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Subarachnoid Hemorrhage – Causes, Symptoms & Treatment

Subarachnoid hemorrhage is a life-threatening bleed into the subarachnoid space surrounding the brain, often causing a sudden, severe headache of extreme intensity.

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Things worth knowing about "Subarachnoid hemorrhage"

Subarachnoid hemorrhage is a life-threatening bleed into the subarachnoid space surrounding the brain, often causing a sudden, severe headache of extreme intensity.

What Is a Subarachnoid Hemorrhage?

A subarachnoid hemorrhage (abbreviated SAH) is a serious type of stroke caused by bleeding into the subarachnoid space – the area between two of the membranes that surround the brain, known as the arachnoid mater and the pia mater. Under normal circumstances, this space is filled with cerebrospinal fluid (CSF), which cushions and protects the brain. A subarachnoid hemorrhage is a medical emergency requiring immediate treatment.

Causes

The most common cause of a subarachnoid hemorrhage is the rupture of a cerebral aneurysm – a balloon-like bulge in the wall of a brain artery. Other possible causes include:

Arteriovenous malformations (AVMs): Abnormal tangles of blood vessels in the brain
Head trauma: Severe head injuries from accidents
High blood pressure: Can weaken blood vessel walls and lead to rupture
Blood clotting disorders: Increased tendency to bleed
Drug abuse: Cocaine in particular can cause vascular damage
Idiopathic: In some cases, no identifiable cause is found

Symptoms

The hallmark symptom of a subarachnoid hemorrhage is the so-called thunderclap headache: a sudden, extremely severe headache that patients often describe as the worst headache of their lives. Additional symptoms may include:

Neck stiffness (meningismus)
Nausea and vomiting
Sensitivity to light (photophobia)
Loss of consciousness or confusion
Neurological deficits such as weakness or visual disturbances
Seizures

If these symptoms occur, emergency services (911 or local emergency number) should be called immediately.

Diagnosis

The diagnosis of a subarachnoid hemorrhage is typically confirmed through the following investigations:

Computed tomography (CT scan): A CT scan of the head is the first-line investigation and can detect blood in the subarachnoid space in most cases.
Lumbar puncture: If the CT scan is negative but clinical suspicion remains high, cerebrospinal fluid is sampled from the spinal canal and examined for the presence of blood.
CT angiography or digital subtraction angiography (DSA): Used to identify aneurysms or vascular malformations as the source of bleeding.
MRI (Magnetic Resonance Imaging): Used as a supplementary tool, particularly in ambiguous cases.

Treatment

Treatment of a subarachnoid hemorrhage is carried out in an intensive care setting and depends on the underlying cause and severity of the bleed.

General Measures

Immediate admission to a neurological intensive care unit or stroke unit
Monitoring of vital signs and intracranial pressure
Pain management and blood pressure control
Prevention of vasospasm (arterial narrowing) using nimodipine

Treatment of the Bleeding Source

Endovascular coiling: The aneurysm is sealed from the inside by inserting platinum coils via a catheter, preventing further blood flow into the aneurysm sac.
Neurosurgical clipping: A metal clip is placed surgically at the base of the aneurysm to cut off its blood supply.

Complications and Follow-Up

Serious complications of subarachnoid hemorrhage include rebleeding, vasospasm with the risk of secondary ischemic stroke, and hydrocephalus (a buildup of CSF causing increased pressure in the brain). Long-term neurological follow-up and rehabilitation are necessary for many patients.

Prognosis

Subarachnoid hemorrhage carries a high mortality rate. Approximately 30 to 40 percent of affected individuals do not survive the initial event. Many survivors experience lasting neurological impairments. Early diagnosis and prompt treatment are critical determinants of outcome.

References

Connolly ES Jr. et al. – Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. Stroke, American Heart Association, 2012;43(6):1711–1737.
Feigin VL et al. – Global, regional, and national burden of neurological disorders. Lancet Neurology, 2019.
Rinkel GJ, Algra A. – Long-term outcomes of patients with aneurysmal subarachnoid haemorrhage. Lancet Neurology, 2011;10(4):349–356.

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