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He collapsed due to subarachnoid hemorrhage in October 11, and divorced in February last year.

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Subarachnoid hemorrhage

Subarachnoid hemorrhage(Spider makukashuketsu, subarachnoid hemorrhage,British: Subarachnoid hemorrhage; CHESS) IsHuman brain3 layers coveringMeningesOf which, the second layerArachnoidAnd the third layerPia materSpace betweenSubarachnoid spaceBleeding occurs,Cerebrospinal fluidinsidebloodRefers to the state in which is mixed.Cerebrovascular diseaseOccupies 8% ofSudden deathIt is said that 6.6% of the cases fall under this category.[1].. It occurs frequently between the ages of 50 and 60, and it is said that there are twice as many women as men.Cerebral aneurysmThe main cause is the rupture ofJapanThen about 1 people a yearDeathIs the cause[2].


Mostly due to rupture of a cerebral aneurysm (about 80%), and othersCerebral arteriovenous malformation,Moyamoya disease,Head injury,Brain tumorAnd due to rupture of cerebral artery dissection[3][4].

Rupture of a cerebral aneurysm

It accounts for most of the endogenous subarachnoid hemorrhage.A cerebral aneurysm is a swelling of a part of an artery that weakens the blood vessel wall.There are sac-type (intracranial aneurysm) and spindle-type depending on the type.

In people with cerebral aneurysms, exercise, anger, excitement, etc. to the brainblood pressureWhen the aneurysm rises, part of the aneurysm tears and causes bleeding.[5]..The bleeding itself takes only a few seconds, but the blood rapidly penetrates the entire subarachnoid space,Intracranial pressureHypersymptoms andMeningeal irritation symptomsCause

In addition, the blood flow that should nourish the brain flows to bleeding, causing transient cerebral ischemia.The Hunt and Hess classification described below is also considered to indicate the severity of the ischemia.Loss of consciousness is due to a very short period of major ischemia, and cardiopulmonary arrest is due to whole cerebral ischemia for several seconds or longer.VagusThis is because it is presumed to be sinus arrest due to superiority (vagal reflex).

Rupture of cerebral arteriovenous malformation

Cerebral arteriovenous malformationThe arteries and veins of the brain are congenitalShuntIt is a malformation that forms a fragile vein wall and is prone to bleeding due to high blood pressure.It is the most common cause of juvenile subarachnoid hemorrhage.

Bleeding due to trauma

The brain exists in a floating state in the spinal fluid, and the specific density of the entire brain isCerebrospinal fluidSlightly heavier.Therefore, when the head is impacted, the brain moves in the skull closer to the point of action of the force.At this time, on the opposite side of the point of action, the vein connecting the brain and the dura mater is cut and bleeding occurs.

Risk factors

smoking,High blood pressure[6],Alcohol polydipsiaHistory[7]Etc. exist as risk factors.AtavismIt is a sexual illness, and if there are people who have developed it in their grandparents' generation, the probability of developing it increases.


suddenlyStart,Strong sustainability OfheadacheIs the main symptom.

VomitingMay be accompanied by.Headaches are described as "a metal bat, like being hit with a hammer."With a small amount of bleeding (minor leak), the headache is often not very strong.The onset of headache is characterized by "sudden" onset.This headache does not go away in a few hours and lasts for several days.It is not uncommon for there to be no other neurological symptoms, in the brainHematomaWithoutHemiplegia,AphasiaThere are no local symptoms of the brain.If the bleeding is severeConsciousness disorderI can't complain of a headache.As a neurological symptomMeningeal irritation symptomsIs often recognized.

  • Central symptoms
  • Physical findings
    • Meningeal irritation symptoms
      • (Neck stiffness): Judgment by the neck flexion test.It is normal if the neck is spontaneously bent forward and the lower jaw is sufficiently close to the chest.Abnormal if forward bending is difficult.
      • Kernig's sign (Kernig's sign)
      • Brudziński's sign
    • Jolt accentuation of headache: Abnormal if the headache is exacerbated by swiftly shaking the head from side to side as if the child were "unpleasant". Try turning your head horizontally at a rate of 2-3 times / sec, and if the headache worsens, it will be positive.[8].
  • Inspection findings
    • It is known that various electrocardiographic changes can be seen.[9].

