The worst headache of your life? It could be a subarachnoid hemorrhage (SAH)!

Have you ever had a sudden, severe headache that felt like a bolt of lightning striking your head? Many people describe it as "the worst headache you've ever had." A sudden, severe headache like this is something we should never take lightly. It could be a sign of serious bleeding inside the brain. Today, we're going to talk about one such medical emergency, a subarachnoid hemorrhage (SAH).

Simply put, what is Subarachnoid Hemorrhage (SAH)?

Okay, this name may sound a bit complicated, but let's keep it simple. Your brain isn't just sitting in the back of your head. It's protected by a three-layered covering of tissue. In medical terms, we call this the meninges.

Think of it like an onion. The inner part of the onion has a thin skin around it, and that's how these membranes are located around the brain.

1. Dura mater: This is the outermost, strong membrane that lies just beneath the skull.

2. Arachnoid: This is the thin, spider-web-like membrane in the middle.

3. Pia mater: This is the innermost membrane that is attached to the brain tissue itself.

Now, the space between the arachnoid membrane in the middle and the pia mater in the innermost layer is called the `Subarachnoid space`. `Sub` means "under". So this refers to the space under the arachnoid membrane. If for some reason, bleeding occurs into this space, that is what we call Subarachnoid Hemorrhage (SAH) .

What is the difference between SAH and Subdural Hematoma?

You may have also heard of a condition called `Subdural Hematoma`. Both are bleeding in the area of ​​the brain. But the difference is where the bleeding occurs. Let's break this down clearly.

The symptoms of both conditions can sometimes be similar. And both are emergencies that can cause brain damage. So it's important to seek medical advice as soon as symptoms appear.

Who is most likely to develop this condition? What are the risk factors?

Although anyone can develop subarachnoid hemorrhage (SAH), it is most common in people between the ages of 40 and 60 .

SAH is most commonly caused by a head injury in older people. It can occur when they fall and hit their head. In younger people, the main cause is motor vehicle accidents.

In addition, there are several other factors that increase the risk of developing SAH. Let's see what they are.

• Having an unruptured aneurysm in the brain or elsewhere in the body: An aneurysm is a weakening of the wall of a blood vessel that bulges like a balloon. This can burst at any time.
• Having a history of a previous ruptured brain aneurysm.
• Smoking: Smoking severely damages blood vessels.
• High blood pressure (Hypertension): Uncontrolled high blood pressure can damage blood vessels, increase the risk of aneurysms forming and bursting.
• Some genetic conditions: Diseases that affect connective tissue, such as Fibromuscular Dysplasia (FMD) and Ehlers-Danlos syndrome.
• Having Polycystic Kidney Disease.
• Drug use: Especially stimulant drugs like cocaine and methamphetamine.
• Excessive alcohol consumption.
• Use of blood-thinning medications: For example, Warfarin.
• Having a strong family history of aneurysms.

What are the symptoms of SAH?

As we discussed earlier, the main and most immediate symptom is a sudden, excruciating headache called a "Thunderclap Headache." This reaches its peak pain within a few seconds.

Imagine, you're doing your normal work. Without any warning, suddenly, you feel a sharp pain in your head, as if a bomb had exploded inside you, or someone had hit you with a hammer. That's what this feels like.

What are the main causes of SAH?

Let's now look at the main reasons behind this dangerous situation.

• Severe head injuries: The most common cause of SAH is a severe blow to the head, such as a serious fall or a car accident.
• Aneurysm rupture: This is the cause of about 85% of SAHs that occur without an accident. A weak spot in a blood vessel in the brain swells like a balloon and suddenly bursts. Blood then leaks into the subarachnoid space under high pressure.
• Blood vessel abnormalities: Bleeding can also occur due to conditions where blood vessels are tangled together, such as arteriovenous malformation (AVM).
• Bleeding disorders: Conditions in which the blood does not clot easily.
• Use of blood-thinning medications.
• Drug use: Drugs like cocaine can cause a sudden increase in blood pressure and cause blood vessels to burst.

How do doctors diagnose this disease?

