Subarachnoid hemorrhage

The subarachnoid hemorrhage occurs between the middle and inner meninges. Read more about causes, symptoms and treatment!

Subarachnoid hemorrhage

A subarachnoid hemorrhage (SAB) is a bleeding between the middle meninges (arachnoid or spiderweb skin) and the inner meninges (pia mater or soft meninges), which is filled with cerebrospinal fluid (cerebrospinal fluid). There are many blood vessels in this narrow, slit-shaped space around the brain. If a vessel bursts before it enters the brain tissue, the escaping blood spreads in the subarachnoid space and presses on the brain from the outside. In the brain tissue itself, however, there is no bleeding. Find out more about the triggers and dangers of subarachnoid hemorrhage.

ICD codes for this disease: ICD codes are internationally valid medical diagnosis codes. They are found e.g. in doctor's letters or on incapacity certificates. I60

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subarachnoid hemorrhage

  • Subarachnoid haemorrhage: causes

  • Subarachnoid haemorrhage: risk factors

  • Subarachnoid haemorrhage: symptoms

  • Subarachnoid haemorrhage: diagnosis

  • Subarachnoid haemorrhage: therapy

  • Subarachnoid haemorrhage: prognosis

Subarachnoid haemorrhage: causes

About five percent of all strokes are caused by a spontaneous (non-traumatic) subarachnoid hemorrhage. In Central Europe and the US, about six to nine out of every 100,000 people suffer an SAB every year. Subarachnoid haemorrhage usually occurs between the ages of 30 and 60, but on average at the age of 50 years. Women are slightly more affected than men.

In about 85 percent of cases, a subarachnoid hemorrhage occurs due to the tearing of a so-called aneurysm in the brain: this is a vascular malformation in the form of a sac like extension of the vessel wall. In the area of ​​this protuberance, the vessel wall is less firm than usual and can easily rupture - the result is a subarachnoid hemorrhage.

The rupture of the aneurysm is not linked to a particular disease, but often occurs in full health without previous discomfort, often even in complete rest. In some people, subarachnoid hemorrhaging is preceded by a physical exertion, such as heavy lifting, aggravated bowel movements (heavy pressing), or sexual intercourse. The cause of the bursting of the aneurysm may also be a sudden increase in blood pressure.

Rarely triggers of subarachnoid haemorrhage are, for example, traumatic brain injury, sinus vein thrombosis (blood clot in a specific cerebral vessel), vascular inflammation, coagulation disorders, tumors, infections and intoxications (such as alcohol, cocaine, amphetamines, drugs). Despite intensive search, no cause for the subarachnoid hemorrhage can be found in some patients.

Subarachnoid haemorrhage: risk factors

The avoidable risk factors for subarachnoid haemorrhage are high blood pressure, smoking, excessive consumption of alcohol and the use of cocaine. Unavoidable risk factors of SAB include age, previous onset of SAB, family history of SAB, and genetic factors. Past craniocerebral injuries, which have resulted in the formation of a vascular wall bulge, can also result in subarachnoid hemorrhage.

Subarachnoid haemorrhage: symptoms

Symptoms of subarachnoid haemorrhage are sudden, intense, never experienced headaches, which spread rapidly from the neck or forehead to the whole head and within the following hours to the back. This "annihilation headache" is often accompanied by nausea, vomiting, photophobia and neck stiffness (meningism). Depending on the extent of the subarachnoid haemorrhage may also adjust to disturbances of consciousness to deep coma.

In addition, a subarachnoid hemorrhage can also lead to other symptoms such as increase or decrease in blood pressure, fluctuations in body temperature and changes in heart rate and respiratory rate. Depending on the location and extent of the bleeding, paralysis and (less frequent) epileptic seizures may occur.

Five degrees of subarachnoid hemorrhage

Experts in Germany classify the severity of subarachnoid hemorrhage into five grades (Hunt and Hess classification). These are based on the severity of the symptoms and can be related to the score in the so-called Glasgow coma scale (GCS): In this scale, the patient receives at the accident site for certain reactions (such as eye opening, reaction to pain stimuli and verbal utterances) each have a defined score. The points are finally added. The worst value is three, the best 15.

  • Hunt and Hess Grade I: no or only slight headache, possibly slight neck stiffness, GCS value 15.
  • Hunt and Hess Grade II: Moderate to severe headache, neck stiffness, no neurological deficits other than cranial nerve disorders due to direct pressure of the leaked blood on the cranial nerves, no change in consciousness, GCS score 13-14.
  • Hunt and Hess Grade III: Drowsiness or somnolence, confusion and / or mild neurological deficits (paralysis, sensory disturbances), GCS score 13-14.
  • Hunt and Hess Grade IV: severe disturbance of consciousness / deep sleep state (Sopor), moderate to severe incomplete hemiparesis, vegetative disorders (such as respiratory or temperature regulation disorders), GCS score 7-12.
  • Hunt and Hess Grade V: deep coma, no light reaction of the pupils, indications in the neurological examination for an obstruction of the brain due to the excessive pressure in the skull, GCS value 3-6.

