Subarachnoid Hemorrhage -

A subarachnoid hemorrhage is bleeding in the space between the brain and the tissues that cover the brain. The space is known as the subarachnoid space. A subarachnoid hemorrhage is a type of stroke. It is a medical emergency that needs treatment right away.

The primary symptom of a subarachnoid hemorrhage is a sudden, very bad headache. Some people describe it as the worst headache they have ever felt. A subarachnoid hemorrhage also may cause nausea, vomiting, a stiff neck and other symptoms.

Bleeding usually happens when an irregular bulge in a blood vessel, known as an aneurysm, bursts in the brain. Bleeding also can happen because of a head injury. Sometimes a tangle of blood vessels in the brain, known as an arteriovenous malformation, causes the bleeding. And other health conditions, including conditions that affect the blood vessels, can cause bleeding.

If a subarachnoid hemorrhage isn’t treated, it can lead to permanent brain damage or death, so it’s important to get treatment right away.

Symptoms
Causes
Risk factors
Diagnosis
Treatment

The most common symptom of a subarachnoid hemorrhage is a very sudden, very bad headache. The headache starts in a split second and becomes very painful right away. Some people describe it as the worst headache they have ever had.

Along with a sudden headache, symptoms may include:

Nausea.
Vomiting.
Stiff neck or neck pain.
Changes in vision.
Brief loss of consciousness.

When to see a doctor

A subarachnoid hemorrhage is a medical emergency.

Get immediate medical attention if you experience a very sudden, very bad headache or if you have other symptoms of a subarachnoid hemorrhage. This is especially important if you have been diagnosed with a brain aneurysm or if you have experienced a head injury.

If you’re with someone who complains of a very bad headache that came on suddenly or who loses consciousness, call 911 or your local emergency number.

A subarachnoid hemorrhage may be caused by:

A brain aneurysm that bursts. A brain aneurysm is a bulge in a blood vessel in the brain. The aneurysm can burst and cause bleeding in the space between the brain and the tissues covering the brain, known as the subarachnoid space. A brain aneurysm is the most common cause of a subarachnoid hemorrhage.
Head injury. Another common cause is a head injury. A head injury from an auto accident, fall or violence can lead to a subarachnoid hemorrhage.
A tangle of blood vessels in the brain, known as an arteriovenous malformation. This irregular tangle of blood vessels can rupture and cause bleeding in the brain.
Swelling of the blood vessels, known as vasculitis. This can cause the walls of the blood vessels to thicken and narrow. Vasculitis can lead to a blood clot or an aneurysm.

Some risk factors for a subarachnoid hemorrhage are not under your control. They include:

Being an older age. Most subarachnoid hemorrhages that result from an aneurysm occur in people between ages 55 and 60. Women in their 50s and 60s, in particular, have a higher risk.
Having a first-degree relative with a brain aneurysm. This includes a parent, child or sibling related by blood
Having certain health conditions. Conditions that increase the risk of a subarachnoid hemorrhage include Ehlers-Danlos syndrome, Marfan syndrome, neurofibromatosis type 1 and polycystic kidney disease.

People who have two or more first-degree relatives with brain aneurysms or who have had a subarachnoid hemorrhage can get screened.

Other risk factors for a subarachnoid hemorrhage can be avoided. They include:

Having high blood pressure.
Smoking.
Misusing alcohol.
Using drugs such as cocaine and methamphetamine.

To diagnose a subarachnoid hemorrhage, you may need the following tests:

CT scan. This imaging test is very effective at detecting bleeding in the brain. But it may not detect bleeding if you have a low red blood cell count or if there is a small amount of bleeding. Your healthcare professional may inject a contrast dye to view your blood vessels in greater detail, known as a CT angiogram.
MRI. This imaging test also can detect bleeding in the brain. An MRI scan may show signs of a subarachnoid hemorrhage in rare cases when it’s not detected by a CT scan. Your healthcare professional might inject a dye into a blood vessel to view the arteries and veins in greater detail, known as an MR angiogram.
Cerebral angiography. You may have a cerebral angiography to get more-detailed images. Angiography also may be done if a subarachnoid hemorrhage is suspected, but the cause isn’t clear or doesn’t appear on other imaging. A long, thin tube known as a catheter is inserted into an artery and threaded to your brain. Dye is injected into the blood vessels of your brain to make them visible under X-ray imaging. Sometimes a cerebral angiogram does not show an aneurysm. If this happens, you may have a second angiogram if your healthcare professional thinks an aneurysm is likely.

For some people with an aneurysm that caused a subarachnoid hemorrhage, the bleeding may not appear on initial imaging. If this happens, you may need a lumbar puncture. During this procedure, a needle is inserted into the lower back. A small amount of the fluid that surrounds the brain and spinal cord, known as cerebrospinal fluid, is removed. The fluid is then studied to look for blood, which may mean that you have a subarachnoid hemorrhage.

Treatment of a subarachnoid hemorrhage focuses on stabilizing the condition. Your healthcare team checks your breathing, blood pressure and blood flow.

If you have a burst aneurysm, you’re treated for it and your healthcare team works to prevent complications.