The "Hunt and Hess scale '74" is used as the classification of severity.Grade 5 may cause respiratory arrest or cardiac arrest.This suggests transient cerebral ischemia and marked increase in intracranial pressure.[10][11], The prognosis in this case is extremely poor.

Grade 0
(Grade 0)
Non-ruptured aneurysm
Grade 1
(Grade 1)
Asymptomatic or mild headache and stiff neck
Grade 1a
(Grade 1a)
AcuteMeningesNo irritation but fixed nerve loss
Grade 2
(Grade 2)
Moderate or higher headache, stiff neck, but no symptoms of nerve loss other than cranial nerve palsy
Grade 3
(Grade 3)
Somnolence, confusion, or mild neurological deficits, impaired consciousness
Grade 4
(Grade 4)
Stupor, moderate hemiplegia,Decerebrate rigidityBeginning of, autonomic nervous system disorder
Grade 5
(Grade 5)
Deep coma,Decerebrate rigidity, Dying

In the case of subarachnoid hemorrhage due to rupture of a cerebral aneurysm, typical neurological symptoms are known depending on the site, which are summarized below.

Rupture siteNeurological symptoms
Internal carotid artery-posterior communicating artery branchOne-sided oculomotor nerve palsy
Anterior communicating arteryTransient paralysis of one or both lower limbs, psychiatric symptoms, akinetic mutism, inaction
Middle cerebral arteryHemiplegia, aphasia
Internal carotid artery aneurysm at the origin of the ophthalmic arteryOne sideblindnessAnd visual impairment
Internal carotid artery aneurysm in the cavernous sinusPain in the back of the eyes
Basilar and vertebral artery aneurysmsGoogly, abduction, pulley,Trigeminal nerveObstacle, bottomBrainstemNeuropathy


Head CT scan

Of the headComputed tomographyHigh absorption area is seen in the subarachnoid space on (CT).Highly absorptive areas are found near the center at the Pentagon level, especially if they are endogenous, but traumatic ones may also be found.In addition, it has been investigated that about 5-8% of cases in Japan are overlooked as colds, hypertension, and migraine at the first visit without performing CT because the headache is mild (12% overseas, etc.). Results are available)[12].

The most famous CT finding of subarachnoid hemorrhage is known to be hemorrhage to the Pentagon.This is intracranialInternal carotid arteryIt is often seen in the case of aneurysm rupture, and other subarachnoid hemorrhage due to aneurysm rupture does not give such an image.It is said that about 30% of ruptured aneurysms are complicated by intracerebral hemorrhage.The most common site of cerebral aneurysm is the anterior communicating artery (Acom),Middle cerebral arteryFirst branch ofInternal carotid artery-The posterior communicating artery (IC-PC).In the anterior communicating artery aneurysmFrontal lobeIn the lower inside and in the IC-PCTemporal lobeIn the middle cerebral artery aneurysmOutsourcingAnd in the temporal lobe, distal anterior cerebral artery aneurysmCorpus callosumからGyrusForm an intracerebral hematoma.The distribution is clearly different from that of hypertensive intracerebral hemorrhage, and in principle, it is accompanied by subarachnoid hemorrhage in the vicinity.Subacute bacterial endocarditis,ChoriocarcinomaIt is known that aneurysm is complicated with subarachnoid hemorrhage and intracerebral hemorrhage.The method for estimating the responsible aneurysm from the bleeding site is summarized below.

Rupture siteSpread of bleeding
Anterior communicating arteryLongitudinal fissureFrom the front, chiasmatic cistern, interpeduncular cistern, etc.Sylvian fissureIt exists symmetrically up to, and is characterized by hematoma in the septum pellucidum.
Middle cerebral arteryCentered around the ipsilateral Sylvian fissure
Intracranial internal carotid artery regionIt exists asymmetrically bilaterally around the upper cistern of the saddle.The so-called Pentagon.
Vertebral basilar artery regionIt exists symmetrically around the detour tank, interpeduncular cistern, and pontine cistern.

