title: Ghetto

text: Recently the word "ghetto" has been used in slang as an adjective rather than a noun. It is used to indicate an object's relation to the inner city and also more broadly to denote something that is shabby or of low quality. While "ghetto" as an adjective can be used derogatorily, the African-American or Black community, particularly the hip hop scene, has taken the word for themselves and begun using it in a more positive sense that transcends its derogatory origins.


title: Ghetto

text: In 1973, "Geographical Review" claimed "The degree of residential segregation of the black community is greater than for any other group in urban America, yet black people have not had the political power necessary to exercise any significant degree of control over the improvement of the basic services necessary for their health, education, and welfare." Scholars have been interested in the study of African-American or Black ghettos precisely for the concentration of disadvantaged residents and their vulnerability to social problems. American ghettos also bring attention to geographical and political barriers, and as Doreen Massey highlights, that racial segregation in African-American or Black ghettos challenge America's democratic foundations. However, it is still advocated that "One solution to these problems depends on our ability to use the political process in eliminating the inequities... geographical knowledge and theory to public-policy decisions about poor people and poor regions is a professional obligation."


title: Ghetto

text: There are many Roma ghettos in the European Union. The Czech government estimates that there are approximately 830 Roma ghettos in the Czech Republic.


title: Ghetto

text: In Northern Ireland, towns and cities have long been segregated along ethnic, religious and political lines. The two main communities of Northern Ireland are:


title: Ghetto

text: Ghettos emerged in Belfast during the riots that accompanied the Irish War of Independence. For safety, people fled to areas where their community was the majority. Many more ghettos emerged after the 1969 riots and beginning of the "Troubles." In August 1969 the British Army was deployed to restore order and separate the two sides. The government built barriers called "peace lines." Many of the ghettos came under the control of paramilitaries such as the (republican) Provisional Irish Republican Army and the (loyalist) Ulster Defence Association. One of the most notable ghettos was Free Derry.


title: Ghetto

text: The existence of ethnic enclaves in the United Kingdom is controversial. Southall Broadway, a predominantly Asian area in Greater London, where less than 12 percent of the population is white, has been cited as an example of a 'ghetto', but in reality the area is home to a number of different ethnic groups and religious groups.


title: Ghetto

text: Analysis of data from Census 2001 revealed that only two wards in England and Wales, both in Birmingham, had one dominant non-white ethnic group comprising more than two-thirds of the local population, but there were 20 wards where whites were a minority making up less than a third of the local population. By 2001, two London boroughs—Newham and Brent—had "minority majority" populations, and most parts of the city tend to have a diverse population.


title: Ghetto

text: Historically, some parts of London have long been noted for the prevalence of a particular ethnic or religious group (such as the Jewish communities of Golders Green and other parts of the London Borough of Barnet, and the West Indian community of Notting Hill), but in each case these populations have been part of a broader multicultural population. In the late 19th and early 20th century, the East End of London was also noted for its Jewish population, but now has a significant British Bangladeshi populace.


title: Ghetto

text: Until 2021 the Danish government sometimes used the word "ghetto" to describe particularly vulnerable public housing areas in the country. The designation was applied to areas based on the residents' income levels, employment status, education levels, criminal convictions and 'non-Western' ethnic background.


title: Ghetto

text: In 2017, the population of Denmark was 5.7 million, of which 8.7% were non-Western immigrants or their descendants. The population proportion of 'ghetto residents' with non-Western background was 66.5%. Since 2010, the Danish Ministry of Transport, Building and Housing publishes the "Ghettolisten" (the 'List of Ghettos') which, in 2018, consists of 25 areas.


title: Ghetto

text: In his 2018 New Year Speech, Danish Prime Minister Lars Løkke Rasmussen announced his government's intention to "end the existence of parallel societies and ghettos by 2030." The government has since proposed measures to solve the issue of integration which include policies like 30 hours of obligatory daycare per week for 'ghetto children' starting age 1, lowering social welfare for ghetto residents, incentives for reducing unemployment, demolition and rebuilding of certain tenements, doubling punishment for certain crimes like theft and vandalism in the ghettos, rights for landlords to refuse housing to convicts, etc. While some proposals like restricting 'ghetto children' to their homes after 8 p.m. have been rejected for being too radical, most of the 22 proposals have been agreed upon by a parliamentary majority. The policies have been criticized for undercutting 'equality before law' and for portraying immigrants, especially Muslim immigrants, in a bad light.


title: Ghetto

text: In June 2019 a new social democratic government was formed in Denmark, with Kaare Dybvad becoming housing minister. He stated that the new government would stop using the word "ghetto" for vulnerable housing areas, as it is both imprecise and derogatory.


title: Ghetto

text: In France, a "banlieue" () is a suburb of a large city. Banlieues are divided into autonomous administrative entities and do not constitute part of the city proper. For instance, 80% of the inhabitants of the Paris area live outside the city of Paris. Like the city centre, suburbs may be rich, middle-class or poor — Versailles, Le Vésinet, Maisons-Laffitte and Neuilly-sur-Seine are affluent banlieues of Paris, while Clichy-sous-Bois, Bondy and Corbeil-Essonnes are less so. However, since the 1970s, "banlieues" increasingly means, in French of France, low-income housing projects (HLMs) in which mainly foreign immigrants and French of foreign descent reside, often in perceived poverty traps.


title: Sybian

text: A Sybian (), or Sybian saddle, is a masturbation device. It consists of a hollow saddle-like seat containing two electric motors, motor speed controller boards, gearing, pulleys, and a platform on cranked axles such that a ridge on the top of the unit can be made to vibrate through a range of speeds as set using a wired external hand controller, and an upward-pointing shaft set on an angle through the ridge can be made to rotate at speeds of up to several hundred rpm, again by use of the wired remote control. Flexible molded attachments are supplied that fit over the vibrating ridge and shaft which mostly have integrated dildos on their top. In use, the rider inserts the dildo into a body orifice for internal stimulation while applying pressure on the vibrating ridge with their external erogenous parts


title: Sybian

text: According to its inventor, Dave Lampert, the Sybian was first conceived in the 1970s and developed in 1983. A prototype was built in 1985 from sheet metal mounted on a wooden frame with a vibrator projecting through an opening inside the housing; a second prototype became the basis for current production models.


title: Sybian

text: Lampert and his team initially called the device "Master Better", shortened to "MB," for about four years before selecting a new name for it. The prefix "syb" in Sybian was derived from Sybaris, an Ancient Greek city in southern Italy which was associated with luxurious living. It is currently manufactured by Abco Research Associates in Monticello, IL.


title: Sybian

text: From research and experience, Lampert theorized that the woman on top position during intercourse works best for female orgasm and that stimulation is enhanced when the penis remains fully inserted and the woman rocks her pelvis forward and backward, making contact with the sensitive G-spot located on the front wall of the vagina.


title: Sybian

text: In addition, the optional penetrating attachments rotate to stimulate the vaginal walls and G-spot at variable speeds while also vibrating to help a woman to have multiple G-spot orgasms. Women are also instructed to rock their pelvis forward and back while using the Sybian with a penetration attachment to enhance stimulation of the G-spot.


title: Sybian

text: In 2016, Lampert was honored with an AVN lifetime achievement award for his invention. He died in July 2021 at the age of 90.


title: Sybian

text: The Sybian weighs , and measures wide, long, and tall excluding the rubber attachment with an power cord. The unit is designed to work with or without a penetration attachment. When in operation, the Sybian distributes vibrations externally along the user's pelvic floor, including clitoral glans, the introitus to her vagina and cavity of the anus. The optional penetration attachments rotate using a 20:1 ratio gear motor providing that can vary from 0 to 120 rpm and vibration is produced using a electric motor that may be controlled from 0 to 6500 rpm. Power and vibration/rotation are controlled with a remote control. The Sybian is able to hold over of weight. It has a padded naugahyde cover. The casing has built-in finger grips for carrying.


title: Sybian

text: Generally, the user of the Sybian straddles the machine and administers the dildo attachment, inserting it into her vagina or the anus. The vibration and rotation can be controlled by separate on/off switches and two rotary controls. The Sybian is sold with up to eleven washable attachments of varying sizes made from synthetic rubber in various shapes, including a finger, a specially designed G-spot stimulator, and various sizes of phallus and the addition of two premium silicone parts in 2015, with additional silicone parts being developed and released in the subsequent years.


title: Sybian

text: After its release in 1987, the Sybian was featured on the cover of the December 1987 issue of "Penthouse Forum". It made its first pornographic video appearance in "Orgasmatic" (1998), which received an AVN award nomination for "most outrageous sex scene" for Ruby the Original's performance with the device.


title: Sybian

text: Although the Sybian has been featured in many pornographic video productions since the early 2000s, primarily on the Internet, the device came to prominence on "The Howard Stern Show" since the show's arrival on Sirius Satellite Radio. Howard Stern was given a Sybian as a birthday gift in 2006.


title: Danhausen (wrestler)

text: Donovan Danhausen (born August 17, 1990), better known mononymously as Danhausen, is an American professional wrestler currently signed to All Elite Wrestling (AEW). He was previously known for his tenures with Ring of Honor (ROH) and Full Impact Pro (FIP) under the same name.


title: Danhausen (wrestler)

text: Danhausen was trained by Jimmy Jacobs and Truth Martini. He made his debut on October 18, 2013, becoming known for sticking to a gimmick illustrated by his spooky attire and painted face. He competed at "BLP Slamilton 2", an event produced by Black Label Pro Wrestling, where he teamed up with Ethan Page and Swoggle to defeat Blood Diamond (Jake Lander, Joshua Bishop and Tre Lamar) for the BLP Tag Team Championship. He competed for Capital City Championship Combat at "C4 Combat Shock - 12th Anniversary" on November 21, 2019, where he defeated Tony Deppen.


title: Danhausen (wrestler)

text: At "FU/Freelance I Don't Think We're In Chicago Anymore" from October 10, 2020, an event produced by Freelance Underground Wrestling, Danhausen teamed up with Warhorse as Warhausen, defeating The Brothers Of Funstruction (Ruffo The Clown and Yabo The Clown) by disqualification, therefore failing to capture the FU Tag Team Championship. At "F1RST Wrestling Saturday Night Nitro", an event produced by F1RST Wrestling on March 7, 2020, Danhausen fought Orange Cassidy into a no-contest.


