蛛网膜下出血是一种涉及出血至脑和脑包裹组织之间空间—即蛛网膜下空间的严重医疗状况。这种出血通常是由动脉瘤破裂引起的，动脉瘤是血管中的一个弱点，会膨胀并可能爆裂。症状通常包括突然出现的严重头痛，常被描述为有生以来“最严重的头痛”，以及颈部疼痛、恶心、呕吐、对光敏感和混乱。这被认为是医疗紧急情况，需要立即治疗以防止可能的严重并发症，包括死亡。

症状

蛛网膜下腔出血（SAH）通常表现为突然的、剧烈的头痛，常被描述为“生命中最严重的头痛”。可能伴有恶心、呕吐、颈部僵硬、对光敏感（畏光），有时还会失去意识。其他症状可能包括癫痫发作、视力模糊或双视以及混乱。

病史结果

在病史中，重要的是要考虑增加SAH风险的因素，例如：
• 病人或家族中有脑血管疾病或动脉瘤的历史。
• 高血压（高血压病）。
• 吸烟和过度饮酒。
• 使用某些药物，如抗凝血药。

体格检查

在体格检查中，医生会寻找颈部僵硬和神经功能缺失的迹象。他们可能会进行检查以检测脑膜刺激的迹象，如Brudzinski和Kernig征，这涉及到因颈部动作而引起的腿部不自觉动作，表明有脑膜炎或出血的迹象。

所需的诊断测试

1. 头部CT扫描：这是诊断SAH的第一项也是最关键的测试。它可以快速显示蛛网膜下腔中的血液。
2. 腰椎穿刺：如果CT扫描结果为阴性但仍高度怀疑SAH，将进行腰椎穿刺（脊髓穿刺），以检查脑脊液（CSF）中的血液。
3. 脑血管造影：这项测试涉及使用染料和X光观察大脑动脉中的血流，以识别和定位动脉瘤或其他出血源。
4. MRI：如果CT扫描和腰椎穿刺未能确诊，则可以使用MRI。

这些测试有助于确认诊断并指导治疗计划。

在鉴别诊断蛛网膜下腔出血（SAH）时，重要的是要考虑其他可能呈现类似症状的疾病，例如剧烈头痛、颈部僵硬和神经功能缺失。需要排除的关键疾病包括：

1. 脑内出血 - 脑组织内部的出血，也可以导致神经系统症状迅速发作。
2. 脑动脉瘤 - 虽然动脉瘤破裂是SAH的常见原因，但未破裂的动脉瘤如果体积大或压迫脑结构，也可以表现出类似症状。
3. 偏头痛 - 严重的偏头痛有时可以模仿SAH的头痛。
4. 脑膜炎 - 脑膜的感染可以导致颈部僵硬和头痛，类似于SAH。
5. 脑瘤 - 瘤体可以增加颅内压，引起与SAH相似的症状。
6. 颈动脉夹层 - 颈动脉的撕裂可以导致出血，可能会与SAH混淆。
7. 静脉窦血栓 - 脑静脉窦中的血栓可以导致颅内压增高，模仿SAH的症状。

应考虑这些条件并使用像CT或MRI的成像技术，可能还需要腰穿，来确认SAH的诊断并排除其他原因。

疑似蛛网膜下腔出血（SAH）的患者评估包括详细的病史采集、体格检查和诊断测试。以下是每个元素通常显示的内容：

1. 病史采集：患者常报告突发的严重头痛，常被描述为一生中最糟糕的头痛。其他常见症状包括恶心、呕吐、畏光（对光敏感）和颈部僵硬。也可能注意到类似事件的历史、高血压、吸烟或家族中有脑血管疾病的历史。

2. 体格检查：在体格检查中，医生可能会发现颈部僵硬和布鲁津斯基（Brudzinski）或科尼格（Kernig）征阳性等脑膜刺激征。根据出血的范围和位置，可能存在局部神经功能缺失。患者还可能表现出意识水平降低的迹象。

3. 诊断测试：
• CT扫描：这是SAH的首选诊断测试。头部CT扫描可以显示蛛网膜下腔中的血液。
• 腰穿：如果CT扫描结果为阴性但仍高度怀疑，将进行腰穿，检查脑脊液中的黄疸色素，这表明血液分解产物的存在。
• CT血管造影或数字减影血管造影（DSA）：这些测试可用于确定出血来源，通常是动脉瘤。

