Subarachnoid haemorrhage (SAH) or ‘brain haemorrhage ” is a very serious life-threatening neuro-surgical emergency condition requiring immediate diagnosis, transfer to a specialised neuro-care centre and intensive (ICU) management. This condition is often seen in both male and female patients, particularly in middle-aged groups. The patient usually experiences a sudden severe headache (worst ever headache in life) followed by loss of consciousness or seizures. The cause of haemorrhage is usually due to the rupture of an aneurysm in the brain.
What is an Aneurysm?
In some individuals, there is a defect in the walls of the blood vessels of the brain. This balloon-like outpouching from the wall is the weakest point of rupture. It is like a bomb in the brain which on explosion throws a significant amount of blood under pressure causing haemorrhage within the brain. This leads to a sudden increase in pressure in the brain (ICP) and can cause brain death. 30% of such patients with severe haemorrhage die before reaching a hospital. Almost 50% may lose their life after reaching the hospital in the first 24 hours.
Diagnosis of SAH
CT scan of the brain gives a prompt diagnosis. Details of the aneurysm like its size, location etc can be obtained further by doing a CT angiogram or a Digital subtraction angiography (DSA).
Management of an Aneurysmal SAH
Essentially involves management of the initial bleed, its complications and sequelae and also preventing further re-bleed. The haemorrhagic blood may disturb the circulation of brain fluid (CSF) causing the ventricles (waterbags) in the brain to increase in size – a condition called hydrocephalus. This often requires a CSF diversion procedure (EVD)involving the placement of a small tube into the ventricle by drilling a burr hole in the skull and draining the CSF externally.
Aneurysmal blood can also cause irritation to blood vessels which can contract in size (vasospasm) and reduce the blood supply to the brain. After initial stabilisation, the aneurysm should be secured to prevent a re-bleed. The aneurysm can be closed by either of the two procedures
- Clipping of the aneurysm
- Coiling of the aneurysm
The clipping procedure involves opening of the skull (craniotomy) and direct visualisation, dissection of the aneurysm under a microscope and occluding its neck by applying a titanium clip while coiling is an endovascular procedure and does not involve a craniotomy.
Management of an aneurysmal haemorrhage is very complex and challenging. Results depend on the severity or grade of haemorrhage, age, other comorbidities and the neurological condition of the patient at the time of arrival at the hospital. Prompt shifting of such patients to hospitals with neuro-care facilities may result in saving life and better prognosis.
Dr Ashwin Borkar
Consultant Neurosurgeon
Wockhardt Hospital