title: Danhausen (wrestler)

text: Danhausen made his first appearance for Ring Of Honor at "ROH Wrestling #429" on November 2, 2019, where he unsuccessfully challenged Shane Taylor for the ROH World Television Championship. He continued to make sporadic appearances such as at "ROH Wrestling #437" where he fell short to Rhett Titus on January 11, 2020, and at "ROH Honor Reigns Supreme 2020" on January 12, where he scored a defeat against Dak Draper. At "ROH Free Enterprise" on February 9, 2020, Danhausen participated in a 20-man battle royal to determine the no.1 contendership for the ROH World Championship, where he competed against the winner Flip Gordon, Gangrel, PJ Black, Tracy Williams and others. At ROH Final Battle 2020 on December 18, he defeated Brian Johnson by disqualification, earning him an ROH contract (behind the scenes, Danhausen credits Alex Shelley with convincing ROH brass to sign him). At ROH 19th Anniversary Show on March 26, 2021, Danhausen competed in a four-way match, falling short to the winner, Brian Johnson, Eli Isom and LSG.


title: Danhausen (wrestler)

text: Danhausen made his All Elite Wrestling (AEW) debut during a special episode of "Dynamite" called Beach Break on January 26, 2022. He appeared during the Lights Out match between Orange Cassidy and Adam Cole. Hours later, AEW President Tony Khan announced that Danhausen had signed with the company. He is currently involved in a storyline with Hook, wherein Hook is proving to be immune to Danhausen's curses, and Danhausen doing little more than occasionally annoy Hook with often humorous results. On the May 6, 2022 episode of "Rampage", Hook declined Danhausen's offer to align with him, and Mark Sterling convinced Tony Nese to challenge Danhausen to a match on the next episode of "Dynamite". On the May 11, 2022 episode of "Dynamite", Danhausen wrestled in his first ever AEW match, losing to Nese following a distraction from Sterling. After the match, Hook would align with Danhausen after saving him from a beatdown from Nese and Sterling. The new tag team would make their debut on May 29 at the Double or Nothing Buy-In, defeating Nese and Sterling.


title: Danhausen (wrestler)

text: Danhausen has described his character as "Conan O'Brien possessed by a demon". In April 2021, he appeared as a guest on O'Brien's podcast "Conan O'Brien Needs a Friend" to discuss this concept. The character wears horror-themed face paint and believes he has supernatural powers, such as shooting lightning from his fingers and the ability to put curses on his enemies. The voice for his character is based on O'Brien and Mark Hamill's Joker. He often refers to himself in the third person, adds the suffix "-hausen" to words, chastises other wrestlers if they use profanity, and describes himself and things he likes as "very nice, very evil". He is also known for nonchalantly dancing a "Pee-wee Herman dance" to the song "Tequila" in the middle of matches.


title: Danhausen (wrestler)

text: In collaboration with the Rootless Coffee Company, Danhausen launched a signature coffee blend called Danhausen Coffeehausen in 2021. Like many wrestlers, Danhausen has trademarked his ring name and catchphrases ("Love that Danhausen" and "Very Nice Very Evil"). In addition, he has trademarked the design of his face paint. The attorney who represented him in this matter, Michael Dockins (who works in conjunction with wrestlers so often he is nicknamed the "Gimmick Lawyer"), believes this to be the first time a wrestler has trademarked his physical appearance.


title: Danhausen (wrestler)

text: Danhausen married Canadian burlesque dancer Lauren Jiles, known professionally as Lou Lou la Duchesse de Rière, in 2018. He is the stepfather of her daughter.


title: Entourage (film)

text: Entourage is a 2015 American comedy film written, directed and produced by Doug Ellin, and serves as a continuation of the HBO television series of the same name. It stars the principal cast of the show, Kevin Connolly, Adrian Grenier, Kevin Dillon, Jerry Ferrara and Jeremy Piven, and follows actor Vincent Chase, who goes over budget on his directorial debut and must ask newly appointed studio head Ari Gold for more money. Like in the series, many celebrity sportspeople and actors appear as themselves, while several supporting cast members from the show reprise their roles.


title: Entourage (film)

text: After it was confirmed the series would end in 2011 with season 8, Ellin and the cast expressed their interest in doing a feature film. After script and production issues, the project was officially announced in 2013, and filming began around Los Angeles in February 2014.


title: Entourage (film)

text: "Entourage" was theatrically released in the United States on June 3, 2015. The film received generally negative reviews from critics and grossed $49 million worldwide, against a production cost of $39 million.


title: Entourage (film)

text: Just nine days after the finale of the show, Vincent Chase has separated from his wife and throws a party on his yacht, with his friends E, Johnny and Turtle joining to cheer him up. Wishing to do something new with his career, he calls his former agent-turned-studio head Ari Gold, who offers Vince a leading role in his first studio production. Vince says he will only star in it if he directs. Eight months later, "Hyde", the directorial debut by Vince, is in the middle of post-production and is over budget by $15 million. Needing more money, Vince asks Ari if they can get an additional $10 million to complete the movie. Reluctant, but wanting to please him, Ari flies to Texas to meet the co-financiers of the movie, Larsen McCredle and his son Travis, to convince them to invest more money into the film. Hesitant, Larsen sends Travis with Ari back to Los Angeles to see a cut of the film at Vince's private screening.


title: Entourage (film)

text: Vince has second thoughts on the rough cut and cancels the screening out of fear no one will enjoy it. He later gives Ari and Travis a copy of the movie for their viewing. Ari and Travis enjoy the movie but Travis requests that Ari cut the scenes with Vince's brother, Johnny "Drama" Chase, out of the movie or he will not give the film the extra money. With Ari giving him no answer, Travis puts the post-production on hold. Vince and Eric "E" Murphy visit Travis to come up with a solution, but this results in Travis saying he did not like Vince's performance either and wants the entire movie to be redone with a new lead and director. In addition, studio CEO John Ellis removes Ari from the production.


title: Entourage (film)

text: The boys soon realize the reason Travis is angry over the movie is because he discovered that Vince is secretly dating Emily Ratajkowski, whom Travis is infatuated with. Learning of this, Ari interrupts Ellis in a boardroom meeting with Larsen and Travis with this information. Surprised, Larsen says he will stay behind the movie but mandates the condition that Ari is no longer working for the studio because, although he agreed his son was being juvenile, Ari had disrespected his son. During this time, the boys are at the hospital as E's ex-fiancée Sloan goes into labor. Sloan gives birth to a girl, Ryan Murphy, resulting in Sloan and E deciding to get back together and vowing to make it work this time.


title: Entourage (film)

text: As the boys celebrate, Ari arrives at the hospital and announces that he resigned, and in lieu of his severance, he has negotiated part of the backend grosses. "Hyde" becomes a box office hit, grossing over $450 million worldwide. At the Golden Globe Awards, Drama ends up winning the award for Best Supporting Actor. Stunned, Drama goes to accept the award and is silent for a moment before yelling his trademark "Viking Quest" phrase, "VICTORY!!!"


title: Entourage (film)

text: In a mid-credits scene, Ari's former assistant Lloyd has his wedding and Ari gives him away. When the group gets together for a picture, Billy Walsh suggests that they should make a film (or TV show) about the lives of Vince and the gang.


title: Entourage (film)

text: In August 2010, when it was confirmed that the eighth season of "Entourage" would be the last, creator Doug Ellin expressed interest in writing a film after the series ended. In September 2011, Adrian Grenier confirmed that there would be a film, and a script just needed to be written first. The series' executive producer Mark Wahlberg also confirmed that a film is in the works and said, "I will do everything to get this film made".


title: Entourage (film)

text: The film was officially green-lit in 2013, with Ellin directing and Warner Bros. distributing. However, by September 2013, amid reports that there had been significant delays in production and contract issues with the film's cast, Ellin stated the film was "less and less likely every day." However, by October 2013, the cast had reached a deal, allowing the film to move forward.


title: Entourage (film)

text: Principal photography officially began on February 19, 2014, in Los Angeles, with additional filming in Miami. While filming in California, the production spent $39 million and received the California Film & Television Tax Credit. Filming was disrupted when Kevin Connolly broke his leg filming a football scene with Russell Wilson, which resulted in a number of script changes to accommodate it. In March 2014, it was reported that adult film actresses Lilly Banks, Maia Davis, Spencer Scott, and Anna Morna had shot scenes for the film. Several cast members shot a scene for the film on the red carpet at the 72nd Golden Globe Awards on January 11, 2015.


title: Entourage (film)

text: The film was previously set for a June 12, 2015 release, but on October 24, 2014, Warner Bros. moved it up a week to June 5, 2015. In April 2015, the release date was moved up two days to June 3, 2015.


title: Entourage (film)

text: "Entourage" grossed $32.4 million in the United States and Canada and $16.9 million in other territories for a worldwide total of $49.3 million, against a production budget of $39 million.


title: Entourage (film)

text: In North America, the film grossed $2 million from its early Tuesday night showings and $5.4 million on its opening day (Wednesday), including Tuesday previews, from 3,058 theaters. The film earned $2 million and $3.7 million on Thursday and Friday, respectively. For its opening weekend (Friday–Sunday), it grossed $10.4 million (a five-day total of $17.8 million), finishing at fourth place at the box office behind "Spy" ($29.1 million), "San Andreas" ($25.8 million), and "" ($22.7 million). Given the film's $39 million production budget, as well as an additional $40.7 million spent on advertisement, Warner Bros. and HBO Films were hoping for an opening of at least $20 million, and the film was considered a financial disappointment. The film dropped 59% in its sophomore weekend to $4.2 million, finishing 5th.


title: Entourage (film)

text: On review aggregator website Rotten Tomatoes, the film holds an approval rating of 33% based on 213 reviews, with an average rating of 4.70/10. The site's critical consensus reads, ""Entourage" retains many elements of the HBO series, but feels less like a film than a particularly shallow, cameo-studded extended episode of the show." On Metacritic, the film has a weighted average score of 38 out of 100, based on 40 critics, indicating "generally unfavorable reviews". In CinemaScore polls, audiences gave the film an average grade of "A−" on an A+ to F scale.


title: Entourage (film)

text: Brian Tallerico, writing for RogerEbert.com, awarded the film one and a half out of four stars, saying "Instead of challenging his characters or giving them something new to do, Ellin just high fives them on the way to the winner's circle." Mark Kermode, writing for "The Guardian", gave the film one out of five stars, and wrote that ""The Human Centipede" was more sensitively attuned to issues of gender politics. And it had better jokes. Even producer/inspiration Marky Mark [Mark Wahlberg] looks embarrassed by his cameo." Ultimately, Kermode would rank "Entourage" as the worst film of 2015 and later, in 2018, the worst film of the decade to that point. IGN awarded "Entourage" a 7.5 out of 10, saying "When it sticks to what it has always been best at, the relationship of these four friends, it is as good as the series ever was".


