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<p>Leaving aside the traumatic etiology, the tearing of a saccular aneurysm is one of the most frequent causes of subarachnoid hemorrhage, although there are other less known causes but which are documented as the case of hemorrhage resulting from a vascular anomaly or the extension of a Primary intracerebral hemorrhage to the subarachnoid space.</p>

<p>To explain it in a way that we can understand, <b>subarachnoid hemorrhage</b> is not, more than, the presence of blood in the subarachnoid space, which is accompanied by meningeal signs.</p>

<center> <img src="https://cdn.steemitimages.com/DQmcSZ4BEfJkWZbzEHgsqwThaCvEgkCsJ2T7xE4ZVBFZJe2/image.png"><a href="https://pixabay.com/es/illustrations/cerebro-el%C3%A9ctrica-conocimiento-1845962/"><br><sup><b>Public domain image. Source Pixabay.</b></sup></a></center>

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<p>Once the rupture or tearing of the aneurysm occurs, the first 30 days of the event represent a high mortality rate with a 45% death in that time limit. However, if the aneurysm is not obliterated, the chances of re-bleeding are 20% in the first two weeks and 3% a year after the event.</p>

<p><i>Ideally, in the first 4 weeks is to avoid late complications: as is vasospasm, re-bleeding, and hydrocephalus.</i></p>

<p>The most frequent locations are the terminal portion of the internal carotid artery, the bifurcation of the middle cerebral artery, and the upper part of the basilar artery. Your risk of tearing is about 6% in the first year after your diagnosis, but they can remain the same size for an indefinite period. They usually produce symptoms by compression of the brain parenchyma or adjacent cranial nerves.</p>

<center> <img src="https://cdn.steemitimages.com/DQmTzSaKP2ysH4JMrp6VqR7Z6fyYxjwTuztRiGPKmfFB9Ak/image.png"><a href="https://es.m.wikipedia.org/wiki/Archivo:Stroke_hemorrhagic.jpg"><br><sup><b>The illustration shows how a hemorrhagic stroke can occur in the brain. Public domain image licensed CC BY-SA 3.0. Source Wikipedia.</b></sup></a></center>

<blockquote>Saccular aneurysms are formed at the bifurcation of large arteries located at the base of the skull, which rupture into the subarachnoid space of the basal cisterns and into the adjacent cerebral parenchyma.</blockquote>

<p>More than 80% of these aneurysms appear in the anterior circulation, especially in the polygon of Willis. They usually present with the presence of multiple aneurysms distributed bilaterally.</p>

<p>In the area of the tear of the vascular malformation, the wall becomes thin and the laceration that causes the hemorrhage usually does not measure more than 0.5 mm in length. The size and site of the aneurysm are important factors in predicting the risk of rupture; those that measure more than 7 mm in diameter and those that are located in the upper part of the basilar trunk and the birth of the posterior communicating artery are the ones with the highest risk of rupturing and bleeding.</p>

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<h2><center> Clinical manifestations according to where the Aneurysm is located </center></h2>
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<p>A large part of intact intracranial aneurysms remains asymptomatic.</p>

<p>We must take into account something very important and is that the signs and symptoms are evident when the aneurysm is broken and the blood reaches the subarachnoid space, this brings as immediate consequence the increase in intracranial pressure, which explains the neurological deterioration and clinical picture of the patient according to the location of the lesion and the amount of bleeding.</p>

<p>In general, the majority of patients suffering from a subarachnoid hemorrhage prior to the event report manifested clinics of progressive and insidious onset with a brief period of intense headache, which predominate in the morning hours, as well as photophobia, alteration of a cranial nerve and even vomiting and nausea.</p>

<p><b>The aneurysms of the anterior communicating artery or the bifurcation of the middle cerebral artery.</b></p>

<p>When these rupture they tend to drain towards the cerebral parenchyma or the adjacent subdural space giving rise to a hematoma of sufficient size to produce a mass effect occupying space, given symptoms of hemiparesis, aphasia, abulia and clinical hypertension Cranial Endo.</p>

