttp://en.wikipedia.org/wiki/Neuroradiologyhttp://en.wikipedia.org/wiki/Neuroradiologyhttp://en.wikipedia.org/wiki/Middle_cerebral_arteryhttp://en.wikipedia.org/wiki/Middle_cerebral_arteryhttp://en.wikipedia.org/wiki/Middle_cerebral_arteryhttp://en.wikipedia.org/wiki/Basilar_arteryhttp://en.wikipedia.org/wiki/Basilar_arteryhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Anterior_cerebral_arteryhttp://en.wikipedia.org/wiki/Anterior_cerebral_arteryhttp://en.wikipedia.org/wiki/Anterior_communicating_arteryhttp://en.wikipedia.org/wiki/Activities_of_daily_livinghttp://en.wikipedia.org/wiki/Activities_of_daily_livinghttp://en.wikipedia.org/wiki/Absolute_risk_reductionhttp://en.wikipedia.org/wiki/Absolute_risk_reductionhttp://en.wikipedia.org/wiki/Absolute_risk_reductionhttp://en.wikipedia.org/wiki/Relative_riskhttp://en.wikipedia.org/wiki/Relative_riskhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=12http://en.wikipedia.org/wiki/Blood_flowhttp://en.wikipedia.org/wiki/Blood_flowhttp://en.wikipedia.org/wiki/Ischemiahttp://en.wikipedia.org/wiki/Acquired_brain_injuryhttp://en.wikipedia.org/wiki/Acquired_brain_injuryhttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Transcranial_dopplerhttp://en.wikipedia.org/wiki/Transcranial_dopplerhttp://en.wikipedia.org/wiki/Metre_per_secondhttp://en.wikipedia.org/wiki/Metre_per_secondhttp://en.wikipedia.org/wiki/Calcium_channel_blockerhttp://en.wikipedia.org/wiki/Calcium_channel_blockerhttp://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Nimodipinehttp://en.wikipedia.org/wiki/Nimodipinehttp://en.wikipedia.org/wiki/Magnesium_sulfatehttp://en.wikipedia.org/wiki/Magnesium_sulfatehttp://en.wikipedia.org/wiki/Intubationhttp://en.wikipedia.org/wiki/Mechanical_ventilationhttp://en.wikipedia.org/wiki/Pulsehttp://en.wikipedia.org/wiki/Respiratory_ratehttp://en.wikipedia.org/wiki/Intensive_care_unithttp://en.wikipedia.org/wiki/Mouthhttp://en.wikipedia.org/wiki/Nasogastric_intubationhttp://en.wikipedia.org/wiki/Parenteralhttp://en.wikipedia.org/wiki/Analgesiahttp://en.wikipedia.org/wiki/Codeinehttp://en.wikipedia.org/wiki/Sedationhttp://en.wikipedia.org/wiki/Deep_vein_thrombosishttp://en.wikipedia.org/wiki/Compression_stockingshttp://en.wikipedia.org/wiki/Pneumatichttp://en.wikipedia.org/wiki/Calf_(anatomy)http://en.wikipedia.org/wiki/Urinary_catheterizationhttp://en.wikipedia.org/wiki/Benzodiazepinehttp://en.wikipedia.org/wiki/Antiemetichttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=11http://en.wikipedia.org/wiki/Hematomahttp://en.wikipedia.org/wiki/Focal_neurologic_symptomhttp://en.wikipedia.org/wiki/Cerebral_angiographyhttp://en.wikipedia.org/wiki/Cerebral_aneurysmhttp://en.wikipedia.org/wiki/Clipping_(medicine)http://en.wikipedia.org/wiki/Guglielmi_Detachable_Coilhttp://en.wikipedia.org/wiki/Craniotomyhttp://en.wikipedia.org/wiki/Femoral_arteryhttp://en.wikipedia.org/wiki/Aortahttp://en.wikipedia.org/wiki/Carotid_arteryhttp://en.wikipedia.org/wiki/Vertebral_arteryhttp://en.wikipedia.org/wiki/Platinumhttp://en.wikipedia.org/wiki/Thrombosishttp://en.wikipedia.org/wiki/Neurosurgeryhttp://en.wikipedia.org/wiki/Neuroradiologyhttp://en.wikipedia.org/wiki/Middle_cerebral_arteryhttp://en.wikipedia.org/wiki/Basilar_arteryhttp://en.wikipedia.org/wiki/Randomized_controlled_trialhttp://en.wikipedia.org/wiki/Anterior_cerebral_arteryhttp://en.wikipedia.org/wiki/Anterior_communicating_arteryhttp://en.wikipedia.org/wiki/Activities_of_daily_livinghttp://en.wikipedia.org/wiki/Absolute_risk_reductionhttp://en.wikipedia.org/wiki/Absolute_risk_reductionhttp://en.wikipedia.org/wiki/Relative_riskhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=12http://en.wikipedia.org/wiki/Blood_flowhttp://en.wikipedia.org/wiki/Ischemiahttp://en.wikipedia.org/wiki/Acquired_brain_injuryhttp://en.wikipedia.org/wiki/Brain_damagehttp://en.wikipedia.org/wiki/Transcranial_dopplerhttp://en.wikipedia.org/wiki/Metre_per_secondhttp://en.wikipedia.org/wiki/Calcium_channel_blockerhttp://en.wikipedia.org/wiki/Calciumhttp://en.wikipedia.org/wiki/Nimodipinehttp://en.wikipedia.org/wiki/Magnesium_sulfate


