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Subarachnoid hemorrhage (SAH) is bleeding into the brain, from a ruptured cerebral aneurysm or head injury. SAH is a form of stroke.

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Subarachnoid hemorrhage is an uncommon cause of stroke that often occurs at a young age, producing a relatively large burden of premature mortality. Delayed ischemic neurological deficit (DIND), a condition where the patient's condition deteriorates, has long been recognized as the leading potentially treatable cause of death and disability in patients with subarachnoid hemorrhage. Endothelin is a long‐lasting agent that causes blood vessel constriction, which has been implicated in the cause of DIND. Drugs that reverse this effect (endothelin receptor antagonists, ETAs) have emerged as a promising treatment for subarachnoid hemorrhage. This review of four trials, involving 2024 participants, showed that ETAs reduced the risk of DIND but did not improve clinical outcomes and had potentially serious side effects, such as low blood pressure and chest infection. There is not enough evidence to conclude that ETAs are beneficial in SAH.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: September 12, 2012

Subarachnoid haemorrhage (SAH) is a serious condition where bleeding occurs over the surface of the brain. This bleeding usually comes from an abnormality (aneurysm) in one of the blood vessels on the brain surface. In addition to the damage caused by the initial bleeding, people with SAH often suffer a later reduction in blood flow to the brain and hence additional delayed brain injury. It has been proposed that cholesterol‐reducing drugs may reduce this delayed brain injury. This review found only one small trial of 39 participants. Cholesterol‐reducing drugs did not reduce the risk of delayed brain injury and did not significantly improve participants' degree of recovery. There were no significant differences in adverse events. This review is based on one small trial and no reliable conclusions can be drawn at present.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: April 30, 2013

The purpose of this review was to examine whether the routine use of antiepileptic medication in preventing epileptic seizures following subarachnoid haemorrhage can be justified. This includes patients who have not yet had a seizure (primary prevention) and those who have already had one (secondary prevention).

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: June 5, 2013

There is no evidence of benefit from corticosteroids for patients with stroke due to bleeding. About one fifth of all strokes are due to bursting of an artery. The burst artery causes bleeding into the brain itself (called intracerebral haemorrhage) or into the space around the brain (called subarachnoid haemorrhage). After either type of bleed the brain tissue may become swollen. The swelling causes a rise in pressure which can cause further brain damage or even death. Corticosteroids could reduce swelling after brain haemorrhage and so improve the chances of the patient recovering. However, corticosteroids can also have important adverse effects such as increased blood sugars, infection, and gastrointestinal bleeding. The trials included in this review had too few participants to provide reliable evidence on any benefits weighed against harms of this treatment for patients with stroke due to bleeding in the brain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: July 20, 2005

There is no evidence on the best time for surgical treatment of aneurysmal subarachnoid haemorrhage. Aneurysmal subarachnoid haemorrhage is a life‐threatening condition. It is due to the bursting of an aneurysm (a weakness in the wall of a blood vessel in the brain). This can be treated by a surgical operation to place a clip over the aneurysm neck. There is uncertainty about whether to perform the operation immediately, or to wait a few days. The review found only one randomised trial which assessed the effect of the timing of surgery. From the limited evidence available, the timing of surgery was not a critical factor in determining the outcome from an aneurysmal subarachnoid haemorrhage, but further research is needed.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: April 23, 2001

Subarachnoid haemorrhage (SAH) is a life‐threatening type of stroke caused when a small blood vessel near the surface of the brain bursts. The bleeding usually comes from an aneurysm (a weakness in the blood vessel wall). The blood enters the fluid‐filled space around the brain called the subarachnoid space, which lies between the outer surface of the brain and the inner surface of the skull. Thus, the condition is called aneurysmal SAH. Approximately one‐third of patients develop a complication of the bleeding in which narrowing of the blood vessels occurs. In turn, this may cause the blood supply to parts of the brain to be reduced or stopped. The resulting brain damage is called delayed cerebral ischaemia. It happens most often four to 10 days after SAH, and it can cause disability or even death. In animal studies, the drug tirilazad appeared to reduce brain damage after SAH. We reviewed the evidence from randomised controlled trials of tirilazad in patients with SAH to see if it could reduce the risk of death or disability. The review did not show any evidence of benefit from tirilazad in patients with aneurysmal SAH.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: February 17, 2010