<p><b>Aneurysm of the posterior communicating artery with the internal carotid artery</b></p>

<p>It usually manifests with a paralysis of the third cranial nerve, accompanied by mydriatic pupils (pupillary dilation,) loss of the ipsilateral pupillary luminous reflex (but with the contralateral conserve) and focal pain above or behind the eyeball.</p>

<p><b>Aneurysm in the cavernous sinus</b></p>

<p>It is characterized by the 7th central cranial nerve lesion.</p>

<p><b>Supraclinoid carotid aneurysm</b></p>

<p>It is evidenced by defects of the visual field, being common the diminution of the superior or inner lateral visual acuity.</p>

<p><b>Cerebellar artery aneurysm</b></p>

<p>The presence of posterior occipital and cervical pain indicates the presence of a lesion at this level.</p>

<p>Some aneurysms suffer small tears that cause tiny blood spills into the subarachnoid space, and for this reason they are called warning extravasations or sentinels.</p>

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<h2><center> Late complications </center></h2>
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<p><b>There are 4 main late complications, with a high rate of morbidity and mortality.</b></p>

<p><b>Re-bleeding:</b> with an incidence of 30% in the first month of the event, whose highest frequency peak is the first 7 days, these patients usually have a gloomy prognosis, with a mortality of more than 60%.</p>

<p><b>Hydrocephalus</b> with great compromise of neurological status, are usually stuporous patients or in a coma, usually formed over the course of several days or weeks. The therapeutic measure to correct this complication consists of a temporary ventricular drain. Some patients exhibit chronic hydrocephalus after several weeks or months of subarachnoid hemorrhage, clinically manifested by gait difficulty, bradypsychia, and bradylalia.</p>

<center> <img src="https://steemitimages.com/400x800/https://cdn.steemitimages.com/DQmNt1YNwuTk3oUGf8QfyFm6csUDHT7gQWupZQC6ngScNxp/image.png"><a href="https://en.wikipedia.org/wiki/Basilar_artery"><br><sup><b>Brain Irrigation. location and distribution of the arteries in the CNS. Image of public domain with Creative Commons license. Source Wikipedia.</b></sup></a></center>

<p><b>Vasospasm</b>, this represents the contraction of the arteries at the base of the brain after subarachnoid hemorrhage, which is capable of causing cerebral ischemia in approximately 30% of affected patients. This complication is observed in the 4th to the 14th day of the event. Late vasospasm is a product of the direct effects of coagulated blood and degradation products on the artery. In general terms, the more blood surrounding the arteries, the greater the risk of this complication.</p>

<p><b>Hyponatremia</b>, usually appears the first two weeks after the hemorrhagic event, which may be fulminating, this may be secondary to the inadequate secretion of a hormone called vasopressin with secretion of natriuretic substances in the atrium and brain that cause nutriereis.</p>

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<h2><center> Diagnostic tests </center></h2>
<br>

<p>The key finding of a ruptured aneurysm is the presence of blood in the cerebrospinal fluid (CSF). Therefore, the Lumbar Puncture (LP) technique can be considered according to risk - benefit as long as a skull tomography can not be performed first and it is necessary to determine the presence of blood in the CSF. We must remember that this technique will only be performed as long as there are no clinical signs that contraindicate it as hypertension Cranial Endo.</p>

<p>Computerized Axial Tomography (CAT) of the simple skull allows us to visualize the presence of blood in the subarachnoid space but not to determine the presence of any vascular malformation or the presence of an aneurysm, for this reason it is evidence of a subarachnoid hemorrhage that is not secondary to a picture of arterial hypertension crisis, a heart rhythm disorder that triggers a cerebral vascular event that explains such bleeding should consider the possibility that this is secondary to a vascular malformation, so it should be requested Angioresonance-type specialized studies or computed tomography (CT) angiography, is usually more specific for its diagnosis.</p>

