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Subarachnoid Hemorrhage

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In one line

·Blood bursts into the cushion space around the brain, causing the worst headache of your life.

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Normal physiology

·Your brain floats in a thin layer of clear fluid called cerebrospinal fluid (CSF), held in a space called the subarachnoid space between two protective layers (the meninges). Blood vessels run through this space but stay sealed tight. No blood should ever leak into this cushion.

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What goes wrong

·A weak balloon on a brain artery (aneurysm) bursts, or a tangle of abnormal vessels (AVM) bleeds, or a head injury tears a vessel. Blood floods the space around the brain where only clear fluid belongs.

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Hallmark signs

·Sudden, severe headache — often called the worst headache of your life
·Stiff neck (can't easily bend your chin down toward your chest)
·Sudden nausea and vomiting
·Sensitivity to light (photophobia — bright light hurts your eyes or makes your headache worse)
·Confusion or trouble staying awake (altered level of consciousness)
·Sudden loss of consciousness or fainting (syncope)
·Seizure (sudden jerking movements or blanking out)
·Weakness or numbness on one side of the body, trouble speaking, or vision loss (focal neurologic deficits)

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Red flags · escalate now

·Sudden, worst headache of your life — especially if it peaks within seconds to minutes (thunderclap headache)
·Loss of consciousness, seizure, or trouble staying awake after the headache starts
·Sudden weakness, numbness, trouble speaking, or vision loss on one side
·Stiff neck with severe headache and sensitivity to light — may signal bleeding around the brain
·Headache after head injury, especially if you passed out or vomited

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Workup

·Non-contrast head CT (computed tomography scan)
·Lumbar puncture with cerebrospinal fluid (CSF) analysis — red blood cell count and xanthochromia (visual inspection or spectrophotometry)
·CT angiography (CTA) of the head and neck
·Electrocardiogram (ECG)
·Troponin I or T
·Serum sodium
·Transcranial Doppler ultrasound (TCD)
·CT or MRI head (follow-up imaging)

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Treatment

·Secure the airway and stabilize blood pressure — target systolic BP 140-160 mmHg (or MAP 70-110 mmHg) until the aneurysm is repaired
·Aneurysm repair — endovascular coiling or surgical clipping within 24 hours (earlier if feasible)
·Nimodipine 60 mg by mouth or nasogastric tube every 4 hours for 21 days
·External ventricular drain (EVD) placement if hydrocephalus develops (ventricular enlargement with rising intracranial pressure or declining mental status)
·Seizure prevention (prophylaxis) — levetiracetam 500-1000 mg intravenously or by mouth twice daily for 3-7 days
·Transcranial Doppler ultrasound monitoring every 1-2 days from day 3 to day 14
·Induced high blood pressure (hypertension) and euvolemia if delayed cerebral starved blood flow (ischemia) (vasospasm-related stroke symptoms) develops despite nimodipine

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NCLEX trap

·Neck stiffness and light sensitivity in subarachnoid bleeding (hemorrhage) come from blood irritating the meninges (the thin protective sheets that wrap the brain and spinal cord), not from germs. Order an emergency CT scan first. Blood lights up white on CT; bacteria do not show up that way. If the CT is clear but you still suspect meningitis, then do a lumbar puncture (spinal tap) — but in subarachnoid bleeding, you will find xanthochromia (a yellow tint from broken-down old blood) or fresh red blood instead of the white blood cells you see in infection.
·A thunderclap headache — the worst headache of your life that hits in seconds like a lightning bolt — is NOT a migraine. Migraines creep up slowly over minutes or hours. Subarachnoid bleeding (hemorrhage) is a life-threatening emergency. Any thunderclap headache gets an emergency CT of the head right now, stat, no waiting.
·In subarachnoid bleeding (hemorrhage), slamming blood pressure down before the aneurysm (the weak bubble on the blood vessel wall) is secured can cause the aneurysm to rupture again or starve the brain of blood and cause a stroke. Keep systolic blood pressure (the top number) under 140 to 160 until the aneurysm is fixed with coiling (tiny wires plugging it from inside) or clipping (a tiny metal clip pinching it shut from outside). After the aneurysm is safe, you can be more aggressive if vasospasm (blood vessels squeezing shut) develops.
·Ten to fifteen out of every 100 subarachnoid bleeding (hemorrhage) patients have a negative CT in the first 6 to 12 hours because the bleed is tiny or the scanner misses it. If you still suspect subarachnoid bleeding strongly — thunderclap headache plus stiff neck plus light sensitivity — do a lumbar puncture (spinal tap). Xanthochromia (yellow color from old blood breaking down) in the spinal fluid proves subarachnoid bleeding even if the CT looked empty.
·Morphine or other pain medicines help the patient feel better, but they do NOT stop the bleeding, prevent vasospasm (blood vessels squeezing), or lower intracranial pressure (the pressure inside the closed skull). The real fix is finding the aneurysm, securing it with coiling or clipping within 24 hours, and giving nimodipine (a medicine that relaxes brain blood vessels) to prevent vasospasm. Pain control is a helper, not the cure.
·Low sodium (hyponatremia) is common after subarachnoid bleeding (hemorrhage) from cerebral salt wasting (the kidneys dumping too much salt) or SIADH (syndrome of inappropriate antidiuretic hormone — the body holding onto too much water and diluting the sodium). It makes confusion worse, triggers seizures, and drops blood pressure. Check sodium levels every day during the first week and replace salt if needed.

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