title: Subarachnoid hemorrhage

text: Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.


title: Subarachnoid hemorrhage

text: SAH may occur as a result of a head injury or spontaneously, usually from a ruptured cerebral aneurysm. Risk factors for spontaneous cases include high blood pressure, smoking, family history, alcoholism, and cocaine use. Generally, the diagnosis can be determined by a CT scan of the head if done within six hours of symptom onset. Occasionally, a lumbar puncture is also required. After confirmation further tests are usually performed to determine the underlying cause.


title: Subarachnoid hemorrhage

text: Treatment is by prompt neurosurgery or endovascular coiling. Medications such as labetalol may be required to lower the blood pressure until repair can occur. Efforts to treat fevers are also recommended. Nimodipine, a calcium channel blocker, is frequently used to prevent vasospasm. The routine use of medications to prevent further seizures is of unclear benefit. Nearly half of people with a SAH due to an underlying aneurysm die within 30 days and about a third who survive have ongoing problems. Between ten and fifteen percent die before reaching a hospital.


title: Subarachnoid hemorrhage

text: Spontaneous SAH occurs in about one per 10,000 people per year. Females are more commonly affected than males. While it becomes more common with age, about 50% of people present under 55 years old. It is a form of stroke and comprises about 5 percent of all strokes. Surgery for aneurysms was introduced in the 1930s. Since the 1990s many aneurysms are treated by a less invasive procedure called endovascular coiling, which is carried out through a large blood vessel.


title: Subarachnoid hemorrhage

text: The classic symptom of subarachnoid hemorrhage is thunderclap headache (a headache described as "like being kicked in the head", or the "worst ever", developing over seconds to minutes). This headache often pulsates towards the occiput (the back of the head). About one-third of people have no symptoms apart from the characteristic headache, and about one in ten people who seek medical care with this symptom are later diagnosed with a subarachnoid hemorrhage. Vomiting may be present, and 1 in 14 have seizures. Confusion, decreased level of consciousness or coma may be present, as may neck stiffness and other signs of meningism.


title: Subarachnoid hemorrhage

text: Neck stiffness usually presents six hours after initial onset of SAH. Isolated dilation of a pupil and loss of the pupillary light reflex may reflect brain herniation as a result of rising intracranial pressure (pressure inside the skull). Intraocular hemorrhage (bleeding into the eyeball) may occur in response to the raised pressure: subhyaloid hemorrhage (bleeding under the hyaloid membrane, which envelops the vitreous body of the eye) and vitreous hemorrhage may be visible on fundoscopy. This is known as Terson syndrome (occurring in 3–13 percent of cases) and is more common in more severe SAH.


title: Subarachnoid hemorrhage

text: Oculomotor nerve abnormalities (affected eye looking downward and outward and inability to lift the eyelid on the same side) or palsy (loss of movement) may indicate bleeding from the posterior communicating artery. Seizures are more common if the hemorrhage is from an aneurysm; it is otherwise difficult to predict the site and origin of the hemorrhage from the symptoms. SAH in a person known to have seizures is often diagnostic of a cerebral arteriovenous malformation.


title: Subarachnoid hemorrhage

text: The combination of intracerebral hemorrhage and raised intracranial pressure (if present) leads to a "sympathetic surge", i.e. over-activation of the sympathetic system. This is thought to occur through two mechanisms, a direct effect on the medulla that leads to activation of the descending sympathetic nervous system and a local release of inflammatory mediators that circulate to the peripheral circulation where they activate the sympathetic system. As a consequence of the sympathetic surge there is a sudden increase in blood pressure; mediated by increased contractility of the ventricle and increased vasoconstriction leading to increased systemic vascular resistance. The consequences of this sympathetic surge can be sudden, severe, and are frequently life-threatening. The high plasma concentrations of adrenaline also may cause cardiac arrhythmias (irregularities in the heart rate and rhythm), electrocardiographic changes (in 27 percent of cases) and cardiac arrest (in 3 percent of cases) may occur rapidly after the onset of hemorrhage. A further consequence of this process is neurogenic pulmonary edema where a process of increased pressure within the pulmonary circulation causes leaking of fluid from the pulmonary capillaries into the air spaces, the alveoli, of the lung.


title: Subarachnoid hemorrhage

text: Subarachnoid hemorrhage may also occur in people who have had a head injury. Symptoms may include headache, decreased level of consciousness and hemiparesis (weakness of one side of the body). SAH is a frequent occurrence in traumatic brain injury, and carries a poor prognosis if it is associated with deterioration in the level of consciousness.


title: Subarachnoid hemorrhage

text: While thunderclap headache is the characteristic symptom of subarachnoid hemorrhage, less than 10% of those with concerning symptoms have SAH on investigations. A number of other causes may need to be considered.


title: Subarachnoid hemorrhage

text: Most cases of SAH are due to trauma such as a blow to the head. Traumatic SAH usually occurs near the site of a skull fracture or intracerebral contusion. It often happens in the setting of other forms of traumatic brain injury. In these cases prognosis is poorer; however, it is unclear if this is a direct result of the SAH or whether the presence of subarachnoid blood is simply an indicator of a more severe head injury.


title: Subarachnoid hemorrhage

text: In 85 percent of spontaneous cases the cause is a cerebral aneurysm—a weakness in the wall of one of the arteries in the brain that becomes enlarged. They tend to be located in the circle of Willis and its branches. While most cases are due to bleeding from small aneurysms, larger aneurysms (which are less common) are more likely to rupture. Aspirin also appears to increase the risk.


title: Subarachnoid hemorrhage

text: In 15–20 percent of cases of spontaneous SAH, no aneurysm is detected on the first angiogram. About half of these are attributed to non-aneurysmal perimesencephalic hemorrhage, in which the blood is limited to the subarachnoid spaces around the midbrain (i.e. mesencephalon). In these, the origin of the blood is uncertain. The remainder are due to other disorders affecting the blood vessels (such as cerebral arteriovenous malformations), disorders of the blood vessels in the spinal cord, and bleeding into various tumors.


title: Subarachnoid hemorrhage

text: Cocaine abuse and sickle cell anemia (usually in children) and, rarely, anticoagulant therapy, problems with blood clotting and pituitary apoplexy can also result in SAH. Dissection of the vertebral artery, usually caused by trauma, can lead to subarachnoid hemorrhage if the dissection involves the part of the vessel inside the skull.


title: Subarachnoid hemorrhage

text: Cerebral vasospasm is one of the complications caused by subarachnoid hemorrhage. It usually happens from the third day after the aneurysm event, and reaches its peak on 5th to 7th day. There are several mechanisms proposed for this complication. Blood products released from subarachnoid hemorrhage stimulates the tyrosine kinase pathway causing the release of calcium ions from intracellular storage, resulting in smooth muscle contraction of cerebral arteries. Oxyhaemoglobin in cerebrospinal fluid (CSF) causes vasoconstriction by increasing free radicals, endothelin-1, prostaglandin and reducing the level of nitric oxide and prostacyclin. Besides, the disturbances of autonomic nervous system innervating cerebral arteries is also thought to cause vasospasm.


title: Subarachnoid hemorrhage

text: As only 10 percent of people admitted to the emergency department with a thunderclap headache are having an SAH, other possible causes are usually considered simultaneously, such as meningitis, migraine, and cerebral venous sinus thrombosis. Intracerebral hemorrhage, in which bleeding occurs within the brain itself, is twice as common as SAH and is often misdiagnosed as the latter. It is not unusual for SAH to be initially misdiagnosed as a migraine or tension headache, which can lead to a delay in obtaining a CT scan. In a 2004 study, this occurred in 12 percent of all cases and was more likely in people who had smaller hemorrhages and no impairment in their mental status. The delay in diagnosis led to a worse outcome. In some people, the headache resolves by itself, and no other symptoms are present. This type of headache is referred to as "sentinel headache", because it is presumed to result from a small leak (a "warning leak") from an aneurysm. A sentinel headache still warrants investigations with CT scan and lumbar puncture, as further bleeding may occur in the subsequent three weeks.


title: Subarachnoid hemorrhage

text: The initial steps for evaluating a person with a suspected subarachnoid hemorrhage are obtaining a medical history and performing a physical examination. The diagnosis cannot be made on clinical grounds alone and in general medical imaging and possibly a lumbar puncture is required to confirm or exclude bleeding.


title: Subarachnoid hemorrhage

text: The modality of choice is computed tomography (CT scan), without contrast, of the brain. This has a high sensitivity and will correctly identify 98.7% of cases within six hours of the onset of symptoms. A CT scan can rule out the diagnosis in someone with a normal neurological exam if done within six hours. Its efficacy declines thereafter, and magnetic resonance imaging (MRI) is more sensitive than CT after several days.


title: Subarachnoid hemorrhage

text: After a subarachnoid hemorrhage is confirmed, its origin needs to be determined. If the bleeding is likely to have originated from an aneurysm (as determined by the CT scan appearance), the choice is between cerebral angiography (injecting radiocontrast through a catheter to the brain arteries) and CT angiography (visualizing blood vessels with radiocontrast on a CT scan) to identify aneurysms. Catheter angiography also offers the possibility of coiling an aneurysm (see below).


title: Subarachnoid hemorrhage

text: In emergency department patients complaining of acute-onset headache without significant risk factors for SAH, evidence suggests that CT scanning of the head followed by CT angiography can reliably exclude SAH without the need for a lumbar puncture. The risk of missing an aneurysmal bleed as the cause of SAH with this approach is less than 1%.


title: Subarachnoid hemorrhage

text: Lumbar puncture, in which cerebrospinal fluid (CSF) is removed from the subarachnoid space of the spinal canal using a hypodermic needle, shows evidence of bleeding in three percent of people in whom a non-contrast CT was found normal. A lumbar puncture or CT scan with contrast is therefore regarded as mandatory in people with suspected SAH when imaging is delayed to after six hours from the onset of symptoms and is negative. At least three tubes of CSF are collected. If an elevated number of red blood cells is present equally in all bottles, this indicates a subarachnoid hemorrhage. If the number of cells decreases per bottle, it is more likely that it is due to damage to a small blood vessel during the procedure (known as a "traumatic tap"). While there is no official cutoff for red blood cells in the CSF no documented cases have occurred at less than "a few hundred cells" per high-powered field.


title: Subarachnoid hemorrhage

text: The CSF sample is also examined for xanthochromia—the yellow appearance of centrifugated fluid. This can be determined by spectrophotometry (measuring the absorption of particular wavelengths of light) or visual examination. It is unclear which method is superior. Xanthochromia remains a reliable ways to detect SAH several days after the onset of headache. An interval of at least 12 hours between the onset of the headache and lumbar puncture is required, as it takes several hours for the hemoglobin from the red blood cells to be metabolized into bilirubin.