这些方法的组合为确认蛛网膜下腔出血的诊断并确定适当的治疗计划提供了全面的方法。

病人信息：
• 姓名： 简·多伊
• 年龄： 45岁
• 性别： 女性
• 入院日期： 2024年4月29日
• 主诉： 突发严重头痛和意识丧失

症状：
• 突如其来的剧烈头痛，被描述为“生平最糟的头痛”
• 恶心和呕吐
• 畏光
• 颈部僵硬
• 短暂意识丧失
• 恢复意识后出现混乱和易怒

病史：
• 高血压，正在服用药物治疗
• 之前无头痛或神经系统问题的历史
• 不吸烟，适度饮酒

体格检查：
• 血压：180/110毫米汞柱
• 心率：98次/分钟
• 神经系统检查显示颈部僵硬和布鲁金斯基征阳性
• 未观察到局部神经缺陷

所需诊断测试：
1. 头部CT扫描： 确认是否有蛛网膜下腔出血。
2. 腰椎穿刺： 如果CT扫描不确定，检查脑脊液中是否有血液。
3. 脑血管造影： 确定出血的可能来源，如动脉瘤。
4. 脑部MRI： 评估是否有其他潜在的病状或并发症。

鉴别诊断：
• 脑内出血
• 带先兆的偏头痛
• 脑膜炎
• 脑瘤

蛛网膜下腔出血（SAH）的一个典型病例可能涉及一名52岁的女性患者，她突然出现严重头痛，被描述为“一生中最糟糕的头痛”，伴有恶心、呕吐和畏光（对光敏感）。患者报告说，在她园艺工作时头痛突然开始。检查时，她看起来非常痛苦，并提到颈部僵硬。她的生命体征显示血压略有升高和心率加快。

立即进行头部非对比CT扫描，显示蛛网膜下腔有弥漫性出血，确认了SAH的诊断。进一步的脑血管造影检查表明，脑动脉瘤破裂是出血的源头。患者被收入神经外科重症监护室，并安排紧急手术干预以固定动脉瘤并防止再出血。治疗还包括预防并发症如脑血管痉挛、脑积水和再出血的措施。

Subarachnoid hemorrhage is a serious medical condition involving bleeding into the subarachnoid space — the area between the brain and the tissues covering the brain. This type of hemorrhage is usually caused by the rupture of an aneurysm, which is a weakened area in a blood vessel that balloons out and can burst. Symptoms often include a sudden, severe headache often described as the "worst headache" ever experienced, along with neck pain, nausea, vomiting, sensitivity to light, and confusion. It's considered a medical emergency and requires immediate treatment to prevent potentially severe complications, including death.

Symptoms of Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) typically presents with a sudden, severe headache often described as "the worst headache of my life." This can be accompanied by nausea, vomiting, stiff neck, sensitivity to light (photophobia), and sometimes loss of consciousness. Other symptoms may include seizures, blurred or double vision, and confusion.

Results of Medical History

In the medical history, it's important to consider factors that increase the risk of SAH, such as:
• A history of cerebrovascular disease or aneurysms in the patient or family.
• High blood pressure (hypertension).
• Smoking and excessive alcohol use.
• Use of certain medications, like blood thinners.

Physical Examination

During a physical examination, the doctor will look for signs of neck stiffness and neurological deficits. They may perform tests to check for meningeal irritation, such as the Brudzinski and Kernig signs, which involve involuntary leg movements in response to neck movements and are indicative of meningitis or hemorrhage.

Diagnostic Tests Required

1. CT Scan of the Head: This is the first and most critical test to diagnose SAH. It can quickly reveal blood in the subarachnoid space.
2. Lumbar Puncture: If the CT scan is negative but suspicion for SAH remains high, a lumbar puncture (spinal tap) is performed to look for blood in the cerebrospinal fluid (CSF).
3. Cerebral Angiography: This test involves using a dye and X-rays to view blood flow in the brain arteries to identify and locate an aneurysm or other source of bleeding.
4. MRI: An MRI can be used if the CT scan and lumbar puncture do not conclusively diagnose the condition.

These tests help to confirm the diagnosis and guide treatment planning.

In the differential diagnosis of subarachnoid hemorrhage (SAH), it's important to consider other conditions that can present with similar symptoms, such as severe headache, neck stiffness, and neurological deficits.