14/17

Some older studies have suggested that statin therapy might reduce vasospasm, but a subsequent meta-analysisincluding three further trials did not demonstrate evidence for benefit of statin use on either vasospasm or clinicaloutcomes. [40]

A protocol referred to as "triple H" is often used as a measure to treat vasospasm when it causes symptoms; this isthe use of intravenous fluids to achieve a state of hypertension (high blood pressure), hypervolemia (excess fluid inthe circulation) and hemodilution (mild dilution of the blood). [41] Evidence for this approach is inconclusive; norandomized controlled trials have been undertaken to demonstrate its benefits. [42]

If the symptoms of delayed ischemia do not improve with medical treatment, angiography may be attempted toidentify the sites of vasospasms and administer vasodilator medication (drugs that relax the blood vessel wall)directly into the artery. Angioplasty (opening the constricted area with a balloon) may also be performed .[3]

[edit ] Other complicationsHydrocephalus (obstruction of the flow of cerebrospinal fluid) may complicate SAH in both the short and long term.It is detected on CT scanning, on which there is enlargement of the lateral ventricles . If the level of consciousness isdecreased, drainage of the excess fluid is performed by therapeutic lumbar puncture, extraventricular drain (atemporary device inserted into one of the ventricles) or occasionally a permanent shunt .[1][3] Relief of hydrocephaluscan lead to an enormous improvement in a person's condition. [5] Fluctuations in blood pressure and electrolytedisturbances , as well as pneumonia and cardiac decompensation occur in about half the hospitalized persons withSAH and may worsen prognosis. [1] Seizures occur during the hospital stay in about a third of cases. [3] Many believethat patients might benefit from prevention with antiepileptic drugs .[3] Although this is widely practiced, [43] it is

controversial and not based on good evidence .[44 ][45]

In some studies, use of these drugs was associated with a worse prognosis; this might be because they actually cause harm, or because they are used more often in persons with a poorer prognosis. [46 ][47] There is a possibility of a gastric hemorrhage due to stress ulcers .[48]

[ edit ] Prognosis

[edit ] Early morbidity and mortalitySAH is often associated with a poor outcome .[2] The death rate (mortality ) for SAH is between 40 and 50%, [17] buttrends for survival are improving. [1] Of those who survive hospitalization, more than a quarter have significantrestrictions in their lifestyle, and less than a fifth have no residual symptoms whatsoever. [32] Delay in diagnosis of minor SAH (mistaking the sudden headache for migraine) contributes to poor outcome. [18] Factors found onadmission that are associated with poorer outcome include poorer neurological grade; systolic hypertension ; a

previous diagnosis of heart attack or SAH; liver disease ; more blood and larger aneurysm on the initial CT scan;

location of an aneurysm in the posterior circulation ; and higher age .[46]