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<h2><center> Clinical case report </center></h2>
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<center><p><b>This is a real case of my work experience.</b></p></center>

<p>A 35-year-old female patient with no known pathological history who has been suffering from a moderate to strong occipital headache for 1 month, persisting partially with oral analgesics, associating with the clinical picture for two weeks a decrease in visual acuity and photophobia, later accompanied by left palpebral ptosis and neck stiffness, in view of symptomatology and exacerbation of the same is taken to the adult emergency service where it is entered.</p>

<p<although, it="" is="" a="" young="" female="" (35="" years="" old)="" with="" no="" previous="" pathological="" history="" that="" presents="" neurological="" symptoms="" and="" meningeal="" signs,="" without="" compromise="" of="" her="" state="" consciousness,="" ruling="" out="" the="" possibility="" patient="" suffering="" from="" infectious="" etiology="" due="" to="" fact="" not="" associated="" typical="" fever="" or="" an="" focus="" near="" central="" nervous="" system="" by="" continuity="" capable="" causing="" neuroinfection="" this="" clinical="" picture.<="" p="">

<p>After discarding the infectious pathology, it is suggested that it is secondary to a vascular malformation not previously diagnosed, so paraclinical studies are requested such as:</p>

<h4>Complete hematology and Blood chemistry</h4>

<table class="egt">
 <tbody><tr>
 <td>White beads</td>
<td>5.600</td>
</tr>
<tr>
<td>Neutrophils</td>
<td>68%</td>
</tr>
<tr>
<td>Hemoglobin</td>
<td>12</td>
</tr>
<tr>
<td>platelets</td>
<td>210.000</td>
</tr>
<tr>
</tr></tbody></table>

<table class="egt">
 <tbody><tr>
 <td>Urea</td>
<td>20</td>
</tr>
<tr>
<td>Creatinine</td>
<td>0,7</td>
</tr>
<tr>
<td>TGO</td>
<td>24</td>
</tr>
<tr>
<td>TGP</td>
<td>20</td>
</tr>
<tr>
<td>TP</td>
<td>13/13</td>
</tr>
<tr>
<td>TPT</td>
<td>30/30</td>
</tr>
<tr>
</tr></tbody></table>

<h4>Axial Computed Tomography of the Skull</h4>

<p>Where the presence of blood in the subarachnoid space is evident in a small amount, probably secondary to a vascular malformation that is localized in a subsequent communicator due to the patient's clinical condition, but to confirm the same, a complementary Angioresonance study is requested.</p>

<center> <img src="https://cdn.steemitimages.com/DQmfYVRoEqAwD58JgNGCB6b4Unq6M9QuTd2U7LLtGZ7AEbW/image.png"><br><sup><b>Image by @anestrada12</b></sup></center>

<center> <img src="https://cdn.steemitimages.com/DQmRfqvt7w3oaWGAXKWUpGZ4sZ8iVBFi8PiMY4aBdAGMs2v/image.png"><br><sup><b>Image by @anestrada12</b></sup></center>

<center> <img src="https://cdn.steemitimages.com/DQmdYH6o5wrxTbPw446hqxB5JzdLuEo1C5vreN5qCT68ftm/image.png"><br><sup><b>Image by @anestrada12</b></sup></center>

<h4><center> Video of the tomography </center></h4>

<iframe width="1423" height="620" src="https://www.youtube.com/embed/_6qK5HBz4Wc" frameborder="0" allow="accelerometer; autoplay; encrypted-media; gyroscope; picture-in-picture" allowfullscreen=""></iframe>
<p>Courtesy of Dr. Ana Estrada</p>

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<h2><center> General treatment </center></h2>

<p>Immediate intervention of the aneurysm prevents acute and late complications and decreases the mortality rate. The treatment can be both medical and surgical.</p>

