Isolated dilation of a pupil and loss of the pupillary light reflex may reflect brain herniation as a result of rising intracranial pressure (pressure inside the skull). Neck stiffness usually presents six hours after initial onset of SAH. Confusion, decreased level of consciousness or coma may be present, as may neck stiffness and other signs of meningism. Vomiting may be present, and 1 in 14 have seizures. About one-third of people have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid hemorrhage. This headache often pulsates towards the occiput (the back of the head). The classic symptom of subarachnoid hemorrhage is thunderclap headache (a headache described as "like being kicked in the head", or the "worst ever", developing over seconds to minutes). Since the 1990s many aneurysms are treated by a less invasive procedure called endovascular coiling, which is carried out through a large blood vessel. Surgery for aneurysms was introduced in the 1930s. It is a form of stroke and comprises about 5 percent of all strokes. While it becomes more common with age, about 50% of people present under 55 years old. Females are more commonly affected than males. Spontaneous SAH occurs in about one per 10,000 people per year. Between ten and fifteen percent die before reaching a hospital. Nearly half of people with a SAH due to an underlying aneurysm die within 30 days and about a third who survive have ongoing problems. The routine use of medications to prevent further seizures is of unclear benefit. Nimodipine, a calcium channel blocker, is frequently used to prevent vasospasm. Efforts to treat fevers are also recommended. Medications such as labetalol may be required to lower the blood pressure until repair can occur. Treatment is by prompt neurosurgery or endovascular coiling. After confirmation further tests are usually performed to determine the underlying cause. Occasionally, a lumbar puncture is also required. Generally, the diagnosis can be determined by a CT scan of the head if done within six hours of symptom onset. Risk factors for spontaneous cases include high blood pressure, smoking, family history, alcoholism, and cocaine use. SAH may occur as a result of a head injury or spontaneously, usually from a ruptured cerebral aneurysm. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed. Neck stiffness or neck pain are also relatively common. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, and sometimes seizures. Subarachnoid hemorrhage ( SAH) is bleeding into the subarachnoid space-the area between the arachnoid membrane and the pia mater surrounding the brain. Neurosurgery or radiologically guided interventions Ĥ5% risk of death at 30 days (aneurysmal) Meningitis, migraine, cerebral venous sinus thrombosis High blood pressure, smoking, alcoholism, cocaine Traumatic, spontaneous (aneurysmal, nonaneurysmal, perimesencephalic) Severe headache of rapid onset, vomiting, decreased level of consciousness ĭelayed cerebral ischemia, cerebral vasospasm, seizures Stein, S.C., Browne, K.D., Chen, X.H., Smith, D.H.
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