Subarachnoid haemorrhage: diagnosis

A subarachnoid haemorrhage manifests itself by devastating headache and is life threatening. Therefore, anyone with massive, sudden headaches he has never experienced before should go to the hospital emergency department (if no concomitant symptoms otherwise occur) or call the ambulance (if there are additional symptoms).

In the hospital, the doctor asks patients about the temporal development of the symptoms. An attendant can provide valuable information, especially if the patient is dizzy or unconscious. The physician also asks about family members with strokes and cerebral hemorrhages, because subarachnoid hemorrhage sometimes occurs in families.

Imaging procedures

When examining the skull using computed tomography (cranial computed tomography, cCT), the physician usually recognizes the subarachnoid hemorrhage as a flat, white area adjacent to the brain surface. Within the first 24 hours after the bleeding, 95% of subarachnoid haemorrhages can be detected in the cCT, after which the rate drops. Therefore, cCT is considered the first-choice examination method in the acute phase after subarachnoid hemorrhage.

MRI (Magnetic Resonance Imaging, MRI) also detects subarachnoid haemorrhage in the first few days after the event. If CT or MRI provide an inconspicuous finding, a lumbar puncture can help with the diagnosis. The spinal fluid removed during lumbar puncture may indicate a subarachnoid haemorrhage due to its altered appearance (eg bloody).

In the course of time, convulsions (vasospasms) may develop in the affected blood vessels in response to the subarachnoid hemorrhage, leading to additional paralysis in some individuals. Vasospasm is detected by a special ultrasound scan of the cerebral vessels (transcranial Doppler sonography, TCD).

To identify the source of bleeding (aneurysm), the doctor can perform a radiographic angiography.

Subarachnoid haemorrhage: therapy

People with subarachnoid haemorrhage must be promptly treated with intensive care because the bleeding can be life-threatening. The basic measures of treatment include bed rest as well as the monitoring and, if necessary, adjustment of blood pressure and blood sugar. Any occurring fever will be treated.

Surgery to eliminate the aneurysm

If a ruptured aneurysm (abnormal vessel eruption) is the cause of subarachnoid hemorrhage, it is separated from the bloodstream as quickly as possible. This is possible in two ways: either surgically by a neurosurgeon (clipping) or via the blood vessels by an experienced neuroradiologist (endovascular coiling).

At the clipping the surgeon clips the aneurysm to its base. This stops the supply of blood to the aneurysm. However, surgery is only possible if there is no spasm of the vessels. Therefore, clipping operations are mainly performed on the first and second day after the first SAB complaints. If there are vasospasms or if the patient is in a poor neurological condition, the doctors are more likely to wait for the operation as the spasm may be amplified by the procedure.

At the coiling the doctor introduces a platinum coil ("platinum coil") into the aneurysm. For this he pushes a catheter over the inguinal artery to the Gefäßaussackung. The coil fills the aneurysm and stops the bleeding. This method is less cumbersome and provokes less vessel cramping than clipping. This is why it is recommended if you can not operate on low-risk. But the aneursyma can not be turned off as effectively by clipping as by clipping. Therefore, after a few months, all patients who have undergone coiling must undergo angiography (vascular imaging using an X-ray contrast medium).

Vascular spasms (vasospasm)

Vascular spasm sets in after the fourth day after subarachnoid hemorrhage and persists for about two to three weeks. By impairing cerebral blood flow, they often cause the onset or increase of paralysis or dysregulation. Vascular spasms are treated with medication.


Another possible complication of subarachnoid hemorrhage is the "hydrocephalus" - an enlargement of the brain chambers due to pent-up cerebral fluid. In some cases, the hydrocephalus spontaneously returns.Most of the pent-up brain water must be discharged for a few days via a hose to the outside. If drainage is necessary over a long period of time, patients will receive a shunt - a surgically inserted catheter that will drain excess brainwash into either the abdominal cavity (ventriculoperitoneal shunt) or the right atrium of the heart (ventriculoatrial shunt).

Read more about the investigations

  • Computed tomography
  • lumbar puncture

Subarachnoid haemorrhage: prognosis

The prognosis of subarachnoid hemorrhage depends on many factors, for example the age of the person affected, the severity of the bleeding and the location of the aneurysm. For example, aneurysms in the posterior parts of the brain have a worse prognosis than those in the front areas of the brain.

Generally speaking, subarachnoid hemorrhage is a life-threatening disease. Overall, about 50 percent of those affected die from the SAB. Of the survivors, about half of them suffer from severe deficits (paralysis, coordination disorders, mental retardation, etc.), and one third remain dependent on help from others for life. Early intensive care treatment of the subarachnoid hemorrhage improves the prognosis.

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