<p>In relation to the surgical treatment, through several techniques, one of them being the placement of a metal clip around the neck of the aneurysm, with the advantage of immediately eliminating the possibility of a new bleeding. This method requires a craniotomy with cerebral retraction, which involves neurological morbidity.</p>

<p>There are more advanced and less invasive techniques that consists of placing platinum spirals inside the aneurysm through a catheter introduced by the femoral artery. The aneurysm is filled as much as possible to facilitate its thrombosis and with time is excluded from the circulation.</p>

<p<regarding medical="" treatment,="" since="" it="" is="" basically="" symptomatic="" and="" mediated="" to="" avoid="" acute="" chronic="" complications,="" the="" essential="" thing="" in="" these="" patients="" monitor="" respiratory="" pattern,="" associated="" infectious="" processes,="" one="" of="" most="" common="" being="" pneumonias="" due="" bronchoaspiration,="" frequent="" with="" severe="" neurological="" compromise.<="" p="">

<p>These patients must remain in absolute rest, it is isolated rooms in low light, the pain management in this case Headache (headache) is important so it is recommended the use of analgesics, as well as the use of stool softeners, for avoid possible sudden movements or work that generates effort, which may worsen the picture.</p><p>

</p><p>The periods of shivering, jerking and extension postures that accompany the loss of consciousness are perhaps a consequence of the sudden rise in intracranial pressure and generalized acute vasospasm.</p>

<p>At the beginning of the rupture of an aneurysm it is rare that seizures appear, but nevertheless evidencing should be indicated phenytoin-type anticonvulsant drugs. However, phenytoin is almost always used as a prophylactic measure since seizures can cause a new hemorrhage.</p>

<p>Vasospasm remains the leading cause of complications and death after aneurysmal subarachnoid hemorrhage and treatment of an aneurysm. In these cases, the treatment is based on Nimodipine-type calcium channel blocking drugs at a dose of 60 mg orally every 4 hours, thus avoiding ischemic cerebrovascular events secondary to vasospasm. We must bear in mind that when using this type of drug, due to its antihypertensive properties, blood pressure controls must always be carried out, since episodes of hypotension are common.</p>

<p>As for hydrocephalus, its correction is purely surgical with the placement of a peritoneal ventricular shunt.</p>

<p>Finally, hyponatremia often improves by administering sodium chloride supplements orally at the same time as normal saline, but sometimes it is necessary to administer hypertonic saline.</p>

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<h2><center> Conclusions </center></h2>

Regarding the patient of the presented case, she remains admitted, receiving medical treatment orally with NIMODIPINA 60 mg every 4 hours, Epamin (phenytoin) 100 mg every 12 hours. Analgesics type Aines every 8 hours in cases of intense headache and avoid measures of valsalva, bed rest accompanied by a diet rich in fiber. Currently the patient is waiting for the completion of complementary studies (Angioresonance) and later resolution if possible.<p></p>

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<h2>Sources of support in the publication</h2>

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<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3361326/">Intracranial Hemorrhage. Am J Respir Crit Care Med. 2011 Nov 1; 184(9): 998–1006.</a></p>

<p><a href="https://www.ncbi.nlm.nih.gov/books/NBK441958/">Subarachnoid Hemorrhage</a></p>

<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4463029/">Aneurysmal Subarachnoid Hemorrhage. J Neurosurg Anesthesiol. 2015 Jul; 27(3): 222–240.</a></p>

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<p><a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3714000/">Review and recommendations on management of refractory raised intracranial pressure in aneurysmal subarachnoid hemorrhage. Vasc Health Risk Manag. 2013; 9: 353–359.</a></p>

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<p><a href="https://accessmedicine.mhmedical.com/content.aspx?bookid=2129&amp;sectionid=192280808">Harrison's Principles of Internal Medicine, 20edition. Chapter 302: Subarachnoid Hemorrhage. J. Claude Hemphill, III; Wade S. Smith; Daryl R. Gress.</a></p>

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