Hemorragia subaracnóidea aneurísmica: manifestações clínicas e diagnóstico

Abstract

Introduction: The classic presentation of patients with aneurysmal SAH is a sudden-onset severe headache typically described as the "worst headache of my life." Every patient with this type of headache, often referred to as a "thunder headache" should be evaluated for SAH. Headache is often an isolated finding. Location is not useful as it can be localized or generalized. For patients who have migraine or tension-type headaches, the headache associated with SAH is qualitatively different and more severe than other headache attacks. In addition to pain, associated symptoms of SAH include brief loss of consciousness, vomiting, and neck pain or stiffness. Meningismus, often accompanied by low back pain, can develop several hours after bleeding, caused by the breakdown of blood products within the cerebrospinal fluid (CSF), leading to aseptic meningitis. Objectives: discuss aneurysmic subarachnoid hemorrhage and its clinical manifestations and diagnosis. Methodology: Integrative literature review based on scientific databases from Scielo, PubMed and VHL, from January to April 2024, with the descriptors “Aneurysmic subarachnoid hemorrhage”, “clinical manifestations” AND “diagnosis”.  Articles from 2019-2024 (total 104) were included, excluding other criteria and choosing 5 full articles. Results and Discussion: The sudden onset of headache, regardless of severity or previous history of headache, should increase the clinical suspicion of SAH and require a diagnostic evaluation. Head computed tomography (CT) without contrast reveals the diagnosis in more than 90% of cases if performed within 24 hours after the start of bleeding. Lumbar puncture is mandatory if there is a strong suspicion of SAH despite a normal head CT, except for selected patients with isolated headache and normal examination with a normal head CT performed within six hours of the onset of pain head. The classic findings are an elevated opening pressure, an elevated red blood cell count that does not decrease from cerebrospinal fluid (CSF) tube 1 to tube 4, and xanthochromia. Prompt centrifugation of the LCF can help differentiate bleeding in SAH from that due to a traumatic lumbar puncture. Once a diagnosis of SAH has been made, the etiology of the hemorrhage must be determined with vascular imaging. Of the available tests, digital subtraction angiography (DSA) has the highest resolution for detecting intracranial aneurysms and defining their anatomical features and remains the gold standard test for this, but computed tomography angiography is increasingly being used as a first-line vascular test. Repeat angiography is necessary if the initial study is negative, unless the hemorrhage pattern is perimesencephalic, in which a repeat angiography may be considered optional. Additional testing is needed for SAH that is not aneurysmal Conclusion: The proportion of stroke due to ischemia, intracerebral hemorrhage, and subarachnoid hemorrhage (SAH) is approximately 87, 10, and 3%, respectively. Most non-traumatic AES are caused by ruptured saccular aneurysms. This is often a devastating clinical event with substantial mortality and high morbidity among survivors.