A subarachnoid haemorrhage (SAH) is a type of stroke due to bleeding in the subarachnoid space, which is the small space between the brain and the skull, and which contains blood vessels that supply the brain. The cause of the bleeding is usually a rupture of a bulge in one of these vessels, which is called an aneurysm. The outcome of patients after SAH is generally poor: 50% of patients die within one month after the haemorrhage, and of those who survive the initial month, 50% remain dependent on someone else for help with activities of daily living (eg, walking, dressing, bathing). One of the causes of poor outcome is a complication of SAH called secondary ischaemia (ischaemia means lack of blood). This complication occurs four to 10 days after the haemorrhage (hence secondary). The cause is not exactly known, but besides contraction of the blood vessels in the brain, there is evidence that clotting of blood platelets plays a role as well. Therefore, trials have been performed with agents that prevent clotting of blood platelets (antiplatelet agents). In this review of seven trials, including 1385 patients, that studied the effects of antiplatelet agents on the outcome after SAH, we found that patients who were treated with antiplatelet agents had a poor outcome less often, and secondary ischaemia less often than patients that received no antiplatelet agent, but the results were not statistically significant and so no definite conclusion can be drawn. Moreover, patients who are treated with antiplatelet agents might have a slightly higher risk of bleeding. Based on these results we conclude that antiplatelet agents after SAH cannot be recommended at the present time.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 17, 2007

There is no evidence that administration of large volume of fluids is beneficial in patients with subarachnoid haemorrhage. Subarachnoid haemorrhage is a subset of stroke that occurs frequently in relatively young persons (mostly 40 to 60 years of age). Secondary ischaemia is an important contributor to poor outcome after a subarachnoid haemorrhage (half the patients die within a month after the haemorrhage). This type of ischaemia occurs 4 to 10 days (hence: secondary) after the haemorrhage, possibly due to fluid loss through increased urinary production. This review shows that there is no evidence to support giving additional fluids to not only compensate for the loss of fluid but also to increase the amount of fluid in the body.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 18, 2004

Endovascular coiling of ruptured aneurysms in the brain leads to a better outcome than surgical clipping. Bleeding on the surface of the brain is called a subarachnoid haemorrhage. The bleeding usually comes from the rupture of a weak spot in an artery carrying blood to the brain. This weak spot is like a small balloon, or blister, which is called an aneurysm. The outcome after subarachnoid haemorrhage is generally poor: half the patients die within one month; and of those who survive the initial month, just under half remain dependent on someone else for help with activities of daily living such as walking, dressing, and bathing. One of the risks in patients with subarachnoid haemorrhage is rebleeding. There are two main ways to try to stop this: operative clipping of the neck of the aneurysm or blocking of the aneurysm from inside by endovascular coiling. This review shows that the number of people who survive and are independent in their daily living is higher after coiling than after clipping. The evidence comes mainly from one large trial.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 19, 2005

A subarachnoid haemorrhage is a bleed in the so‐called subarachnoid space, which is the very small space between the brain and the skull, and which contains blood vessels that supply the brain. The cause of the bleeding usually is a rupture of a bulge in one of these vessels. This bulging or blister on a vessel is called an aneurysm. A subarachnoid haemorrhage is a relatively uncommon type of stroke; it accounts for about one in 20 (5%) of all strokes. Subarachnoid haemorrhage often occurs at a relatively young age: half the patients are younger than 55 years old. The outcome of patients after subarachnoid haemorrhage is generally poor: half the patients die within one month after the haemorrhage, and of those who survive the initial month, half remain dependent on someone else for help with activities of daily living (e.g. walking, dressing, bathing). One of the causes of poor outcome is a complication of subarachnoid haemorrhage called secondary ischaemia (ischaemia means lack of blood). This complication occurs four to 10 days (hence secondary) after the haemorrhage. The cause is not exactly known, but one of the factors involved is narrowing of blood vessels in the brain. Calcium antagonists are a type of drug that block calcium channels in cells and are often used for the treatment of high blood pressure. They have also been shown to counteract the narrowing of blood vessels after subarachnoid haemorrhage and to protect the brain against periods of ischaemia. This review of 16 trials, involving 3361 patients, has found that the outcome after subarachnoid haemorrhage, in terms of survival and being independent in activities of daily living, is improved by treatment with calcium channel blockers (antagonists). If the largest trial is excluded from the analysis, the results are no longer statistically significant, and therefore the evidence is not beyond all doubt. However, given the high likelihood of benefits and the modest risks associated with this treatment, the review authors conclude that calcium antagonists, in the form of oral nimodipine 60 mg every four hours, are useful in patients with subarachnoid haemorrhage from a ruptured aneurysm. Magnesium is another calcium antagonist with promising results, but larger trials with this drug are needed before we can be certain about a beneficial effect.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: July 18, 2007