title: Subarachnoid hemorrhage

text: Electrocardiographic changes are relatively common in subarachnoid hemorrhage, occurring in 40–70 percent of cases. They may include QT prolongation, Q waves, cardiac dysrhythmias, and ST elevation that mimics a heart attack.


title: Subarachnoid hemorrhage

text: Also one of the characteristic ECG changes that could be found in patients with subarachnoid hemorrhage, is the J waves or Osborn waves, which are positive deflections that occur at the junction between QRS complexes and ST segments, where the S point, also known as the J point, has a myocardial infarction-like elevation. J waves or Osborn waves, which represent an early repolarization and delayed depolarization of the heart ventricles, are thought to be caused by the high catecholamines surge released in patients with subarachnoid hemorrhage or brain damage, the issue that might lead to ventricular fibrillation and cardiac arrest in unmanaged patients.


title: Subarachnoid hemorrhage

text: There are several grading scales available for SAH. The Glasgow Coma Scale (GCS) is ubiquitously used for assessing consciousness. Its three specialized scores are used to evaluate SAH; in each, a higher number is associated with a worse outcome. These scales have been derived by retrospectively matching characteristics of people with their outcomes.


title: Subarachnoid hemorrhage

text: The first widely used scale for neurological condition following SAH was published by Botterell and Cannell in 1956 and referred to as the Botterell Grading Scale. This was modified by Hunt and Hess in 1968:


title: Subarachnoid hemorrhage

text: This scale has been modified by Claassen and coworkers, reflecting the additive risk from SAH size and accompanying intraventricular hemorrhage (0 – none; 1 – minimal SAH w/o IVH; 2 – minimal SAH with IVH; 3 – thick SAH w/o IVH; 4 – thick SAH with IVH);.


title: Subarachnoid hemorrhage

text: The World Federation of Neurosurgeons (WFNS) classification uses Glasgow coma score and focal neurological deficit to gauge severity of symptoms.


title: Subarachnoid hemorrhage

text: A comprehensive classification scheme has been suggested by Ogilvy and Carter to predict outcome and gauge therapy. The system consists of five grades and it assigns one point for the presence or absence of each of five factors: age greater than 50; Hunt and Hess grade 4 or 5; Fisher scale 3 or 4; aneurysm size greater than 10 mm; and posterior circulation aneurysm 25 mm or more.


title: Subarachnoid hemorrhage

text: Screening for aneurysms is not performed on a population level; because they are relatively rare, it would not be cost-effective. However, if someone has two or more first-degree relatives who have had an aneurysmal subarachnoid hemorrhage, screening may be worthwhile.


title: Subarachnoid hemorrhage

text: Autosomal dominant polycystic kidney disease (ADPKD), a hereditary kidney condition, is known to be associated with cerebral aneurysms in 8 percent of cases, but most such aneurysms are small and therefore unlikely to rupture. As a result, screening is only recommended in families with ADPKD where one family member has had a ruptured aneurysm.


title: Subarachnoid hemorrhage

text: An aneurysm may be detected incidentally on brain imaging; this presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications. The International Study of Unruptured Intracranial Aneurysms (ISUIA) provided prognostic data both in people having previously had a subarachnoid hemorrhage and people who had aneurysms detected by other means. Those having previously had a SAH were more likely to bleed from other aneurysms. In contrast, those having never bled and had small aneurysms (smaller than 10 mm) were very unlikely to have a SAH and were likely to sustain harm from attempts to repair these aneurysms. On the basis of the ISUIA and other studies, it is now recommended that people are considered for preventive treatment only if they have a reasonable life expectancy and have aneurysms that are highly likely to rupture. Moreover, there is only limited evidence that endovascular treatment of unruptured aneurysms is actually beneficial.


title: Subarachnoid hemorrhage

text: Management involves general measures to stabilize the person while also using specific investigations and treatments. These include the prevention of rebleeding by obliterating the bleeding source, prevention of a phenomenon known as vasospasm, and prevention and treatment of complications.


title: Subarachnoid hemorrhage

text: Stabilizing the person is the first priority. Those with a depressed level of consciousness may need to be intubated and mechanically ventilated. Blood pressure, pulse, respiratory rate, and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care unit may be preferable, especially since 15 percent may have further bleeding soon after admission. Nutrition is an early priority, mouth or nasogastric tube feeding being preferable over parenteral routes. In general, pain control is restricted to less-sedating agents such as codeine, as sedation may impact on the mental status and thus interfere with the ability to monitor the level of consciousness. Deep vein thrombosis is prevented with compression stockings, intermittent pneumatic compression of the calves, or both. A bladder catheter is usually inserted to monitor fluid balance. Benzodiazepines may be administered to help relieve distress. Antiemetic drugs should be given to awake persons.


title: Subarachnoid hemorrhage

text: People with poor clinical grade on admission, acute neurologic deterioration, or progressive enlargement of ventricles on CT scan are, in general, indications for the placement of an external ventricular drain by a neurosurgeon. The external ventricular drain may be inserted at the bedside or in the operating room. In either case, strict aseptic technique must be maintained during insertion. In people with aneurysmal subarachnoid hemorrhage the EVD is used to remove cerebrospinal fluid, blood, and blood byproducts that increase intracranial pressure and may increase the risk for cerebral vasospasm.


title: Subarachnoid hemorrhage

text: Efforts to keep a person's systolic blood pressure somewhere between 140 and 160 mmHg is generally recommended. Medications to achieve this may include labetalol or nicardipine.


title: Subarachnoid hemorrhage

text: People whose CT scan shows a large hematoma, depressed level of consciousness, or focal neurologic signs may benefit from urgent surgical removal of the blood or occlusion of the bleeding site. The remainder are stabilized more extensively and undergo a transfemoral angiogram or CT angiogram later. It is hard to predict who will have a rebleed, yet it may happen at any time and carries a dismal prognosis. After the first 24 hours have passed, rebleeding risk remains around 40 percent over the subsequent four weeks, suggesting that interventions should be aimed at reducing this risk as soon as possible. Some predictors of early rebleeding are high systolic blood pressure, the presence of a hematoma in the brain or ventricles, poor Hunt-Hess grade (III-IV), aneurysms in the posterior circulation, and an aneurysm >10 mm in size.


title: Subarachnoid hemorrhage

text: If a cerebral aneurysm is identified on angiography, two measures are available to reduce the risk of further bleeding from the same aneurysm: clipping and coiling. Clipping requires a craniotomy (opening of the skull) to locate the aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the large blood vessels (endovascularly): a catheter is inserted into the femoral artery in the groin and advanced through the aorta to the arteries (both carotid arteries and both vertebral arteries) that supply the brain. When the aneurysm has been located, platinum coils are deployed that cause a blood clot to form in the aneurysm, obliterating it. The decision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of a neurosurgeon, neuroradiologist, and often other health professionals.


title: Subarachnoid hemorrhage

text: In general, the decision between clipping and coiling is made on the basis of the location of the aneurysm, its size and the condition of the person. Aneurysms of the middle cerebral artery and its related vessels are hard to reach with angiography and tend to be amenable to clipping. Those of the basilar artery and posterior cerebral artery are hard to reach surgically and are more accessible for endovascular management. These approaches are based on general experience, and the only randomized controlled trial directly comparing the different modalities was performed in relatively well people with small (less than 10 mm) aneurysms of the anterior cerebral artery and anterior communicating artery (together the "anterior circulation"), who constitute about 20 percent of all people with aneurysmal SAH. This trial, the "International Subarachnoid Aneurysm Trial" (ISAT), showed that in this group the likelihood of death or being dependent on others for activities of daily living was reduced (7.4 percent absolute risk reduction, 23.5 percent relative risk reduction) if endovascular coiling was used as opposed to surgery. The main drawback of coiling is the possibility that the aneurysm will recur; this risk is extremely small in the surgical approach. In ISAT, 8.3 percent needed further treatment in the longer term. Hence, people who have undergone coiling are typically followed up for many years afterwards with angiography or other measures to ensure recurrence of aneurysms is identified early. Other trials have also found a higher rate of recurrence necessitating further treatments.


title: Subarachnoid hemorrhage

text: Vasospasm, in which the blood vessels constrict and thus restrict blood flow, is a serious complication of SAH. It can cause ischemic brain injury (referred to as "delayed ischemia") and permanent brain damage due to lack of oxygen in parts of the brain. It can be fatal if severe. Delayed ischemia is characterized by new neurological symptoms, and can be confirmed by transcranial doppler or cerebral angiography. About one third of people admitted with subarachnoid hemorrhage will have delayed ischemia, and half of those have permanent damage as a result. It is possible to screen for the development of vasospasm with transcranial Doppler every 24–48 hours. A blood flow velocity of more than 120 centimeters per second is suggestive of vasospasm.


title: Subarachnoid hemorrhage

text: The pathogenesis of cerebral vasospasm following subarachnoid hemorrhage is attributed to the higher levels of endothelin 1, a potent vasoconstrictor, and the lower levels of endothelial NOS (eNOS), a potent vasodilator. Both of which are produced from a series of events that begin from the inflammatory reaction caused by the products released from erythrocytes' degradation. Following subarachnoid hemorrhage, different clotting factors and blood products are released into the surrounding perivascular spaces known as (Virchow-Robin spaces). The released clotting factors like; fibrinopeptides, thromboxane A2 and others lead to microthrombosis around near vessels that leads to extrinsic vasoconstriction of these vessels. Besides that extrinsic vasoconstriction, the erythrocytes' degradation products like; bilirubin and oxyhemoglobin lead to neuroinflammation that in turn increases the production of reactive oxygen species (ROS) which increases and decreases the production of endothelin 1 and endothelial NOS, respectively, the issue that yields in intrinsic vasoconstriction of the neighboring blood vessels and results in cerebral ischemia if left untreated.


title: Subarachnoid hemorrhage

text: The use of calcium channel blockers, thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for prevention. The calcium channel blocker nimodipine when taken by mouth improves outcome if given between the fourth and twenty-first day after the bleeding, even if it does not reduce the amount of vasospasm detected on angiography. It is the only Food and Drug Administration (FDA)-approved drug for treating cerebral vasospasm. In "traumatic" subarachnoid hemorrhage, nimodipine does not affect long-term outcome, and is not recommended. Other calcium channel blockers and magnesium sulfate have been studied, but are not presently recommended; neither is there any evidence that shows benefit if nimodipine is given intravenously.