When you go to the hospital with symptoms like these, doctors treat it as an emergency and quickly perform tests.

1. CT Scan (Computerized Tomography Scan): This is the first and most important test. This takes pictures of the inside of the head and can clearly see if there is blood around the brain. Sometimes a special scan called CT Angiography (CTA) is done. In this, a dye is injected into a vein to check the condition of the blood vessels.

2. Lumbar Puncture: Sometimes a CT scan may not detect a very small amount of bleeding. In such cases, doctors do this test. In this, a very thin needle is inserted into the lower back and a small amount of cerebrospinal fluid (CSF) is removed from the area around the brain and spinal cord. The fluid is checked for red blood cells or xanthochromia (yellowing). This fluid turns yellow after a short period of bleeding.

3. MRI Scan (Magnetic Resonance Imaging): If there is a suspicion of recent bleeding, this test can detect it.

Once the diagnosis is confirmed, further tests, such as a cerebral angiogram, can be performed to determine the exact cause of the bleeding.

How is it treated?

Because SAH is life-threatening, the patient is usually admitted to the hospital's intensive care unit (ICU) and treated by a team of doctors who specialize in neurological diseases. The main goals of treatment are:

• Saving the patient's life.
• Repair the cause of the bleeding.
• Controlling symptoms.
• Preventing complications (e.g. vasospasm, hydrocephalus).

Treatments to save life and control symptoms:

• Providing life support.
• Inserting a draining tube to reduce pressure in the brain.
• Taking steps to protect the respiratory tract.
• Giving IV (intravenous) medication to control blood pressure.
• Giving medication to prevent blood vessel constriction (vasospasm).
• Giving painkillers and anti-anxiety medications for severe headaches.
• Giving medication to prevent or control seizures.

Treating the cause of the bleeding:

• If an aneurysm has ruptured: Surgery is performed to repair it. This can be done using techniques such as `Surgical Clipping` (closing the neck of the aneurysm with a clip) or `Endovascular Coiling` (closing the aneurysm with a wire coil through a blood vessel).
• If blood has accumulated due to an accident: Surgery may be needed to reduce pressure on the brain and remove the accumulated blood.

Typically, someone with SAH may need to stay in the hospital for 10 to 20 days or more, depending on the condition and rehabilitation needs.

What are the long-term effects and complications of this condition?

This is a very serious condition. According to statistics, about half of people who have SAH die suddenly. Of those who come to the hospital:

• One-third die in the hospital.
• One in three lives with some kind of disability.
• One third return to normal life.

SAH can cause brain damage, which can lead to long-term or permanent problems.

• Physical problems: Constant tiredness and sleepiness, numbness or weakness in body parts, difficulty swallowing, loss of balance.
• Cognitive issues: memory problems, difficulty concentrating, difficulty planning and performing complex tasks.
• Speech difficulties: slurred speech, slow speech, difficulty finding the right words.
• Mental health issues: Since this is a major life trauma, conditions such as depression, generalized anxiety, and post-traumatic stress disorder (PTSD) can occur.

To manage these long-term complications, treatments such as physical therapy, occupational therapy, speech therapy, and psychotherapy can provide great relief.

What can we do to reduce the risk?

Since the main causes of SAH are head injuries and aneurysm rupture, it is best to take steps to prevent both of these events.

To prevent head injuries:

• Always wear a helmet when riding bicycles or motorcycles or playing risky sports.
• Drive safely and obey traffic laws.
• If you fall frequently, seek advice from a physical therapist and learn ways to prevent falls and make your home safer.

To reduce the risk of aneurysm:

• Control high blood pressure. Take your medication exactly as prescribed by your doctor. Make lifestyle changes (reduce salt intake, exercise).
• Stop smoking completely.
• Exercise regularly, but avoid lifting heavy weights at once, as excessive exertion can cause an aneurysm to burst.
• Eat a balanced diet.
• Completely avoid alcohol and drug use, especially stimulants like cocaine.

If your doctor has told you that you have an unruptured aneurysm, talk to him or her about the treatment options and management methods available.