Factors that carry a worse prognosis duringthe hospital stay include occurrence of delayed ischemia resulting from vasospasm, development of intracerebralhematoma or intraventricular hemorrhage (bleeding into the ventricles of the brain) and presence of fever on theeighth day of admission .[46]

So-called "angiogram-negative subarachnoid hemorrhage", SAH that does not show an aneurysm with four-vesselangiography, carries a better prognosis than SAH with aneurysm; however, it is still associated with a risk of ischemia, rebleeding and hydrocephalus .[12] Perimesencephalic SAH (bleeding around the mesencephalon in the

brain), however, has a very low rate of rebleeding or delayed ischemia, and the prognosis of this subtype isexcellent .[49]

The prognosis of head trauma is thought to be influenced in part by the location and amount of subarachnoid bleeding. [13] It is difficult to isolate the effects of SAH from those of other aspects of traumatic brain injury; it isunknown whether the presence of subarachnoid blood actually worsens the prognosis or whether it is merely a signthat a significant trauma has occurred. [13] People with moderate and severe traumatic brain injury who have SAHwhen admitted to a hospital have as much as twice the risk of dying as those who do not .[13] They also have a higher

risk of severe disability and persistent vegetative state , and traumatic SAH has been correlated with other markers of poor outcome such as post traumatic epilepsy , hydrocephalus, and longer stays in the intensive care unit. [13]

However, more than 90% of people with traumatic subarachnoid bleeding and a Glasgow Coma Score over 12 havea good outcome .[13]

There is also modest evidence that genetic factors influence the prognosis in SAH. For example, having two copiesof ApoE4 (a variant of the gene encoding apolipoprotein E that also plays a role in Alzheimer's disease ) seems toincrease risk for delayed ischemia and a worse outcome. [50] The occurrence of hyperglycemia (high blood sugars)after an episode of SAH confers a higher risk of poor outcome .[51]