title: Subarachnoid hemorrhage

text: Nimodipine is readily authorized in the form of tablets and solution for infusion for the prevention and treatment of complications due to vasospasm following subarachnoid hemorrhage. Another sustained formulation of nimodipine administered via an external ventricular drain (EVD), called EG-1962, is also available. In contrast to the tablets and solution formulations of Nimodipine which require an administration every 4hrs for a total of 21 days, the sustained formulation, EG-1962, needs to be administered once directly into the ventricles. The CSF concentrations from EG-1962, however, were at least 2 orders of magnitude higher than those with oral nimodipine. These results supported a phase 3 study that demonstrated a favorable safety profile for EG-1962 but yielded inconclusive efficacy results due to notable differences in clinical outcome based on baseline disease severity.


title: Subarachnoid hemorrhage

text: Some older studies have suggested that statin therapy might reduce vasospasm, but a subsequent meta-analysis including further trials did not demonstrate benefit on either vasospasm or outcomes. While corticosteroids with mineralocorticoid activity may help prevent vasospasm their use does not appear to change outcomes.


title: Subarachnoid hemorrhage

text: A protocol referred to as "triple H" is often used as a measure to treat vasospasm when it causes symptoms; this is the use of intravenous fluids to achieve a state of hypertension (high blood pressure), hypervolemia (excess fluid in the circulation), and hemodilution (mild dilution of the blood). Evidence for this approach is inconclusive; no randomized controlled trials have been undertaken to demonstrate its effect.


title: Subarachnoid hemorrhage

text: If the symptoms of delayed ischemia do not improve with medical treatment, angiography may be attempted to identify the sites of vasospasms and administer vasodilator medication (drugs that relax the blood vessel wall) directly into the artery. Angioplasty (opening the constricted area with a balloon) may also be performed.


title: Subarachnoid hemorrhage

text: Hydrocephalus (obstruction of the flow of cerebrospinal fluid) may complicate SAH in both the short and long term. It is detected on CT scanning, on which there is enlargement of the lateral ventricles. If the level of consciousness is decreased, drainage of the excess fluid is performed by therapeutic lumbar puncture, extraventricular drain (a temporary device inserted into one of the ventricles), or occasionally a permanent shunt. Relief of hydrocephalus can lead to an enormous improvement in a person's condition. Fluctuations in blood pressure and electrolyte imbalance, as well as pneumonia and cardiac decompensation occur in about half the hospitalized persons with SAH and may worsen prognosis. Seizures occur during the hospital stay in about a third of cases.


title: Subarachnoid hemorrhage

text: People have often been treated with preventative antiepileptic medications. This is controversial and not based on good evidence. In some studies, use of these medications was associated with a worse prognosis; although it is unclear whether this might be because the drugs themselves actually cause harm, or because they are used more often in persons with a poorer prognosis. There is a possibility of a gastric hemorrhage due to stress ulcers.


title: Subarachnoid hemorrhage

text: SAH is often associated with a poor outcome. The death rate (mortality) for SAH is between 40 and 50 percent, but trends for survival are improving. Of those that survive hospitalization, more than a quarter have significant restrictions in their lifestyle, and less than a fifth have no residual symptoms whatsoever. Delay in diagnosis of minor SAH (mistaking the sudden headache for migraine) contributes to poor outcome. Factors found on admission that are associated with poorer outcome include poorer neurological grade; systolic hypertension; a previous diagnosis of heart attack or SAH; liver disease; more blood and larger aneurysm on the initial CT scan; location of an aneurysm in the posterior circulation; and higher age. Factors that carry a worse prognosis during the hospital stay include occurrence of delayed ischemia resulting from vasospasm, development of intracerebral hematoma, or intraventricular hemorrhage (bleeding into the ventricles of the brain) and presence of fever on the eighth day of admission.


title: Subarachnoid hemorrhage

text: So-called "angiogram-negative subarachnoid hemorrhage", SAH that does not show an aneurysm with four-vessel angiography, carries a better prognosis than SAH with aneurysm, but it is still associated with a risk of ischemia, rebleeding, and hydrocephalus. Perimesencephalic SAH (bleeding around the mesencephalon in the brain), however, has a very low rate of rebleeding or delayed ischemia, and the prognosis of this subtype is excellent.


title: Subarachnoid hemorrhage

text: The prognosis of head trauma is thought to be influenced in part by the location and amount of subarachnoid bleeding. It is difficult to isolate the effects of SAH from those of other aspects of traumatic brain injury; it is unknown whether the presence of subarachnoid blood actually worsens the prognosis or whether it is merely a sign that a significant trauma has occurred. People with moderate and severe traumatic brain injury who have SAH when admitted to a hospital have as much as twice the risk of dying as those who do not. They also have a higher risk of severe disability and persistent vegetative state, and traumatic SAH has been correlated with other markers of poor outcome such as post traumatic epilepsy, hydrocephalus, and longer stays in the intensive care unit. More than 90 percent of people with traumatic subarachnoid bleeding and a Glasgow Coma Score over 12 have a good outcome.


title: Subarachnoid hemorrhage

text: There is also modest evidence that genetic factors influence the prognosis in SAH. For example, having two copies of ApoE4 (a variant of the gene encoding apolipoprotein E that also plays a role in Alzheimer's disease) seems to increase risk for delayed ischemia and a worse outcome. The occurrence of hyperglycemia (high blood sugars) after an episode of SAH confers a higher risk of poor outcome.


title: Subarachnoid hemorrhage

text: Neurocognitive symptoms, such as fatigue, mood disturbances, and other related symptoms, are common sequelae. Even in those who have made good neurological recovery, anxiety, depression, posttraumatic stress disorder, and cognitive impairment are common; 46 percent of people who have had a subarachnoid hemorrhage have cognitive impairment that affects their quality of life. Over 60 percent report frequent headaches. Aneurysmal subarachnoid hemorrhage may lead to damage of the hypothalamus and the pituitary gland, two areas of the brain that play a central role in hormonal regulation and production. More than a quarter of people with a previous SAH may develop hypopituitarism (deficiencies in one or more of the hypothalamic–pituitary hormones such as growth hormone, luteinizing hormone, or follicle-stimulating hormone). SAH is also associated with SIADH and cerebral salt wasting, and is the most common cause of the latter.


title: Subarachnoid hemorrhage

text: According to a review of 51 studies from 21 countries, the average incidence of subarachnoid hemorrhage is 9.1 per 100,000 annually. Studies from Japan and Finland show higher rates in those countries (22.7 and 19.7, respectively), for reasons that are not entirely understood. South and Central America, in contrast, have a rate of 4.2 per 100,000 on average.


title: Subarachnoid hemorrhage

text: Although the group of people at risk for SAH is younger than the population usually affected by stroke, the risk still increases with age. Young people are much less likely than middle-age people (risk ratio 0.1, or 10 percent) to have a subarachnoid hemorrhage. The risk continues to rise with age and is 60 percent higher in the very elderly (over 85) than in those between 45 and 55. Risk of SAH is about 25 percent higher in women over 55 compared to men the same age, probably reflecting the hormonal changes that result from the menopause, such as a decrease in estrogen levels.


title: Subarachnoid hemorrhage

text: Genetics may play a role in a person's disposition to SAH; risk is increased three- to fivefold in first-degree relatives of people having had a subarachnoid hemorrhage. But lifestyle factors are more important in determining overall risk. These risk factors are smoking, hypertension (high blood pressure), and excessive alcohol consumption. Having smoked in the past confers a doubled risk of SAH compared to those who have never smoked. Some protection of uncertain significance is conferred by caucasian ethnicity, hormone replacement therapy, and diabetes mellitus. There is likely an inverse relationship between total serum cholesterol and the risk of non-traumatic SAH, though confirmation of this association is hindered by a lack of studies. Approximately 4 percent of aneurysmal bleeds occur after sexual intercourse and 10 percent of people with SAH are bending over or lifting heavy objects at the onset of their symptoms.


title: Subarachnoid hemorrhage

text: Overall, about 1 percent of all people have one or more cerebral aneurysms. Most of these are small and unlikely to rupture.


title: Subarachnoid hemorrhage

text: While the clinical picture of subarachnoid hemorrhage may have been recognized by Hippocrates, the existence of cerebral aneurysms and the fact that they could rupture was not established until the 18th century. The associated symptoms were described in more detail in 1886 by Edinburgh physician Dr Byrom Bramwell. In 1924, London neurologist Sir Charles P. Symonds (1890–1978) gave a complete account of all major symptoms of subarachnoid hemorrhage, and he coined the term "spontaneous subarachnoid hemorrhage". Symonds also described the use of lumbar puncture and xanthochromia in diagnosis.


title: Subarachnoid hemorrhage

text: The first surgical intervention was performed by Norman Dott, who was a pupil of Harvey Cushing then working in Edinburgh. He introduced the wrapping of aneurysms in the 1930s, and was an early pioneer in the use of angiograms. American neurosurgeon Dr Walter Dandy, working in Baltimore, was the first to introduce clips in 1938. Microsurgery was applied to aneurysm treatment in 1972 in order to further improve outcomes. The 1980s saw the introduction of triple H therapy as a treatment for delayed ischemia due to vasospasm, and trials with nimodipine in an attempt to prevent this complication. In 1983, the Russian neurosurgeon Zubkov and colleagues reported the first use of transluminal balloon angioplasty for vasospasm after aneurysmal SAH. The Italian neurosurgeon Dr Guido Guglielmi introduced his endovascular coil treatment in 1991.


title: Riboflavin

text: Riboflavin, also known as vitamin B, is a vitamin found in food and sold as a dietary supplement. It is essential to the formation of two major coenzymes, flavin mononucleotide and flavin adenine dinucleotide. These coenzymes are involved in energy metabolism, cellular respiration, and antibody production, as well as normal growth and development. The coenzymes are also required for the metabolism of niacin, vitamin B, and folate. Riboflavin is prescribed to treat corneal thinning, and taken orally, may reduce the incidence of migraine headaches in adults.


title: Riboflavin

text: Riboflavin deficiency is rare and is usually accompanied by deficiencies of other vitamins and nutrients. It may be prevented or treated by oral supplements or by injections. As a water-soluble vitamin, any riboflavin consumed in excess of nutritional requirements is not stored; it is either not absorbed or is absorbed and quickly excreted in urine, causing the urine to have a bright yellow tint. Natural sources of riboflavin include meat, fish and fowl, eggs, dairy products, green vegetables, mushrooms, and almonds. Some countries require its addition to grains.