To treat a ruptured brain aneurysm, your healthcare professional might recommend:

Surgery. The surgeon makes an incision in the scalp and locates the brain aneurysm. A metal clip is placed on the aneurysm to stop the blood flow to it.
Endovascular embolization. The surgeon inserts a catheter into an artery and threads it to your brain. Detachable platinum coils are guided through the catheter and placed in the aneurysm. The coils reduce blood flow into the aneurysm and cause the blood to clot. Different types of coils have been developed to treat aneurysms.
Other endovascular treatments. Certain aneurysms can be treated with endovascular embolization that uses newer technology. These newer techniques include stent-assisted or balloon-assisted coiling or devices that divert blood flow.

Treating the ruptured aneurysm quickly can help prevent bleeding from happening again.

It’s also important to prevent other complications. A subarachnoid hemorrhage may lead to low salts such as sodium in the blood. It also may cause high or low blood sugar. Your healthcare team monitors these levels and treats them if needed.

There also may be poor blood flow to the brain. A common complication of a subarachnoid hemorrhage due to a burst aneurysm is a constriction and narrowing of the blood vessels in the brain, known as vasospasm. This can cause a stroke if blood flow decreases to a certain level. A stroke may be avoided by raising blood pressure or by widening blood vessels in the brain with medicines. The medicine nimodipine (Nymalize) also can lower the risk of vasospasm.

Another common complication is a buildup of fluid in cavities within the brain, known as hydrocephalus. This can be treated with drains inserted in the head or lower back.

Sometimes, procedures need to be repeated. After your initial treatment, follow-up appointments with your healthcare team are important to watch for any changes. You also may need physical, occupational and speech therapies.

References

Winn HR. Perioperative management of subarachnoid hemorrhage. In: Youmans and Winn Neurological Surgery. 8th ed. Philadelphia, Pa.: Elsevier; 2023. https://www.clinicalkey.com. Accessed May 6, 2022.
Connolly ES, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for the healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012; doi: 10.1161/str.0b013e3182587839
Siddiq F. Nonaneurysmal subarachnoid hemorrhage. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
Ferri FF. Subarachnoid hemorrhage. In: Ferri’s Clinical Advisor 2022. Elsevier; 2022. https://www.clinicalkey.com. Accessed May 6, 2022.
Singer RJ, et al. Aneurysmal subarachnoid hemorrhage: Epidemiology, risk factors, and pathogenesis. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
Dubosh NM, et al. Diagnosis and initial emergency department management of subarachnoid hemorrhage. Emergency Medical Clinics of North America. 2021; doi: 10.1016/j.emc.2020.09.005
Chakraborty T, et al. CT-negative subarachnoid hemorrhage in the first six hours. Journal of Stroke and Cerebrovascular Diseases. 2020; doi: 10.1016/j.jstrokecerebrovasdis.2020.105300
Singer RJ, et al. Clinical manifestations and diagnosis of aneurysmal subarachnoid hemorrhage. https://www.uptodate.com/contents/search. Accessed May 6, 2022
Torregrossa F, et al. Therapeutic approaches for cerebrovascular dysfunction after aneurysmal subarachnoid hemorrhage: An update and future perspectives. World Neurosurgery. 2022; doi: 10.1016/j.wneu.2021.11.096
Singer RJ, et al. Treatment of aneurysmal subarachnoid hemorrhage. https://www.uptodate.com/contents/search. Accessed May 6, 2022.
Tawk, RG, et al. Diagnosis and treatment of unruptured intracranial aneurysms and aneurysmal subarachnoid hemorrhage. Mayo Clinic Proceedings. 2021; doi: 10.1016/j.mayocp.2021.01.005
Daroff RB, et al. Intracranial aneurysms and subarachnoid hemorrhage. In: Bradley and Daroff’s Neurology in Clinical Practice. 8th ed. Elsevier; 2022. https://www.clinicalkey.com. Accessed May 6, 2022.
Singer RJ, et al. Treatment of cerebral aneurysms. https://www.uptodate.com/contents/search. Accessed July 5, 2022.
Youssef PP, et al. Woven endobridge(WEB) device in the treatment of ruptured aneurysms. Journal of Interventional Surgery. 2021; doi: 10.1136/neurintsurg-2020-016405
Gupta R, et al. Primary results of the Vesalio NeVa VS for the treatment of symptomatic cerebral vasospasm following aneurysm subarachnoid hemorrhage (vital) study. Journal of Interventional Surgery.2021; doi: 10.1136/neurintsurg.2021.017859
Guerra H, et al. The first CT in a subarachnoid hemorrhage: A picture tells a story. Practical Neurology. 2017; doi: 10.1136/practneurol-207-001639
Kramer CL, et al. Refining the association of fever with functional outcome in aneurysmal subarachnoid hemorrhage. Neurocritical Care. 2017; doi: 10.1007/s12028-0160281-7
Rinaldo L, et al. Transfer to high-volume centers associated with reduced mortality after endovascular treatment of acute stroke. Stroke. 2017; doi: 10.1161/strokeaha.116360
Pegoli M, et al. Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery. 2015; doi: 10.3171/2014.10jns14290
Nguyen HT. Allscripts EPSi. Mayo Clinic. April 22, 2022.
Medical review (expert opinion). Mayo Clinic. July 1, 2022.

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