Consultancy Corner: Headache? May be a bleeding in the brain

It suddenly became severe. The room spun around her and as she called to her husband for help, she lost consciousness. A CT scan revealed that she had suffered a bleed in her head (Subarachnoid Haemorrhage). Not all headaches are related to disastrous events in the brain.  One of the serious ones is that which occurs when there is a bleeding within the brain. Intracranial bleeding which occurs spontaneously may either occur in the substance of the brain (Intracerebral Hematoma) or in the space surrounding the brain (subarachnoid space). Bleeding into the subarachnoid space is called Subarachnoid Hemorrhage (SAH). 

The most common cause of SAH is a brain aneurysm (bulge in one of the blood vessels). Other causes of SAH include tumours in the brain, arterio-venous malformations, disorders of blood and anti-coagulation therapy.   Aneurysms, common in the age-group 35-60 are associated with polycystic disease of the kidneys or coarctation of the aorta. 

SAH is best diagnosed from a CT scan of the brain. When the scan is normal, and does not reveal any bleeding, and when the physician strongly suspects SAH because of the clinical history, the patient should undergo a lumbar puncture and analysis of the cerebro-spinal fluid (CSF) that is collected. 

All patients with SAH must be assumed to have an aneurysm unless otherwise proved. This is a dictum that has to be religiously followed. For diagnosing and study of aneurysms, one takes up an investigation called angiography. It gives the physician an idea of the blood flow pattern of the brain. A recent technological advance has been that of CT angiography which provides digital images of the blood vessels. 

Once an aneurysm has bled, the risk of rebleed is  highest in the first week after the first bleed. Re-bleeding must therefore be prevented. This is best done by not allowing the blood to enter the aneurysm. Surgery is performed to exclude the aneurysm from circulation. Post-operatively medications are continued to ensure good hydration and flow in normal blood vessels. A patient who recovers well from aneurysm surgery is cured for life. 

Ms C was operated and she made a good post-operative recovery. Three months after the surgery, she is doing well.  SAH is perhaps one of the most devastating cause of headache and the survival following the first bleed is about 70 percent. However, modern technology and modern microsurgical techniques allow physicians to treat such a problem effectively.