title: Riboflavin

text: Riboflavin was discovered in 1920, isolated in 1933, and first synthesized in 1935. In its purified, solid form, it is a water-soluble yellow-orange crystalline powder. In addition to its function as a vitamin, it is used as a food coloring agent. Biosynthesis takes place in bacteria, fungi and plants, but not animals. Industrial synthesis of riboflavin was initially achieved using a chemical process, but current commercial manufacturing relies on fermentation methods using strains of fungi and genetically modified bacteria.


title: Riboflavin

text: Riboflavin, also known as vitamin B, is a water-soluble vitamin and is one of the B vitamins. Unlike folate and vitamin B, which occur in several chemically related forms known as vitamers, riboflavin is only one chemical compound. It is a starting compound in the synthesis of the coenzymes flavin mononucleotide (FMN, also known as riboflavin-5'-phosphate) and flavin adenine dinucleotide (FAD). FAD is the more abundant form of flavin, reported to bind to 75% of the number of flavin-dependent protein encoded genes in the all-species genome (the flavoproteome) and serves as a co-enzyme for 84% of human-encoded flavoproteins.


title: Riboflavin

text: In its purified, solid form, riboflavin is a yellow-orange crystalline powder with a slight odor and bitter taste. It is soluble in polar solvents, such as water and aqueous sodium chloride solutions, and slightly soluble in alcohols. It is not soluble in non-polar or weakly polar organic solvents such as chloroform, benzene or acetone. In solution or during dry storage as a powder, riboflavin is heat stable if not exposed to light. When heated to decompose, it releases toxic fumes containing nitric oxide.


title: Riboflavin

text: Riboflavin is essential to the formation of two major coenzymes, FMN and FAD. These coenzymes are involved in energy metabolism, cell respiration, antibody production, growth and development. Riboflavin is essential for the metabolism of carbohydrates, protein and fats. FAD contributes to conversion of tryptophan to niacin (vitamin B) and the conversion of vitamin B to the coenzyme pyridoxal 5'-phosphate requires FMN. Riboflavin is involved in maintaining normal circulating levels of homocysteine; in riboflavin deficiency, homocysteine levels increase, elevating the risk of cardiovascular diseases.


title: Riboflavin

text: Redox reactions are processes that involve the transfer of electrons. The flavin coenzymes support the function of roughly 70-80 flavoenzymes in humans (and hundreds more across all organisms, including those encoded by archeal, bacterial and fungal genomes) that are responsible for one- or two-electron redox reactions which capitalize on the ability of flavins to be converted between oxidized, half-reduced and fully reduced forms. FAD is also required for the activity of glutathione reductase, an essential enzyme in formation of the endogenous antioxidant, glutathione.


title: Riboflavin

text: Riboflavin, FMN, and FAD are involved in the metabolism of niacin, vitamin B, and folate. The synthesis of the niacin-containing coenzymes, NAD and NADP, from tryptophan involves the FAD-dependent enzyme, kynurenine 3-monooxygenase. Dietary deficiency of riboflavin can decrease the production of NAD and NADP, thereby promoting niacin deficiency. Conversion of vitamin B to its coenzyme, pyridoxal 5'-phosphate synthase, involves the enzyme, pyridoxine 5'-phosphate oxidase, which requires FMN. An enzyme involved in folate metabolism, 5,10-methylenetetrahydrofolate reductase, requires FAD to form the amino acid, methionine, from homocysteine.


title: Riboflavin

text: Riboflavin deficiency appears to impair the metabolism of the dietary mineral, iron, which is essential to the production of hemoglobin and red blood cells. Alleviating riboflavin deficiency in people who are deficient in both riboflavin and iron improves the effectiveness of iron supplementation for treating iron-deficiency anemia.


title: Riboflavin

text: Biosynthesis takes place in bacteria, fungi and plants, but not animals. The biosynthetic precursors to riboflavin are ribulose 5-phosphate and guanosine triphosphate. The former is converted to L-3,4-dihydroxy-2-butanone-4-phosphate while the latter is transformed in a series of reactions that lead to 5-amino-6-(D-ribitylamino)uracil. These two compounds are then the substrates for the penultimate step in the pathway, catalysed by the enzyme lumazine synthase in reaction .


title: Riboflavin

text: In the final step of the biosynthesis, two molecules of 6,7-dimethyl-8-ribityllumazine are combined by the enzyme riboflavin synthase in a dismutation reaction. This generates one molecule of riboflavin and one of 5-amino-6-(D-ribitylamino) uracil. The latter is recycled to the previous reaction in the sequence.


title: Riboflavin

text: Conversions of riboflavin to the cofactors FMN and FAD are carried out by the enzymes riboflavin kinase and FAD synthetase acting sequentially.


title: Riboflavin

text: The industrial-scale production of riboflavin uses various microorganisms, including filamentous fungi such as "Ashbya gossypii", "Candida famata" and "Candida flaveri", as well as the bacteria "Corynebacterium ammoniagenes" and "Bacillus subtilis". "B. subtilis" that has been genetically modified to both increase the production of riboflavin and to introduce an antibiotic (ampicillin) resistance marker, is employed at a commercial scale to produce riboflavin for feed and food fortification. By 2012, over 4,000 tonnes per annum were produced by such fermentation processes.


title: Riboflavin

text: In the presence of high concentrations of hydrocarbons or aromatic compounds, some bacteria overproduce riboflavin, possibly as a protective mechanism. One such organism is "Micrococcus luteus" (American Type Culture Collection strain number ATCC 49442), which develops a yellow color due to production of riboflavin while growing on pyridine, but not when grown on other substrates, such as succinic acid.


title: Riboflavin

text: The first total synthesis of riboflavin was carried out by Richard Kuhn's group. A substituted aniline, produced by reductive amination using D-ribose, was condensed with alloxan in the final step:


title: Riboflavin

text: Keratoconus is the most common form of corneal ectasia, a progressive thinning of the cornea. The condition is treated by corneal collagen cross-linking, which increases corneal stiffness. Cross-linking is achieved by applying a topical riboflavin solution to the cornea, which is then exposed to ultraviolet A light.


title: Riboflavin

text: In its 2012 guidelines, the American Academy of Neurology stated that high-dose riboflavin (400 mg) is "probably effective and should be considered for migraine prevention," a recommendation also provided by the UK National Migraine Centre. A 2017 review reported that daily riboflavin taken at 400 mg per day for at least three months may reduce the frequency of migraine headaches in adults. Research on high-dose riboflavin for migraine prevention or treatment in children and adolescents is inconclusive, and so supplements are not recommended.


title: Riboflavin

text: Riboflavin is used as a food coloring (yellow-orange crystalline powder), and is designated with the E number, E101, in Europe for use as a food additive.


title: Riboflavin

text: The National Academy of Medicine updated the Estimated Average Requirements (EARs) and Recommended Dietary Allowances (RDAs) for riboflavin in 1998. for riboflavin for women and men aged 14 and over are 0.9 mg/day and 1.1 mg/day, respectively; the RDAs are 1.1 and 1.3 mg/day, respectively. RDAs are higher than EARs to provide adequate intake levels for individuals with higher than average requirements. The RDA during pregnancy is 1.4 mg/day and the RDA for lactating females is 1.6 mg/day. For infants up to the age of 12 months, the Adequate Intake (AI) is 0.3–0.4 mg/day and for children aged 1–13 years the RDA increases with age from 0.5 to 0.9 mg/day. As for safety, the IOM sets tolerable upper intake levels (ULs) for vitamins and minerals when evidence is sufficient. In the case of riboflavin there is no UL, as there is no human data for adverse effects from high doses. Collectively the EARs, RDAs, AIs and ULs are referred to as Dietary Reference Intakes (DRIs).


title: Riboflavin

text: The European Food Safety Authority (EFSA) refers to the collective set of information as Dietary Reference Values, with Population Reference Intake (PRI) instead of RDA, and Average Requirement instead of EAR. AI and UL are defined the same as in United States. For women and men aged 15 and older the PRI is set at 1.6 mg/day. The PRI during pregnancy is 1.9 mg/day and the PRI for lactating females is 2.0 mg/day. For children aged 1–14 years the PRIs increase with age from 0.6 to 1.4 mg/day. These PRIs are higher than the U.S. RDAs. The EFSA also considered the maximum safe intake and like the U.S. National Academy of Medicine, decided that there was not sufficient information to set an UL.


title: Riboflavin

text: In humans, there is no evidence for riboflavin toxicity produced by excessive intakes and absorption becomes less efficient as doses increases. Any excess riboflavin is excreted via the kidneys into urine, resulting in a bright yellow color known as flavinuria. During a clinical trial on the effectiveness of riboflavin for treating the frequency and severity of migraines, subjects were given up to 400 mg of riboflavin orally per day for periods of 3–12 months. Abdominal pains and diarrhea were among the side effects reported.


title: Riboflavin

text: For U.S. food and dietary supplement labeling purposes the amount in a serving is expressed as a percent of Daily Value (%DV). For riboflavin labeling purposes 100% of the Daily Value was 1.7 mg, but as of May 27, 2016, it was revised to 1.3 mg to bring it into agreement with the RDA. A table of the old and new adult daily values is provided at Reference Daily Intake.


title: Riboflavin

text: The United States Department of Agriculture, Agricultural Research Service maintains a food composition database from which riboflavin content in hundreds of foods can be searched.


title: Riboflavin

text: The milling of wheat results in an 85% loss of riboflavin, so white flour is enriched in some countries. Riboflavin is also added to baby foods, breakfast cereals, pastas and vitamin-enriched meal replacement products. It is difficult to incorporate riboflavin into liquid products because it has poor solubility in water, hence the requirement for riboflavin-5'-phosphate (FMN, also called E101 when used as colorant), a more soluble form of riboflavin. The enrichment of bread and ready-to-eat breakfast cereals contributes significantly to the dietary supply of the vitamin. Free riboflavin is naturally present in animal-sourced foods along with protein-bound FMN and FAD. Cows' milk contains mainly free riboflavin, but both FMN and FAD are present at low concentrations.


title: Riboflavin

text: Some countries require or recommend fortification of grain foods. As of 2021, 56 countries, mostly in North and South America and southeast Africa, require food fortification of wheat flour or maize (corn) flour with riboflavin or riboflavin-5'-phosphate sodium. The amounts stipulated range from 1.3 to 5.75 mg/kg. An additional 16 countries have a voluntary fortification program. For example, the Indian government recommends 4.0 mg/kg for "maida" (white) and "atta" (whole wheat) flour.


