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Monday, 2 December 2013

Upper head hemorrhaging: Subarachnoid hemorrhage (SAH) - The Symptoms and Risk Factors

Hemorrhaging is also known as bleeding or abnormal bleeding as a result of blood loss due to internal.external leaking from blood vessels or through the skin.
Subarachnoid hemorrhage (SAH)
Subarachnoid hemorrhage (SAH) is defined as a condition of the presence of blood  within the subarachnoid space (the area between the brain and the thin tissues that cover the brain).
Symptoms
1.  Thunderclap headache, neck stiffness, psychosocial consequences
 Classic signs and symptoms include sudden onset of 'thunderclap' headache but patients can present with atypical symptoms such as neck stiffness. For patients who survive SAH, the psychosocial consequences can be devastating and can affect their families or carers(11).

2.  Head ache and Meningeal signs 
In the study of 193 adult aSAH patients confirmed headache as well as meningeal signs as the most frequent symptom on presentation to the emergency department, and this was cited as the most common reason for seeking medical treatment(12).

3. Confusion, seizures.  impairment of language ability and vasospasm
eizures are a recognized complication of subarachnoid hemorrhage (SAH). They can increase the cerebral metabolic demands and lead to cardiopulmonary compromise. This could be detrimental in the setting of delayed cerebral ischemia (DCI), when the brain tissue is vulnerable to further reductions in oxygen delivery or increases in demand. An association between seizures and worsening ischemia could influence the decision to use antiepileptic drug (AED) prophylaxis in patients with vasospasm(13). 

4. Intracranial pressure (pressure inside the skull), drop of cerebral blood flowand Cushing reflex respons, brain edema formation, loss of hippocampal neurons, neurological dysfunction
SAH induced a sharp increase of intracranial pressure (ICP) from 5.1+/-1.2 to 78.5+/-9.3 mm Hg (mean+/-SD; p<0.05), a concomitant drop of cerebral blood flow (rCBF) by 81+/-4% (p<0.05), and a significant Cushing reflex response (p<0.05). rCBF measurements alone could not reliably detect SAH. SAH resulted in significant brain edema formation (brain water content increase at 72 h: 2.9+/-0.9%; p<0.05), loss of hippocampal neurons (CA1: -56%, CA2: -55%; CA3: -72%; 7 days; p<0.05), severe neurological dysfunction over 7 days, and a mortality of 30%.(14).

5. Other symptoms
There is a report of a 50-year-old male patient suffered from subarachnoid hemorrhage (SAH). No abnormal condition was found in intracranial vascular digital subtraction angiography (DSA). But, this patient presented with positive hantavirus-IgM and IgG, with typical clinical process, which lead to the diagnosis of EHF followed by SAH.  Meticulous assessment of EHF patients with a serious condition had one or more central nervous system (CNS) abnormalities, such as sudden headache, vomiting, confusion, meningismus, and convulsions, which is necessary for diagnosing and giving timely treatment to improve the prognosis(14a). 

Risk factors
a, Gene defect
In the study to evaluate whether genes influencing coagulation are associated with the occurrence of aneurysmal subarachnoid hemorrhage (SAH) and with secondary cerebral ischemia and rebleeding in patients with aneurysmal SAH, showed that aneurysmal SAH patients are more often carriers of the subunit B His95Arg factor XIII polymorphism compared to controls. This suggests that carriers of the subunit B His95Arg factor XIII polymorphism have an increased risk of aneurysmal SAH(7).

b. von Willebrand's disease
von Willebrand's disease is associated with the onset of  subarachnoid hemorrhage (SAH)(8).

c. Vitamin K deficiency
Although late VKDB leads to significant morbidity and mortality, it can be avoided by providing vitamin K prophylaxis to all newborns. Administration of vitamin K (1 mg) at birth can prevent intracranial bleeding and other hemorrhagic manifestations, according to the study by Erciyes University, Talas, Kayseri, Turkey(9).

d. Factor XI deficiency
Aneurismal subarachnoid haemorrhage (SAH) is a devastating event affecting patients at a fairly young age and accounting for significant morbidity and mortality.  Researchers at the National and Kapodistrian University of Athensm reported a unique case of aneurismal SAH in a patient with underlying coagulation FXI deficiency which was incidentally identified after patient's admission, as routine blood tests revealed increased activated partial thromboplastin time. Despite early successful treatment with coiling, the patient had a second episode of SAH a few months after his discharge, due to aneurysm revascularization and rupture(10).

d. Etc.
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Sources
(10) http://www.ncbi.nlm.nih.gov/pubmed/19367158
(11) http://www.ncbi.nlm.nih.gov/pubmed/20437757
(12) http://www.ncbi.nlm.nih.gov/pubmed/22578393
(13) http://www.ncbi.nlm.nih.gov/pubmed/21427775
(14) http://www.ncbi.nlm.nih.gov/pubmed/20457182
(14a) http://www.ncbi.nlm.nih.gov/pubmed/22135608