[edit ] Long-term outcomes
http://en.wikipedia.org/wiki/Statinhttp://en.wikipedia.org/wiki/Statinhttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Hypervolemiahttp://en.wikipedia.org/wiki/Hypervolemiahttp://en.wikipedia.org/wiki/Hypervolemiahttp://en.wikipedia.org/wiki/Vasodilatorhttp://en.wikipedia.org/wiki/Vasodilatorhttp://en.wikipedia.org/wiki/Angioplastyhttp://en.wikipedia.org/wiki/Angioplastyhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=13http://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Lateral_ventricleshttp://en.wikipedia.org/wiki/Lateral_ventricleshttp://en.wikipedia.org/wiki/Extraventricular_drainhttp://en.wikipedia.org/wiki/Extraventricular_drainhttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Electrolyte_disturbancehttp://en.wikipedia.org/wiki/Electrolyte_disturbancehttp://en.wikipedia.org/wiki/Electrolyte_disturbancehttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Left_ventricular_failurehttp://en.wikipedia.org/wiki/Left_ventricular_failurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Prophylaxishttp://en.wikipedia.org/wiki/Prophylaxishttp://en.wikipedia.org/wiki/Antiepileptic_drughttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Evidence_based_medicinehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=14http://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=15http://en.wikipedia.org/wiki/Mortality_ratehttp://en.wikipedia.org/wiki/Mortality_ratehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Systolic_hypertensionhttp://en.wikipedia.org/wiki/Systolic_hypertensionhttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Posterior_(anatomy)http://en.wikipedia.org/wiki/Posterior_(anatomy)http://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Intracerebral_hematomahttp://en.wikipedia.org/wiki/Intracerebral_hematomahttp://en.wikipedia.org/wiki/Ventricular_systemhttp://en.wikipedia.org/wiki/Ventricular_systemhttp://en.wikipedia.org/wiki/Ventricular_systemhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Mesencephalonhttp://en.wikipedia.org/wiki/Mesencephalonhttp://en.wikipedia.org/wiki/Persistent_vegetative_statehttp://en.wikipedia.org/wiki/Post_traumatic_epilepsyhttp://en.wikipedia.org/wiki/Post_traumatic_epilepsyhttp://en.wikipedia.org/wiki/Post_traumatic_epilepsyhttp://en.wikipedia.org/wiki/Apolipoprotein_Ehttp://en.wikipedia.org/wiki/Apolipoprotein_Ehttp://en.wikipedia.org/wiki/Apolipoprotein_Ehttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=16http://en.wikipedia.org/wiki/Statinhttp://en.wikipedia.org/wiki/Intravenous_fluidhttp://en.wikipedia.org/wiki/Hypertensionhttp://en.wikipedia.org/wiki/Hypervolemiahttp://en.wikipedia.org/wiki/Vasodilatorhttp://en.wikipedia.org/wiki/Angioplastyhttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=13http://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Lateral_ventricleshttp://en.wikipedia.org/wiki/Extraventricular_drainhttp://en.wikipedia.org/wiki/Cerebral_shunthttp://en.wikipedia.org/wiki/Electrolyte_disturbancehttp://en.wikipedia.org/wiki/Electrolyte_disturbancehttp://en.wikipedia.org/wiki/Pneumoniahttp://en.wikipedia.org/wiki/Left_ventricular_failurehttp://en.wikipedia.org/wiki/Seizurehttp://en.wikipedia.org/wiki/Prophylaxishttp://en.wikipedia.org/wiki/Antiepileptic_drughttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Evidence_based_medicinehttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=14http://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=15http://en.wikipedia.org/wiki/Mortality_ratehttp://en.wikipedia.org/wiki/Subarachnoid_hemorrhagehttp://en.wikipedia.org/wiki/Systolic_hypertensionhttp://en.wikipedia.org/wiki/Myocardial_infarctionhttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Posterior_(anatomy)http://en.wikipedia.org/wiki/Circle_of_Willishttp://en.wikipedia.org/wiki/Intracerebral_hematomahttp://en.wikipedia.org/wiki/Intracerebral_hematomahttp://en.wikipedia.org/wiki/Ventricular_systemhttp://en.wikipedia.org/wiki/Feverhttp://en.wikipedia.org/wiki/Hydrocephalushttp://en.wikipedia.org/wiki/Mesencephalonhttp://en.wikipedia.org/wiki/Persistent_vegetative_statehttp://en.wikipedia.org/wiki/Post_traumatic_epilepsyhttp://en.wikipedia.org/wiki/Apolipoprotein_Ehttp://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Hyperglycemiahttp://en.wikipedia.org/w/index.php?title=Subarachnoid_hemorrhage&action=edit&section=16


15/17

Neurocognitive symptoms, such as fatigue , mood disturbances, and other related symptoms are common sequelae . Even in those who have made good neurological recovery, anxiety, depression, posttraumatic stress disorder andcognitive impairment are common; 46% of people who have suffered a subarachnoid hemorrhage have cognitiveimpairment that affects their quality of life. [3] Over 60% report frequent headaches .[52] Aneurysmal subarachnoidhemorrhage may lead to damage of the hypothalamus and the pituitary gland , two areas of the brain that play acentral role in hormonal regulation and production. More than a quarter of people with a previous SAH may develophypopituitarism (deficiencies in one or more of the hypothalamic-pituitary hormones such as growth hormone , luteinizing hormone or follicle-stimulating hormone ).[53]

[ edit ] EpidemiologyAverage number of people with SAH per 100,000 person-years, broken down byage. [54]

According to a review of 51 studies from 21 countries, the average incidence of subarachnoi

Statin Risks May Outweigh Benefits for Patients With a History of Brain Hemorrhage

Documents

Transcript of Statin Risks May Outweigh Benefits for Patients With a History of Brain Hemorrhage