title: Riboflavin

text: More than 90% of riboflavin in the diet is in the form of protein-bound FMN and FAD. Exposure to gastric acid in the stomach releases the coenzymes, which are subsequently enzymatically hydrolyzed in the proximal small intestine to release free riboflavin.


title: Riboflavin

text: Absorption occurs via a rapid active transport system, with some additional passive diffusion occurring at high concentrations. Bile salts facilitate uptake, so absorption is improved when the vitamin is consumed with a meal. One small clinical trial in adults reported that the maximum amount of riboflavin that can be absorbed from a single dose is 27 mg. The majority of newly absorbed riboflavin is taken up by the liver on the first pass, indicating that postprandial appearance of riboflavin in blood plasma may underestimate absorption. Three riboflavin transporter proteins have been identified: RFVT1 is present in the small intestine and also in the placenta; RFVT2 is highly expressed in brain and salivary glands; and RFVT3 is most highly expressed in the small intestine, testes, and prostate. Infants with mutations in the genes encoding these transport proteins can be treated with riboflavin administered orally.


title: Riboflavin

text: Riboflavin is reversibly converted to FMN and then FAD. From riboflavin to FMN is the function of zinc-requiring riboflavin kinase; the reverse is accomplished by a phosphatase. From FMN to FAD is the function of magnesium-requiring FAD synthase; the reverse is accomplished by a pyrophosphatase. FAD appears to be an inhibitory end-product that down-regulates its own formation.


title: Riboflavin

text: When excess riboflavin is absorbed by the small intestine, it is quickly removed from the blood and excreted in urine. Urine color is used as a hydration status biomarker and, under normal conditions, correlates with urine specific gravity and urine osmolality. However, riboflavin supplementation in large excess of requirements causes urine to appear more yellow than normal. With normal dietary intake, about two-thirds of urinary output is riboflavin, the remainder having been partially metabolized to hydroxymethylriboflavin from oxidation within cells, and as other metabolites. When consumption exceeds the ability to absorb, riboflavin passes into the large intestine, where it is catabolized by bacteria to various metabolites that can be detected in feces. There is speculation that unabsorbed riboflavin could affect the large intestine microbiome.


title: Riboflavin

text: Riboflavin deficiency is uncommon in the United States and in other countries with wheat flour or corn meal fortification programs. From data collected in biannual surveys of the U.S. population, for ages 20 and over, 22% of females and 19% of men reported consuming a supplement that contained riboflavin, typically a vitamin-mineral multi-supplement. For the non-supplement users, the dietary intake of adult women averaged 1.74 mg/day and men 2.44 mg/day. These amounts exceed the RDAs for riboflavin of 1.1 and 1.3 mg/day respectively. For all age groups, on average, consumption from food exceeded the RDAs. A 2001-02 U.S. survey reported that less than 3% of the population consumed less than the Estimated Average Requirement of riboflavin.


title: Riboflavin

text: Riboflavin deficiency (also called ariboflavinosis) results in stomatitis, symptoms of which include chapped and fissured lips, inflammation of the corners of the mouth (angular stomatitis), sore throat, painful red tongue, and hair loss. The eyes can become itchy, watery, bloodshot, and sensitive to light. Riboflavin deficiency is associated with anemia. Prolonged riboflavin insufficiency may cause degeneration of the liver and nervous system. Riboflavin deficiency may increase the risk of preeclampsia in pregnant women. Deficiency of riboflavin during pregnancy can result in fetal birth defects, including heart and limb deformities.


title: Riboflavin

text: People at risk of having low riboflavin levels include alcoholics, vegetarian athletes, and practitioners of veganism. Pregnant or lactating women and their infants may also be at risk, if the mother avoids meat and dairy products. Anorexia and lactose intolerance increase the risk of riboflavin deficiency. People with physically demanding lives, such as athletes and laborers, may require higher riboflavin intake. The conversion of riboflavin into FAD and FMN is impaired in people with hypothyroidism, adrenal insufficiency, and riboflavin transporter deficiency.


title: Riboflavin

text: Riboflavin deficiency is usually found together with other nutrient deficiencies, particularly of other water-soluble vitamins. A deficiency of riboflavin can be primary (i.e. caused by poor vitamin sources in the regular diet) or secondary, which may be a result of conditions that affect absorption in the intestine. Secondary deficiencies are typically caused by the body not being able to use the vitamin, or by an increased rate of excretion of the vitamin. Diet patterns that increase risk of deficiency include veganism and low-dairy vegetarianism. Diseases such as cancer, heart disease and diabetes may cause or exacerbate riboflavin deficiency.


title: Riboflavin

text: There are rare genetic defects that compromise riboflavin absorption, transport, metabolism or use by flavoproteins. One of these is riboflavin transporter deficiency, previously known as Brown-Vialetto-Van Laere syndrome. Variants of the genes SLC52A2 and SLC52A3 which code for transporter proteins RDVT2 and RDVT3, respectively, are defective. Infants and young children present with muscle weakness, cranial nerve deficits including hearing loss, sensory symptoms including sensory ataxia, feeding difficulties, and respiratory distress caused by a sensorimotor axonal neuropathy and cranial nerve pathology. When untreated, infants with riboflavin transporter deficiency have labored breathing and are at risk of dying in the first decade of life. Treatment with oral supplementation of high amounts of riboflavin is lifesaving.


title: Riboflavin

text: Other inborn errors of metabolism include riboflavin-responsive multiple acyl-CoA dehydrogenase deficiency, also known as a subset of glutaric acidemia type 2, and the C677T variant of the methylenetetrahydrofolate reductase enzyme, which in adults has been associated with risk of high blood pressure.


title: Riboflavin

text: The assessment of riboflavin status is essential for confirming cases with non-specific symptoms whenever deficiency is suspected. Total riboflavin excretion in healthy adults with normal riboflavin intake is about 120 micrograms per day, while excretion of less than 40 micrograms per day indicates deficiency. Riboflavin excretion rates decrease as a person ages, but increase during periods of chronic stress and the use of some prescription drugs.


title: Riboflavin

text: Indicators used in humans are erythrocyte glutathione reductase (EGR), erythrocyte flavin concentration and urinary excretion. The "erythrocyte glutathione reductase activity coefficient" (EGRAC) provides a measure of tissue saturation and long-term riboflavin status. Results are expressed as an activity coefficient ratio, determined by enzyme activity with and without the addition of FAD to the culture medium. An EGRAC of 1.0 to 1.2 indicates that adequate amounts of riboflavin are present; 1.2 to 1.4 is considered low, greater than 1.4 indicates deficient. For the less sensitive "erythrocyte flavin method", values greater than 400 nmol/L are considered adequate and values below 270 nmol/L are considered deficient. Urinary excretion is expressed as nmol of riboflavin per gram of creatinine. Low is defined as in the range of 50 to 72 nmol/g. Deficient is below 50 nmol/g. Urinary excretion load tests have been used to determine dietary requirements. For adult men, as oral doses were increased from 0.5 mg to 1.1 mg, there was a modest linear increase in urinary riboflavin, reaching 100 micrograms for a subsequent 24-hour urine collection. Beyond a load dose of 1.1 mg, urinary excretion increased rapidly, so that with a dose of 2.5 mg, urinary output was 800 micrograms for a 24-hour urine collection.


title: Riboflavin

text: The name "riboflavin" comes from "ribose" (the sugar whose reduced form, ribitol, forms part of its structure) and "flavin", the ring-moiety which imparts the yellow color to the oxidized molecule (from Latin "flavus", "yellow"). The reduced form, which occurs in metabolism along with the oxidized form, appears as orange-yellow needles or crystals. The earliest reported identification, predating any concept of vitamins as essential nutrients, was by Alexander Wynter Blyth. In 1879, Blyth isolated a water-soluble component of cows' milk whey, which he named "lactochrome", that fluoresced yellow-green when exposed to light.


title: Riboflavin

text: In the early 1900s, several research laboratories were investigating constituents of foods, essential to maintain growth in rats. These constituents were initially divided into fat-soluble "vitamine" A and water-soluble "vitamine" B. (The "e" was dropped in 1920.) Vitamin B was further thought to have two components, a heat-labile substance called B and a heat-stable substance called B. Vitamin B was tentatively identified to be the factor necessary for preventing pellagra, but that was later confirmed to be due to niacin (vitamin B) deficiency. The confusion was due to the fact that riboflavin (B) deficiency causes stomatitis symptoms similar to those seen in pellagra, but without the widespread peripheral skin lesions. For this reason, early in the history of identifying riboflavin deficiency in humans the condition was sometimes called "pellagra sine pellagra" (pellagra without pellagra).


title: Riboflavin

text: In 1935, Paul Gyorgy, in collaboration with chemist Richard Kuhn and physician T. Wagner-Jauregg, reported that rats kept on a B-free diet were unable to gain weight. Isolation of B from yeast revealed the presence of a bright yellow-green fluorescent product that restored normal growth when fed to rats. The growth restored was directly proportional to the intensity of the fluorescence. This observation enabled the researchers to develop a rapid chemical bioassay in 1933, and then isolate the factor from egg white, calling it ovoflavin. The same group then isolated the a similar preparation from whey and called it lactoflavin. In 1934, Kuhn's group identified the chemical structure of these flavins as identical, settled on "riboflavin" as a name, and were also able to synthesize the vitamin.


title: Riboflavin

text: Circa 1937, riboflavin was also referred to as "Vitamin G". In 1938, Richard Kuhn was awarded the Nobel Prize in Chemistry for his work on vitamins, which had included B and B. In 1939, it was confirmed that riboflavin is essential for human health through a clinical trial conducted by William H. Sebrell and Roy E. Butler. Women fed a diet low in riboflavin developed stomatitis and other signs of deficiency, which were reversed when treated with synthetic riboflavin. The symptoms returned when the supplements were stopped.


title: Rashtrapati Bhavan

text: The Rashtrapati Bhavan (, rāsh-truh-puh-ti bha-vun; ; originally Viceroy's House and later Government House) is the official residence of the President of India at the western end of Rajpath, Raisina Hill, New Delhi, India. Rashtrapati Bhavan may refer to only the 340-room main building that has the president's official residence, including reception halls, guest rooms and offices, also called the mansion; it may also refer to the entire 130-hectare (320-acre) Presidential Estate that additionally includes the presidential gardens, large open spaces, residences of bodyguards and staff, stables, other offices and utilities within its perimeter walls. In terms of area, it is the largest residence of any head of state in India. The other presidential homes are the Rashtrapati Nilayam in Hyderabad, Telangana and The Retreat Building in Shimla, Himachal Pradesh.