In the rupture of a middle cerebral artery aneurysm in the Sylvian fissure, the hematoma reaches into the brain parenchyma andIntracerebral hemorrhageMay be diagnosed, but in this caseClinicalThe course and treatment certainly overlap with intracerebral hemorrhage, so it cannot be said to be a misdiagnosis.


Nuclear magnetic resonance imaging(MRI)FLAIRWhen taken in sequence, the detection rate is equivalent to that of CT (but limited to the latest high-field device).It has also been reported that when the amount of hematoma is small, the detection rate is higher than that of CT in cases where time has passed since the onset.Magnetic resonance angiographyThere is also the advantage that (MRA, MR angiography, which will be described later) can be taken at the same time.

Lumbar puncture

Lumbar punctureDue to blood contamination (acute)(English edition(Oldness) is recognized with the naked eye.however,BradycardiaLumbar puncture is recommended when there are symptoms of increased intracranial pressure such as fundus edema and fundus edema.Brain herniaIt is contraindicated because it may promote.

  • Lumbar puncture showed no xanthochromia in the cerebrospinal fluid,Red blood cellNumber 2000 × 106It was reported that aneurysmic subarachnoid hemorrhage could be ruled out if it was less than / L (感 度100%,Specificity91.2%)[13].

Cerebral angiography

Cerebrovascular angiography reveals cerebral aneurysms and cerebral arteriovenous malformations.

As a method of photographing blood vessels,X-ray inspectionWhile seeing through on a planecatheterContrast agentTo shootCarotid angiography (Carotid angiography)Vertebral artery angiography (Vertebral angiography) has the highest sensitivity and specificity.Another advantage is that it can be treated at the same time as the test (aneurysm)Coiling and embolization, Or perfusion of vasodilators for complications of vasospasm), but the disadvantages areInvasionIt is highly bleeding in itself and is iatrogenic due to coiling and embolization.cerebral infarctionAnd so on.

Other methods include three-dimensional angiography CT (3DCTA) and MR angiography (MRA), which are taken by high-resolution CT by tomography using a contrast medium, but both sensitivity and specificity are suitable for angiography. Inferior.However, since angiography takes a longer time to complete imaging than 3DCTA or MRA, angiography is often not performed for urgent subarachnoid hemorrhage.



Rebleeding occurs in about 20% of subarachnoid hemorrhage due to ruptured cerebral aneurysm, most often within 24 hours after onset.[14][15]..When rebleeding occursPoor prognosis.

In Hunt and Kösnik grade 3 and above, some patients experienced mild headaches more than hours before onset, "it is the first bleeding in itself and the bleeding at the visit is rebleeding." The possibility is also pointed out in some parts[16][17].

With traumatic subarachnoid hemorrhage, rebleeding rarely occurs.

Cerebral vasospasm

The effect of hematoma is that the arteries in the brain shrinkCerebral vasospasmIt develops between 4 and 14 days after the onset.It occurs in 3-4% of subarachnoid hemorrhage due to rupture of a cerebral aneurysm, and it may develop into infarction due to ischemia due to spasm of blood vessels other than the blood vessel that caused the hemorrhage.

  • Cerebral aneurysmCircle of WillisIt is often formed near the (Circle of Willis).
  • Blood flow to the brain always passes through the circle of willis.
  • There is no collateral circulation in the arterial innervation after the circle of willis.

Due to the above factors, infarction due to vasospasm becomes more serious than normal cerebral infarction.

The mechanism of cerebral vasospasm is as follows.