A subarachnoid haemorrhage (SAH) is a bleed into the small space between the brain and skull that contains blood vessels that supply the brain (the subarachnoid space). The cause of a bleeding here is usually a rupture of a weak spot in one of these vessels. A SAH is a relatively uncommon type of stroke, but it often occurs at a young age (half the patients are younger than 50 years). The outcome of SAH is often poor: one‐third of people die after the haemorrhage and of those who survive, one‐fifth will require help for everyday activities. An important cause of poor recovery after SAH is a second bleed from the weakened vessel (rebleeding). This is thought to be caused by the dissolving of the blood clot at the original bleeding site that results from natural blood clot dissolving (fibrinolytic) activity. Antifibrinolytic therapy that reduces this activity was introduced as a treatment for reducing rebleeding and therefore for improving recovery after SAH. This review included 10 trials, totaling 1904 participants that investigated the effect of these drugs in people with SAH. Antifibrinolytic treatment does indeed reduce the risk of rebleeding, but does not improve survival or the chance of being independent in everyday activities. This may be due to an increase in one of the other common complications of SAH. We conclude that antifibrinolytic treatment should not routinely be given to people with SAH, but new randomised trials are needed to establish if short‐term treatment might be beneficial.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: August 30, 2013

Aneurysmal subarachnoid haemorrhage (SAH) is a serious event where spontaneous bleeding on the surface of the brain is usually caused by the rupture of an abnormal swelling of an artery (aneurysm). If effective treatment is not provided (e.g. surgery or drug therapy) rebleeding may occur, causing death or disability for the patient. Some researchers observed that the highest risk period for rebleeding in people with a SAH was between two and four weeks after symptom onset, if they did not receive effective treatment. Total bedrest for four to six weeks has, therefore, been considered to be one of the basic interventions to avoid rebleeding. However, despite comprehensive searching, we did not identify any suitable studies that provided evidence for or against staying in bed for at least four weeks after symptom onset in people who did not, or could not, have any treatment for their ruptured aneurysm. Treatment strategies to reduce the risk of rebleeding in SAH patients before aneurysm repair, or in those patients not suitable for surgical treatment, or who prefer conservative treatments, deserve further attention.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: May 31, 2013

Acute traumatic brain injury is a major cause of death and disability. Not all damage to the brain occurs at the moment of injury; reduction of blood flow and oxygen supply to the brain can occur afterwards and cause further brain damage, which is an important cause of avoidable death and disability. In the early stages after injury it is therefore important that efforts are made to minimise secondary brain damage and to provide the best chances of recovery from established brain damage.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: October 20, 2003

We reviewed the evidence about the effect of cooling the brain during surgery for brain aneurysms. We found three studies of acceptable quality and analysed the results to see if cooling the brain during open‐skull surgery for brain aneurysms prevents death or severe disability.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: March 22, 2016

Lumbar puncture is an invasive procedure that medical personnel use to get a sample of cerebrospinal fluid for diagnostic purposes (e.g. to diagnose meningitis or subarachnoid haemorrhage) by inserting a needle into the lower spinal region. It can also be used to inject medications such as anaesthetics and analgesics (to perform regional anaesthesia), chemotherapy or radiological contrast agents.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: February 28, 2013

A survey of anaesthesiologists showed that 53% of those who replied used loss of resistance technique (LOR) with saline, 37% used LOR with air and 6% LOR with both air and saline; 3% used a different technique with or without one of the above LOR approaches. The methods used for identification of the epidural space are important for good quality of anaesthesia and for avoidance of complications such as epidural haematoma (i.e. accumulation of blood between the skull and the dura mater) and occasional low back pain.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: July 17, 2014

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