van Gijn Jan, Kerr Richard S, Rinkel Gabriel J E
Department of Neurology, Rudolf Magnus Institute of Neuroscience, University Medical Centre Utrecht, 3584CX Utrecht, Netherlands.
Lancet. 2007 Jan 27;369(9558):306-18. doi: 10.1016/S0140-6736(07)60153-6.
Subarachnoid haemorrhage accounts for only 5% of strokes, but occurs at a fairly young age. Sudden headache is the cardinal feature, but patients might not report the mode of onset. CT brain scanning is normal in most patients with sudden headache, but to exclude subarachnoid haemorrhage or other serious disorders, a carefully planned lumbar puncture is also needed. Aneurysms are the cause of subarachnoid haemorrhage in 85% of cases. The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping). Another complication is delayed cerebral ischaemia; the risk is reduced with oral nimodipine and probably by maintaining circulatory volume. Hydrocephalus might cause gradual obtundation in the first few hours or days; it can be treated by lumbar puncture or ventricular drainage, dependent on the site of obstruction.
蛛网膜下腔出血仅占中风病例的5%，但发病年龄相对较轻。突发头痛是其主要特征，但患者可能无法描述发病方式。大多数突发头痛患者的脑部CT扫描结果正常，但为排除蛛网膜下腔出血或其他严重疾病，还需要精心安排腰椎穿刺检查。85%的蛛网膜下腔出血病例是由动脉瘤引起的。动脉瘤出血后的病死率为50%；八分之一的蛛网膜下腔出血患者死于院外。再出血是最紧迫的危险；因此首要目标是封堵动脉瘤。通过铂金螺旋圈（栓塞）进行血管内闭塞是首选的治疗方式，但有些患者需要直接进行神经外科手术（夹闭）。另一个并发症是迟发性脑缺血；口服尼莫地平并维持循环血容量可能会降低这种风险。脑积水可能在最初数小时或数天内导致逐渐昏迷；可根据梗阻部位通过腰椎穿刺或脑室引流进行治疗。
