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out any preceding complaint Decerebrate rigidity and brief clonic jerking of the limbs may occur at the onset of the hemorrhage, in association with unconsciousness If the hemorrhage is massive, death may ensue in a matter of minutes or hours, so that ruptured aneurysm must be considered in the differential diagnosis of sudden death A considerable proportion of such patients probably never reach a hospital Persistent deep coma is accompanied by irregular respirations, attacks of extensor rigidity, and nally respiratory arrest and circulatory collapse In these rapidly fatal cases, the subarachnoid blood has greatly increased the intracranial pressure to a level that approaches arterial pressure and caused a marked reduction in cerebral perfusion In some instances the hemorrhage has dissected intracerebrally and entered the ventricular system Rupture of the aneurysm usually occurs while the patient is active rather than during sleep, and in a few instances during sexual intercourse, straining at stool, lifting heavy objects, or other sustained exertion (see page 160) Momentary Valsalva maneuvers, as in coughing or sneezing, have generally not caused aneurysmal rupture (they may cause arterial dissection) In patients who survive the initial rupture, the most feared complication is rerupture, an event that may occur at any time from minutes up to 2 or 3 weeks In less severe cases, consciousness, if lost, may be regained within a few minutes or hours, but a residuum of drowsiness, confusion, and amnesia accompanied by severe headache and stiff neck persists for several days It is not uncommon for the drowsiness and confusion to last 10 days or longer Since the hemorrhage is con ned to the subarachnoid space, there are few if any focal neurologic signs That is to say, gross lateralizing signs in the form of hemiplegia, hemiparesis, homonymous hemianopia, or aphasia are absent in the majority of cases On occasion, a jet of blood emanating from an aneurysm may rupture into the adjacent brain or clot in the insular cistern and produce a hemiparesis or other focal syndrome There may also be a focal syndrome from acute or delayed ischemia in the territory of the aneurysm-bearing artery Usually this occurs several days after a large subarachnoid hemorrhage The pathogenesis of such manifestations is not fully understood, but a transitory fall in pressure in the circulation distal to the aneurysm is postulated in early cases and vasospasm is responsible for the later focal signs Transient de cits are not common, but they do constitute reliable indicators of the site of the ruptured aneurysm (see below) Convulsive seizures, usually brief and generalized, occur in 10 to 25 percent of cases according to Hart et al (but far less often in our experience) in relation to acute bleeding or rebleeding These early seizures do not correlate with the location of the aneurysm and do not appear to alter the prognosis Prior to rupture, saccular aneurysms are usually asymptomatic Exceptionally, if large enough to compress pain-sensitive structures, they may cause localized cranial pain With a cavernous or anterolaterally situated aneurysm on the rst part of the middle cerebral artery, the pain may be projected to the orbit An aneurysm on the posteroinferior or anteroinferior cerebellar artery may cause unilateral occipital or cervical pain The presence of a partial oculomotor palsy with dilated pupil may be indicative of an aneurysm of the posterior communicating internal carotid junction (less often posterior communicating posterior cerebral junction) Occasionally, large aneurysms just anterior to the cavernous sinus may compress the optic nerves or chiasm, third nerve, hypothalamus, or pituitary gland In the cavernous sinus they may compress the third, fourth, or sixth nerve or the ophthalmic division of the fth nerve A monocular visual eld defect may also develop with a. asp.net gs1 128 EAN - 128 ASP . NET Control - EAN - 128 barcode generator with free ...
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