A subarachnoid hemorrhage (SAH) occurs very suddenly, without any form of warning. This hemorrhage derives its name from the location in the head: just above the brain, under the arachnoid mater. An AVM in this subarachnoid space can result in a SAH. You will be admitted urgently for the treatment of the consequences of the hemorrhage.
The blood that collects in the arachnoid mater around the brain can spread to the ventricles of the brain.
Symptoms include: acute severe headache, nausea, vomiting, neurological loss of function, stiff neck, epilepsy and reduced consciousness or loss of consciousness.
The risk of a new hemorrhage is greatest in the first hours after a subarachnoid hemorrhage. If the AVM is not treated, then this risk remains elevated in the first weeks after the hemorrhage. A new hemorrhage results in acute deterioration, non-responsive or unequal pupils or reduced consciousness.
Problems relating to the blood flow to the brain tissue can develop between three and 14 days after a subarachnoid hemorrhage. This is also referred to as Delayed Cerebral Ischemia (DCI), or “Delayed cerebral infarction”. It is not entirely clear why this happens. Doctors think that DCI is caused by an inflammatory response in the brain to the presence of the blood. The capillaries in a part (or parts) of the brain receive less or no blood flow. The symptoms vary greatly. They can include loss of certain neurological functions, decreased consciousness or confusion. This can recover spontaneously. If this persists for a long time, it can cause irreversible damage or even death as a result of a part of the brain being starved of oxygen for too long. A cerebral infarction has developed.
Following a subarachnoid hemorrhage, you will always receive medication to prevent a DCI (Nimotop). This does not always work sufficiently. If a DCI does occur, you will be admitted to the Intensive Care Unit or Medium Care Unit where your blood pressure will be increased by extra fluid administration. If this does not produce an adequate effect, then your blood pressure will be increased further by means of medication via an infusion. This will require an IV line in a large blood vessel.
Another cause of ischemia is a clot or calcification that dislodges during the treatment. This can also cause a cerebral infarction. In addition, the large cerebral arteries may contract (vascular spasm) during the treatment or in response to the hemorrhage, resulting in reduced blood flow to the brain and subsequent cerebral infarction.
Hydrocephalus is the accumulation of cerebrospinal fluid in the ventricles, also called water on the brain. Hydrocephalus can develop suddenly if the hemorrhage blocks the passage between ventricles and the cerebrospinal fluid can no longer be drained. It can also develop gradually if the relatively large blood cells block the drainage of the watery cerebrospinal fluid. It is like a kitchen or bathroom drain that becomes blocked, causing the pressure in the brain to increase. The high pressure in the brain causes the patient to become increasingly drowsy, can cause the eyes to become fixed in a downward position or can result in constricted and non-responsive pupils. The patient often suffers from increased headache, nausea and vomiting.
The treatment of hydrocephalus consists of inserting a drain from the ventricles of the brain to the outside (External Ventricle Drain or EVD). If hydrocephalus develops gradually at a later stage, then the intracranial pressure can be measured via a lumbar puncture and the doctor can allow the fluid to drain off to reduce the pressure. The doctor can also leave a drain in place so that fluid can continue to drain off (External Lumbar Drain or ELD). Hydrocephalus is also visible on a CT scan, the ventricles look “bloated”.
Drainage of the cerebrospinal fluid is required in that case. You can read more about this under the heading cerebrospinal fluid drainage.
The brain and spinal cord are surrounded by cerebrospinal fluid (liquor). Cerebrospinal fluid has several important functions, specifically:
- Protection of the brain. The brain is surrounded by the cerebrospinal fluid and can therefore not come into contact with the skull. The cerebrospinal fluid also protects us against the absorption of toxic substances into the blood.
- Passing information from the brain to other cells in our body.
Why a shunt?If the circulation of the cerebrospinal fluid does not run smoothly, the fluid will accumulate in the brain. Accumulation of cerebrospinal fluid increases the pressure in the brain. This can disrupt the function of the brain and damage it. When cerebrospinal fluid accumulates, we have to do something to limit the damage as much as possible.
An external ventricular drain (EVD) is a thin tube (drain) that is surgically placed through your skull into the ventricle. During surgery, the doctor makes a small incision in the skin. An incision is made in the cranium with a diameter of about 1 cm. A piece of the drainage tube is then inserted into the ventricle of the brain. After that, the skin is closed and the drainage tube is secured by means of a suture or bandage.
The collection system of the drain hose is attached to your bed, which means you must remain in bed. The doctor determines where the collection system will be attached.
Ventriculoperitoneal shunt (VP shunt)
If the absorption of the cerebrospinal fluid is a long-term problem, a ventriculoperitoneal shunt (VP shunt) is an option. This shunt helps drain the cerebrospinal fluid. The shunt is a tube that the doctor inserts into the ventricle of the brain. From here the shunt runs internally to your abdomen. The shunt has a pressure control valve. This valve is located under the scalp and can be felt above the right ear. It ensures that cerebrospinal fluid is discharged to the abdomen via the shunt if the pressure in the head becomes too high. When the pressure in your head has returned to normal, the drainage of cerebrospinal fluid stops. The placement of this shunt is done during an operation. It is a fairly simple procedure. The doctor drills a hole into the right side of the skull. Through this hole the doctor inserts the shunt into the cerebral chamber and passes it subcutaneously through to the abdominal cavity. The operation takes about an hour.
ComplicationsExternal lumbar drain
There is a risk of complication with every surgical procedure. The most common complication with a VP shunt is an infection, or insufficient function of the shunt. The doctor will discuss the possible complications of this operation with you.