Key diseases to rule out include:
1. Intracerebral hemorrhage - bleeding within the brain tissue itself, which can also cause rapid onset of neurological symptoms.
2. Cerebral aneurysm - although an aneurysm rupture is a common cause of SAH, an unruptured aneurysm can present with similar symptoms if it is large or pressing on brain structures.
3. Migraine - severe migraines can sometimes mimic the headache of SAH.
4. Meningitis - infection of the meninges can cause neck stiffness and headache, resembling SAH.
5. Brain tumor - a tumor can increase intracranial pressure, leading to symptoms similar to those of SAH.
6. Cervical artery dissection - a tear in one of the cervical arteries can lead to bleeding that might be confused with SAH.
7. Venous sinus thrombosis - a clot in the venous sinuses of the brain can cause increased intracranial pressure and mimic SAH symptoms.

These conditions should be considered and appropriately tested for using imaging techniques like CT or MRI, and possibly lumbar puncture, to confirm the diagnosis of SAH and rule out other causes.

The assessment of a patient with a suspected subarachnoid hemorrhage (SAH) involves a detailed medical history, physical examination, and diagnostic tests. Here's what each of these elements typically reveals:

1. Medical History: Patients often report a sudden, severe headache which is frequently described as the worst headache of their life. Other common symptoms include nausea, vomiting, photophobia (sensitivity to light), and neck stiffness. A history of similar events, hypertension, smoking, or a family history of cerebrovascular diseases may also be noted.

2. Physical Examination: During the physical examination, the doctor may find signs of meningeal irritation such as neck stiffness and a positive Brudzinski’s or Kernig's sign. Focal neurological deficits may be present, depending on the extent and location of the hemorrhage. The patient may also show signs of reduced level of consciousness.

3. Diagnostic Tests:
• CT Scan: This is the primary diagnostic test for SAH. A CT scan of the head can reveal blood in the subarachnoid space.
• Lumbar Puncture: If the CT scan is negative but suspicion remains high, a lumbar puncture is performed to check for xanthochromia in the cerebrospinal fluid, which indicates the presence of blood breakdown products.
• CT Angiography or Digital Subtraction Angiography (DSA): These tests may be used to identify the source of the bleeding, often an aneurysm.

The combination of these methods provides a comprehensive approach to confirming the diagnosis of subarachnoid hemorrhage and determining the appropriate treatment plan.

Medical Record Example in English

Patient Information:
• Name: Jane Doe
• Age: 45
• Sex: Female
• Date of Admission: April 29, 2024
• Presenting Complaint: Sudden, severe headache and loss of consciousness

Symptoms:
• Sudden onset of a severe headache described as "the worst headache of my life"
• Nausea and vomiting
• Photophobia (sensitivity to light)
• Neck stiffness
• Brief loss of consciousness
• Confusion and irritability upon regaining consciousness

Medical History:
• Hypertension, managed with medication
• No previous history of headaches or neurological issues
• Non-smoker, moderate alcohol use

Physical Examination:
• Blood Pressure: 180/110 mmHg
• Heart Rate: 98 bpm
• Neurological exam shows neck rigidity and a positive Brudzinski's sign
• No focal neurological deficits observed

Diagnostic Tests Required:
1. CT Scan of the Head: To confirm the presence of subarachnoid hemorrhage.
2. Lumbar Puncture: If CT scan is inconclusive, to check for blood in the cerebrospinal fluid.
3. Cerebral Angiography: To identify potential sources of bleeding such as aneurysms.
4. MRI of the Brain: To assess for any other underlying conditions or complications.

Differential Diagnosis:
• Intracerebral hemorrhage
• Migraine with aura
• Meningitis
• Brain tumor

A sample patient case of subarachnoid hemorrhage (SAH) might involve a 52-year-old female patient presenting with a sudden onset of a severe headache, described as the "worst headache of her life," accompanied by nausea, vomiting, and photophobia (sensitivity to light). The patient reports that the headache started abruptly while she was gardening. On examination, she appears distressed and mentions neck stiffness. Her vital signs reveal a slightly elevated blood pressure and a rapid heart rate.

A non-contrast CT scan of the head is immediately performed, showing a diffuse bleed in the subarachnoid space, confirming the diagnosis of SAH. Further investigation with cerebral angiography indicates a ruptured cerebral aneurysm as the source of the hemorrhage. The patient is admitted to the neurosurgical intensive care unit and scheduled for urgent surgical intervention to secure the aneurysm and prevent rebleeding. Management also includes measures to prevent complications such as cerebral vasospasm, hydrocephalus, and rebleeding.