  • First, it is included in the hematoma around the blood vesselhemoglobinDeteriorated in 3-4 daysHemosiderin,HeminBecomes
  • These are secreted by the surrounding blood vessel wallNitric oxideDecompose (NO).
  • Arteries are substances that constantly dilate blood vessels (NO) and substances that constrict (NO).Endothelin) Is secreted, and the blood flow is controlled independently by adjusting the amount.However, when NO is decomposed, only the vasoconstrictor remains.
  • In addition, cerebral blood vessels are compressed by the swelling of brain tissue that has caused / is still causing ischemia since the onset.
  • See belowDiabetes insipidusAlso, the intravascular volume and blood pressure decrease and the perfusion pressure weakens.
  • Furthermore, it is spillover due to the effects of injury.cortexDepolarizationIs the brainoxygenIncreases demand, even with mild ischemiaNerve cellWill die[18].

Diagnosis of cerebral vasospasm is made by transcranial Doppler echo.If the blood flow is faster than usual at this time, it means that cerebral vasospasm has begun to occur.In addition, when infarction has completely occurred, the diagnosis is confirmed by the large low absorption area on CT.The risk of cerebral vasospasm can be predicted to some extent by expressing the size and distribution of hematomas on CT in Fischer grade.

Mild vasospasm that does not lead to infarction is seen in almost all cases of subarachnoid hemorrhage due to ruptured cerebral aneurysm, so it should be called "delayed cerebral infarction" or "delayed cerebral infarction disorder". Has also been proposed.

Cardiovascular complications

By onsetstressBlood pressure rises sharply due to the reaction, and it causes cardiac load.Endocrine systemDue to ataxiaPulmonary EdemaHappens.again,心 臓T-wave negative rotation may be seen even if there is no abnormality in[19]..In severe casesCreatine kinaseMB andTroponin TIs also seen to rise[20], High loadMyocardiumSuggests that you are damaging[21]..This is an octopus trap typeCardiomyopathyWoke up[22], Death is not uncommon.

Diabetes insipidus

Brain edemaWhen the brain pressure increases due toHypothalamusandPituitary glandGoes dysfunctional,Posterior pituitarySecreted byVasopressinSuch ashormoneBy decreasingPeeThe amount increases.This interferes with the 3H therapy described below.Diabetes insipidus, depending on morphologyAntidiuretic hormone incompatibility syndromeThere are three types: (Syndrome of inappropriate anti-diuretic hormone) and Salt-wasting sydrome.Human in bloodAtrial natriuretic peptideBy measuringHyponatremiaIt is reported that the risk of[23].

Normal pressure hydrocephalus

Normal pressure hydrocephalusIs seen in the late post-acute phase and has little effect on life prognosis but functionsprognosisTo reduce.


The prognostic factors for subarachnoid hemorrhage are rebleeding, cerebral vasospasm, and obstruction of cerebral blood flow by hematoma and cerebral edema.We will focus on these three treatments.NeurosurgeryTransported to a specialized hospital for urgent treatment of the cause,complicationsPrevent the appearance of.

In general, treatment for subarachnoid hemorrhage due to ruptured cerebral aneurysm depends on the severity.Hunt and Konsnik's severity classifications are well-known as severity classifications.

  • In the case of ruptured cerebral aneurysm, rebleeding often occurs immediately after the onset (especially within 24 hours), keep rest, and avoid invasive treatment and examination.If it is not severe, Grade 1-3 should be adequately hypotensive, sedated, and analgesic, and surgery should be performed within 72 hours unless it is impossible due to age or systemic complications (earlier if the general condition is stable). good).Anticonvulsants may be administered from an early stage as a measure against convulsions.In the case of aneurysm rupture, complications such as rebleeding (within 14 days), delayed cerebral vasospasm (4-14 days later), and normal pressure hydrocephalus (several months later), which are complications of subarachnoid hemorrhage. Management is also required.
  • In the case of craniotomy, to prevent late-onset cerebral vasospasm, early removal of intracerebral hematoma with cistern drainage, fasdil hydrochloride, etc.Calcium channel blocker(Nimodipine) is administered systemically.Besides, triple H therapy,Papaverine hydrochlorideThere are various treatments such as selective intraarterial infusion therapy and PTA.
  • In relatively severe cases Grade 4, improvement of cerebral circulatory dynamics is important, and it is necessary to administer drugs for intracranial pressure drop and manage systemic circulatory dynamics with attention to cardiac complications.If the condition can be improved by treating acute hydrocephalus and intracerebral hemorrhage at the same time, surgical treatment is actively performed.
  • In principle, the most severe case, Grade 5, is poorly indicated for prevention of rebleeding.However, rebleeding prevention surgery is performed in special cases where symptoms can be expected to improve as in relatively severe cases.Normal pressure hydrocephalus (NPH), which occurs months later, is important because it can be treated with a VP shunt.

