Suddenly, without further ado, an immense headache shook Raquel Txavarria. He felt like a very strong pressure on the back of his skull, he became dizzy, vomited and was very sleepy. "I knew I was dying because that headache was not normal, it was very intense," explains the 26-year-old girl. In just a few hours, she, young, healthy and without previous illnesses, was admitted to the intensive care unit of the Hospital del Mar in Barcelona in critical condition. He suffered a subarachnoid hemorrhage due to a ruptured aneurysm , a stroke that occurs from a malformation in the wall of an artery: the vessel dilates, forming a kind of balloon (aneurysm) that, when ruptured, causes bleeding outside of the brain, between the two meningeal membranes. The prognosis is very bad, especially if it is detected late. Raquel was lucky and had clear symptoms, but one of the threats of subarachnoid hemorrhage is that it sometimes only manifests with a severe headache that can confuse the diagnosis. A study from the Hospital del Mar reveals that one in four cases is, in fact, mistaken for a migraine.
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Subarachnoid hemorrhage plays a game of confusion. There are no previous warning signs or major associated risk factors that can alert you to what is to come. It accounts for 5% of strokes – 9 cases per 100,000 inhabitants – and the most common (80%) is that it occurs due to a ruptured aneurysm, although it can also occur due to brain trauma. The only common pattern is that, when it appears, the person suffers a sudden and very severe headache. “It is a type of stroke that is characterized by affecting young people. There are no vascular risk factors and it is very devastating. It is a hemorrhage that is distributed through the furrows of the brain and produces an increase in intracranial pressure. Patients say that it is like the worst headache they have suffered in their life ”, explains Ana Rodríguez, head of the Stroke Unit at Hospital del Mar.
It is precisely this intense headache that can condition the diagnosis. A study by the Barcelona hospital found, after analyzing 400 patients, that 26% of cases of subarachnoid hemorrhage are misdiagnosed. Treating these strokes as migraines – from headache – or cervical contractures – from stiffness in the cervical area of the neck – are the most common mistakes, according to research published in the journal Stroke . “If the rupture of the aneurysm is very severe, it is not confused with anything because a lot of blood comes out, it can even enter the brain and produce a very spectacular picture. But there are less serious ways in which the rupture is minor and the blood stays in the subarachnoid space and occurs like an intense headache: there are people who stay at home and those who go to the hospital, if there is no medical team experienced, it can be mistaken for a banal disease. The problem is that the diagnostic delay affects the prognosis ”, alerts Jaume Roquer, head of Neurology at Hospital del Mar.
The expertise of the professionals is key to diagnose as soon as possible. “The most important thing is to take a good medical history: what the headache is like, its location, how long it lasts, how it appeared, if it increases in intensity… When the headache increases when coughing or making a significant effort, if it wakes you up at night or it is accompanied by other neurological symptoms, they are alarm signals and one must be suspicious, ”warns Mar Castellanos, coordinator of the Study Group for Cerebrovascular Diseases of the Spanish Society of Neurology.
“Subarachnoid hemorrhage is pain that appears suddenly, explosively, from zero to maximum intensity in one second. And it can be accompanied by lightheadedness and loss of consciousness "
And that intense headache, although it may seem like a migraine, it is not. And there is a way to know. “In subarachnoid hemorrhage, the patient is well and suddenly, he suffers a severe headache. Migraine, on the other hand, usually appears on one side of the head, it is pulsatile and progressive, not so intense, ”Castellanos clarifies. Roquer agrees: "Subarachnoid hemorrhage is pain that appears suddenly, explosively, from zero to maximum intensity in a second. And it can be accompanied by lightheadedness and loss of consciousness.
Time, in this type of pathology, is money. According to the Barcelona hospital study, when there is an incorrect initial diagnosis, the delay in receiving treatment is one week; if it is correct the first time, the patient is treated in less than a day. But the prognosis, in any case, is not at all promising: half of the patients suffer sequelae and mortality can reach 30%.
In a box of the semi-critical unit of Hospital del Mar, converted into a non-covid ICU in times of pandemic, Raquel fought for life against all odds. No explanations why to her. "It's like a lottery," lamented the intensivist, Ana Zapatero, during the morning of December 1. Raquel had already been hospitalized for a week, in a coma, and was beginning to suffer vasospasm, a serious complication that occurs due to a narrow artery. Around her bed, an army of intensivists, neurologists, nurses and assistants, tried to take her forward despite the complications: she had to be operated on to put vasodilators on her.
“Subarachnoid hemorrhage care does not have to be as immediate as ischemic stroke , but it is a neurocritical urge as well. The first thing to do is close the aneurysm, but there may be complications: epileptic seizures, cerebral infarcts, vasospasms… ”, says Rodríguez. Another Del Mar study published in the journal Neurology points out that short-term mortality stands at 8.7% one week after treatment, during the hospitalization period. It rises to 18.4% after three months, rises to almost 23% one year after diagnosis and borders on 30% five years later. Regarding the disabling sequelae, 7% of the surviving patients after five years presented them. “The sequelae will depend on intracerebral damage. There may be hemiplegia, sensory disorders, sequelae similar to those of stroke… ”, points out Roquer.
In Raquel's case, all the setbacks that could arise happened. They even had to perform a decompressive craniectomy, that is, removing a part of the skull bone so that the inflamed brain expands and intracranial pressure is reduced. “Because of the hemorrhage, neuronal edema occurs, the pressure in the brain increases and, if you do nothing, it ends the life of the patient. The only way to fix this is a craniectomy so that the brain expands: if it is done soon, the neurons do not suffer damage ”, says Roquer.
Raquel spent almost a month in the ICU, Christmas on a floor of the Hospital de la Esperanza —another center linked to the Del Mar health complex— and at the end of the year at the Guttmann Institute, specialized in neurorehabilitation. “When I woke up from the coma, I didn't understand anything. It was very shocking: I had no hair on one side of my head and my skull was missing. From the shock , I stopped talking, I didn't want to, ”says the young woman from her home, in the Raval neighborhood of Barcelona.
Of all those sequels that threatened her life —if she managed to get ahead—, Raquel has taken home an epilepsy that, according to his doctors, is temporary. She maintains a long brown hair that falls on her left shoulder while, on the craniectomy side, her hair grows back strongly. They have not yet replaced the shell (the cranial vault), which remains preserved in the Vall d'Hebron tissue bank, but he predicts that it will be soon. Only that and the "arsenal of drugs" that have been prescribed remind him of what happened that morning of November 23. To his surprise and that of his doctors, there are no more sequelae. “It was like being born again,” the young woman resolves.
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