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IV./4.2.: Symptoms
IV./4.2.1.: General symptoms
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Usually the first symptom of the subarachnoid bleeding is a sudden, severe, so-called “thunderclap” headache. In half of the cases the headache is combined with nausea, vomiting, neck pain and photophobia. Meanwhile, it is important to emphasize that the strength and the localization of the headache, or the additional symptoms show individual variety. 40% of the subarachnoid hemorrhage patients complain of nothing else than headache at the beginning of the disease. Theoretically, a patient with a dull, rim-like headache and who is otherwise symptom-free may have suffered subarachnoid bleeding.
The probability of subarachnoid hemorrhage is higher if the headache occurred after physical activity (e.g. lifting weights) and nuchal rigidity, meningeal sings, confusion or diminished consciousness are seen during neurological examination. It is important to notice, that a continuous, localized headache with visual filed deficit or cranial nerve signs could be the first manifestation of a growing, non-ruptured aneurysm. Rarely, subarachnoid bleeding could start without headache, only focal signs are seen.
IV./4.2.2.: Localization of the aneurysm
The aneurysms form mainly at the bifurcation of the arterial branches; 80% of them are present in the anterior part (internal carotid system) and 20% are in the posterior part (vertebro-basilar system) of the circle of Willis. The frequency of the ruptured aneurysm in the different branches is as follows: 30-37% is present in the internal carotid artery, 31% in the anterior cerebral artery and 25% in the middle cerebral artery system. 10% of the ruptured aneurysms are located in the vertebro-basilar territory.
IV./4.2.3.: Site specific symptoms of the aneurysm rupture
The rupture of an aneurysm, independently from its location, could generally lead to nuchal rigidity, papilla edema, retinal or subhyaloidal bleeding.
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However, some of the symptoms imply to the site of the aneurysm, e.g.:
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1) rupture of aneurysm in the posterior communicating artery leads to oculomotor nerve palsy;
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2) bleeding in the middle cerebral artery system causes contralateral, upper limb dominant hemiparesis combined with – in case of the left hemisphere – aphasia, or with visual neglect – in case of the right hemisphere;
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3) paraparesis with akinetic mutism and abulia are seen when an aneurysm ruptures in the anterior communicating artery;
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4) aneurysm in the posterior fossa leads to nystagmus, ataxia and abducent nerve palsy; however, this latter may independently appears as a result of elevated intracranial pressure.
IV./4.2.4.: Altered consciousness
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Altered consciousness and convulsion are often present in subarachnoid hemorrhage. The level of the consciousness could be varied from mild disturbance (psychomotor restlessness, tenebrous state) to deep coma. Sudden changes in the level of consciousness may related to secondary complications, such as hydrocephalus, cerebral hemorrhage (jet bleeding) or brain ischemia due to vasoconstriction. Further complications of the subarachnoid hemorrhage might be the diffuse brain edema, the hyponatremia and their combined result, the convulsion.
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