Sensory deprivation

With a sedative, the risk of rebleeding is extremely high for the first 24 hoursPhotophobiaPrevention (darkroom) prevents blood pressure from rising.

Craniotomy aneurysm clipping

  • 利 点
    • An aneurysm can be confirmed under direct vision.
    • It has been performing for many years and has a low risk of re-burst.
    • If hematoma is present, it can be removed together.
  • Disadvantage
    • Difficult if the aneurysm is not saccular.
    • Damage to the brain and blood vessels.

Ideally, it should be done within 48 hours.However, since the bleeding from the aneurysm may not have stopped immediately after bleeding, the craniotomy should be performed at least 6 hours after the onset.

The clip used in this surgeryTitaniumMost of them are made of.The reason for not using iron is to avoid making MRI unusable.Hematomas are also removed at the same time to prevent vasospasm.

If untreated, about one week after the onset, surgery may cause vasospasm, so treatment is not performed until the possibility of vasospasm is reduced.

Endovascular treatment

In the aneurysm under contrastplatinumCoil embolization (cerebral aneurysm coiling) to occlude by packing a coil made of wood, vasodilator for vasospasm (Papaverine hydrochlorideEtc.) intra-arterial infusion therapy is performed.In recent years, treatment results have surpassed craniotomy.[24]However, there is also an element due to the establishment of an emergency transport system and intensive care system for cerebrovascular disease, and a specialist must decide which treatment is more suitable.

3H therapy

Prevention of vasospasm, as wellBrain edemaHypertension (Hypertension), hypervolemia (Hypervolemic), and blood dilution (Hemodilusion) therapy are performed to maintain arterial perfusion even in this state.Specifically, large doses of hypertonic infusion, sometimesAlginic acid,albuminIs also administered.High calorie infusionIn the past, hyperglycemia reduces prognosis[25](Increased oxygen consumption in the brain, resulting in CO2Increased production →Angiogenic edemaIt is going down due to the exacerbation of the fire.

Other treatments

blood sugarControl[26][27],Magnesium sulfateThere are intravenous injections, etc.evidenceHas not been presented yet.


The first bleeding kills one-third.Furthermore, due to the effects of vasospasm and rebleeding, it is said that about half will die within 3 weeks.Even if you can save your life againSequelaeThere are many cases in which the disease remains, and the probability of complete healing is as low as 2% among those who have had subarachnoid hemorrhage.

After the onsetprognosisAs related toWorld Federation of Neurosurgeons(WFNS) isAwareness levelWe propose a severity classification according to the degree of.this isGlasgow Coma ScaleAnd local neurological symptoms (Aphasia,paralysisIt is a method of classifying into 5 stages according to (etc.).In this classification, there is a large difference in prognosis between grade III and grade IV, and grade V in particular is said to have a case fatality rate of almost 100%.Therefore, many hospitals do not treat grade IV or higher as meaningless.

severityGCS scoreMajor local neurological symptoms
grade I15None
grade II14 – 13
grade IIIYes
grade IV12 – 7No question
grade V6 – 3



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  • Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P. "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/ American Stroke Association. " Stroke. 2012 Jun; 43 (6): 1711-1737. Epub 2012 May 3. PMID 22556195
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[How to use footnotes]
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  2. ^ [Medical Renaissance] 5/5 "Sudden farewell" with cerebral aneurysmYomiuri Shimbun』Morning edition March 2022, 6 Living side
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