title: Rashtrapati Bhavan

text: The Governor-General of Fort William resided in Belvedere House, Calcutta, until the early nineteenth century, when Government House, Calcutta (now Raj Bhavan, Kolkata) was constructed. Lord Wellesley, who is reputed to have said that ‘India should be governed from a palace, not from a country house’, ordered the construction of a grand mansion between 1799 and 1803 and in 1854, the Lieutenant Governor of Bengal took up residence there. The decision to build a residence in New Delhi for the British Viceroy was taken after it was decided during the Delhi Durbar in December 1911 that the capital of India would be relocated from Calcutta to Delhi. When the plan for a new city, New Delhi, adjacent to the end south of Old Delhi, was developed after the Delhi Durbar, the new palace for the Viceroy of India was given an enormous size and prominent position. About of land was acquired to begin the construction of Viceroy's House, as it was originally called, and adjacent Secretariat Building between 1911 and 1916 by relocating Raisina and Malcha villages that existed there and their 300 families under the Land Acquisition Act, 1894.


title: Rashtrapati Bhavan

text: The British architect Edwin Landseer Lutyens, a major member of the city-planning process, was given the primary architectural responsibility. The completed Governor-General's palace turned out very similar to the original sketches which Lutyens sent Herbert Baker, from Simla, on 14 June 1912. Lutyens' design is grandly classical overall, with colours and details inspired by Indian architecture. Lutyens and Baker, who had been assigned to work on Viceroy's House and the Secretariats, began on friendly terms. Baker had been assigned to work on the two secretariat buildings which were in front of the Viceroy's House. The original plan was to have Viceroy's House on the top of Raisina Hill, with the secretariats lower down. It was later decided to build it 400 yards back and put both buildings on top of the plateau.


title: Rashtrapati Bhavan

text: Lutyens campaigned for its fixing but was not able to get it to be changed. Lutyens wanted to make a long inclined grade to Viceroy's House with retaining walls on either side. While this would give a view of the house from further back, it would also cut through the square between the secretariat buildings. The committee with Lutyens and Baker established in January 1914 said the grade was to be no steeper than 1 in 25, though it eventually was changed to 1 in 22, a steeper gradient which made it more difficult to see the Viceroy's palace. While Lutyens knew about the gradient and the possibility that the Viceroy's palace would be obscured by the road, it is thought that Lutyens did not fully realise how little the front of the house would be visible. In 1916 the Imperial Delhi committee dismissed Lutyens's proposal to alter the gradient. Lutyens thought Baker was more concerned with making money and pleasing the government, rather than making a good architectural design.


title: Rashtrapati Bhavan

text: Lutyens travelled between India and England almost every year for twenty years and worked on the construction of the Viceroy's House in both countries. Lutyens reduced the building from to because of the budget restrictions of hashirama senju , 1st Hokage]].


title: Rashtrapati Bhavan

text: The gardens were initially designed and laid out in Mughal style by William Robert Mustoe who was influenced by Lady Hardinge who in turn had sought inspiration in the book by Constance Villiers-Stuart in her "Gardens of the Great Mughals" (1913). The designs underwent changes and alterations under subsequent viceroys and after Indian Independence. After independence, it was renamed as Government House.


title: Rashtrapati Bhavan

text: When Chakravarti Rajagopalachari assumed office as the first Indian-born Governor General of India and became the occupant of this palace, he preferred to stay in a few rooms in the former Guest Wing, which is now the family wing of the President; he converted the then Viceroy's apartments into the Guest Wing, where visiting heads of state stay while in India.


title: Rashtrapati Bhavan

text: On 26 January 1950, when Rajendra Prasad became the first President of India and occupied this building, it was renamed Rashtrapati Bhavan – the President's House.


title: Rashtrapati Bhavan

text: Consisting of four floors and 340 rooms, with a floor area of , it was built using 1 billion bricks and of stone with little steel.


title: Rashtrapati Bhavan

text: The design of the building fell into the period of the Edwardian Baroque, a time at which emphasis was placed on the use of heavy classical motifs to emphasise power and imperial authority. The design process of the mansion was long, complicated and politically charged. Lutyens' early designs were all starkly classical and entirely European in style. His disrespect for the local building tradition he dismissed as primitive is evident in his numerous sketches with appended scrawls such as 'Moghul tosh' and his short remark that 'they want me to do Hindu – "Hindodon't" I say!' In the post-Mutiny era, however, it was decided that sensitivity must be shown to the local surroundings to better integrate the building within its political context, and after much political debate, Lutyens conceded to incorporating local Indo-Saracenic motifs, albeit in a rather superficial decoration form on the skin of the building.


title: Rashtrapati Bhavan

text: Various Indian elements were added to the building. These included several circular stone basins on top of the building, as water features are an important part of Indian architecture. There was also a traditional Indian chujja or chhajja, which occupied the place of a frieze in classical architecture; it was a sharp, thin, protruding element which extended from the building, and created deep shadows. It blocks harsh sunlight from the windows and also shields the windows from heavy rain during the monsoon season. On the roofline were several chuttris, which helped to break up the flatness of the roofline not covered by the dome. Lutyens appropriated some Indian design elements but used them sparingly and effectively throughout the building.


title: Rashtrapati Bhavan

text: The column has a "distinctly peculiar crown on top, a glass star springing out of bronze lotus blossom".


title: Rashtrapati Bhavan

text: There were pierced screens in red sandstone, called jalis or jaalis, inspired by Rajasthani designs. The front of the palace, on the east side, has twelve unevenly spaced massive columns with the Delhi Order capitals, a "nonce order" Lutyens invented for this building, with Ashokan details. The capitals have a fusion of acanthus leaves with the four pendant Indian bells. The bells are similar in style to Indian Hindu and Buddhist temples, the idea is inspired by a Jain temple at Moodabidri in Karnataka. One bell is on each corner at the top of the column. As there is an ancient Indian belief that bells signalled the end of a dynasty, it was said that as the bells were silent British rule in India would not end. The front of the building does not have windows, except in the wings at the sides.


title: Rashtrapati Bhavan

text: Whereas previous British examples of so-called Indo-Saracenic Revival architecture had mostly grafted elements from Mughal architecture onto essentially Western carcasses, Lutyens drew also from the much earlier Buddhist Mauryan art. This can be seen in the Dehli Order, and in the main dome, where the drum below has decoration recalling the railings around early Buddhist stupas such as Sanchi. There is also the presence of Mughal and European colonial architectural elements. Overall the structure is distinctly different from other contemporary British Colonial symbols, although other New Delhi buildings, such as the Secretariat Building, New Delhi, mainly by Herbert Baker, have similarities.


title: Rashtrapati Bhavan

text: Lutyens added several small personal elements to the house, such as an area in the garden walls and two ventilator windows on the stateroom to look like the glasses which he wore. The Viceregal Lodge was completed largely by 1929, and (along with the rest of New Delhi) inaugurated officially in 1931. The building took seventeen years to complete and eighteen years later India became independent. After Indian independence in 1947, the now ceremonial Governor-General continued to live there, being succeeded by the President in 1950 when India became a republic and the house was renamed "Rashtrapati Bhavan".


title: Rashtrapati Bhavan

text: It has 355 decorated rooms and a floor area of 200,000 square feet (19,000 m). The structure includes 700 million bricks and 3.5 million cubic feet (85,000 m³) of stone, with only minimal usage of steel. Lutyens established ateliers in Delhi and Lahore to employ local craftsmen. The chief engineer of the project was Sir Teja Singh Malik, and four main contractors included Sir Sobha Singh.


title: Rashtrapati Bhavan

text: The layout plan of the building is designed around a massive square with multiple courtyards and open inner areas within. The plan called for two wings; one for the Viceroy and residents and another for guests. The residence wing is a separate four-storey house in itself, with its court areas within. This wing was so large that the last Indian governor-general, Chakravarti Rajagopalachari, opted to live in the smaller guest wing, a tradition followed by subsequent presidents. The original residence wing is now used primarily for state receptions and as a guest wing for visiting heads of state.


title: Rashtrapati Bhavan

text: Rashtrapati Bhavan has many halls which are used for state functions and other purposes. Two of them, Durbar Hall and Ashoka Hall, are the most prominent.


title: Rashtrapati Bhavan

text: "Durbar Hall" is situated directly under the double-dome of the main building. Known as the "Throne Room" before independence, it had two separate thrones for the Viceroy and Vicereine. Presently, a single high chair for the President is kept here under a Belgian glass chandelier hanging from a height of 33 m. The flooring of the hall is made of chocolate-coloured Italian marble. The columns in Durbar Hall are made in Delhi Order which combines vertical lines with the motif of a bell. The vertical lines from the column were also used in the frieze around the room, which could not have been done with one of the traditional Greek orders of columns. The columns are made from yellow Jaisalmer marble, with a thick line running along the centre.


title: Rashtrapati Bhavan

text: Durbar Hall has a capacity of 500 people and it is here in this building that Jawaharlal Nehru took the oath of office of Prime Minister from Lord Mountbatten at 8.30 am on 15 August 1947.


title: Rashtrapati Bhavan

text: Ashoka Hall is a rectangular room of 32×20 m. It was originally built as a state ballroom with wooden flooring. The Persian painting on its ceiling depicts a royal hunting expedition led by King Fateh Ali Shah of Persia. The walls have fresco paintings.


title: Rashtrapati Bhavan

text: The two-state drawing rooms, the state supper room and the state library are each on the four corners of Durbar Hall. There are also other rooms such as many loggias (galleries with open air on one side) that face out into the courtyards, a large dining hall with an extremely long table to seat 104 persons, sitting rooms, billiards rooms and staircases.


title: Rashtrapati Bhavan

text: The dome, in the middle, reflects both Indian and British styles. In the centre is a tall copper-faced dome, surmounting a very tall drum in several sections, which stands out from the rest of the building. The dome is exactly in the middle of the diagonals between the four corners of the building. It is more than twice the height of the building itself.


title: Rashtrapati Bhavan

text: The height of the dome was increased by Lord Hardinge in the plan of the building in 1913. The dome combines classical and Indian styles. Lutyens said the design evolved from that of the Pantheon in Rome, although externally it has little resemblance to that, either in the curve of the dome or the high drum; both have an oculus in the centre. The exterior of the dome was modelled partly after the early Buddhist stupas, such as that at Sanchi, which it resembles far more in the exterior profile. There is a Buddhist-style "railing" design around the section of the drum below the dome. It is supported by evenly spaced columns which form a porch with an open area between. In the New Delhi summer heat haze, this gives an impression of the dome being afloat. Workers began to form the reinforced concrete shell of the outer dome at the beginning of 1929. The last stone of the dome was laid on 6 April 1929.