If the accumulation of fluid causes problems a few days after the bleeding, an external lumbar drain (ELD) will be considered. An ELD is a thin tube (drain) that is placed through your skin in the lower part of your back. The drain is placed by making a puncture with a thin needle. During the puncture, you must move into a special position, lying or sitting, in which your back is as curved as possible. This is to make the space between the vertebrae as large as possible. The doctor and nurse will accompany and support you in taking this position. The collection system of the drain tube is attached to your bed, so you have to remain in bed. The doctor determines where the collection system will be attached.
Drain challenge closure of the EVD/ELDIf you have an EVD/ELD, there will come a time when the EVD/ELD can be removed. To test if your body can handle this, the EVD/ELD is closed for 24 hours. This is what we call the drain challenge. In these 24 hours, your consciousness and your vital functions, such as your breathing, pulse rate, temperature, and blood pressure are checked every 2 hours.
If your consciousness and your vital functions remain good, a pressure measurement will be taken the next morning. During the pressure measurement, your brain pressure is measured to assess whether your body is draining the fluid (liquor) in the correct way. If this measurement is good, a decision will be made, in consultation with your attending physician, as to whether the EVD/ELD can be removed.
Increasing brain pressure
During the 24 hours that the EVD/ELD is closed, brain pressure may increase. This makes you woozy, causes more headaches, and can make you nauseous. If your brain pressure increases, the EVD/ELD will be reopened in consultation with your attending physician
A subarachnoid hemorrhage can result in temporary disruption of various metabolic processes. Abnormal potassium, sodium, magnesium or glucose concentrations in the blood are common. Excessive amounts of urine are sometimes produced, or extra electrolytes are excreted via the urine. We will check the electrolyte concentrations in your blood on a daily basis and administer extra electrolytes or extra fluids if necessary.
Delirium is common following a cerebral hemorrhage. It is a state of confusion accompanied by hallucinations or non-realistic thoughts, often with agitation and anxiety, but sometimes the patient becomes apathetic and quiet. Symptoms that are characteristic of delirium are varying levels of consciousness and worsening of the symptoms during the evening and night. Delirium after a cerebral hemorrhage can be caused by the bleeding, an infection or a disruption of the metabolism.
If the cerebrospinal fluid is drained via an external drain, then there is a risk of bacterial meningitis. A urinary catheter can also quickly result in urinary tract infections and prolonged periods in bed on a ventilator can increase the risk of developing a lung infection. A prolonged hospital admission weakens a person’s immune system and increases the risk of an infection. If there are signs of an infection, for example fever or increased infection parameters in the blood, then cultures will be collected to determine the cause of the infection and to identify the bacteria, so that we can treat you with the correct antibiotics. This will take place in consultation with the medical microbiologist.
Fever after a SAH is also common without a bacterial cause. This happens because the brain’s ability to regulate body temperature is disrupted.
Various cardiac arrhythmias (heart rhythm abnormalities) can occur after a subarachnoid hemorrhage, these usually recover spontaneously. In a small number of cases, the subarachnoid hemorrhage was the cause of the cardiac arrest for which the patient was initially taken to the Emergency Department. In some cases, partial paralysis of the heart muscle can occur, called Tsako-tsubo syndrome. This usually repairs itself within several weeks.
A heart that is already struggling to maintain full pumping function can struggle to process the extra fluids that are administered after a subarachnoid hemorrhage. This can result in heart failure. This heart failure or the hemorrhage itself can cause fluid to accumulate in the lungs, making it more difficult to breathe or to come off the ventilator.
Lying still in bed can cause thrombosis (a blood clot). This blood clot can detach and travel to the lungs. This will cause an acute deterioration and shortness of breath.
In order to prevent the problems described above during bed rest, the following precautions will be taken: compression stockings, cycling in bed, mobilization in bed or sitting in the chair as soon as possible.
Discharge from the hospital
The medical-technical treatment by the neurosurgeon will gradually decrease during the time spent on the nursing ward. The focus of your admission will switch to rehabilitation.
During your recovery, you will be given advice from your treatment team about where you can recover after the hospital admission.
Discharge to homeIf you are able to perform daily tasks independently and safely, then you can be discharged to home. Your family or relatives can collect you at the agreed time. If you require further therapy at home, then you will be referred to — for example — a physical therapy or occupational therapy practice. If you require care at home, the nurse will complete an application for home nursing care. An expert from the Centrum Indicatiestelling Zorg (CIZ) [Healthcare Indication Center] will give you advice about the care that you require at home.
You may notice after some time that you continue to experience problems with fatigue, processing of stimuli, concentration or memory. This will be discussed during the follow-up appointments and if necessary you will be referred to a rehabilitation center for day treatment.
Rehabilitation in a rehabilitation centerFor you to receive rehabilitation treatment in a rehabilitation center (Specialized Medical Rehabilitation), you must have the capacity to undergo the treatment and there must be a prospect of future discharge to the home situation. If you are selected for this form of rehabilitation, then the rehabilitation physician will enroll you. After completing the neurosurgical treatment, you may be transferred to the peripheral hospital where you were originally admitted during the waiting time for a place in the rehabilitation center.
Rehabilitation in a nursing homeIf your capacity to undergo treatment is limited to such an extent that you need to rest a lot in between treatments and you do have the prospect of being discharged to the home situation in the future, then you can opt for Geriatric Rehabilitation Care (GRC) in a nursing home. After completing the neurosurgical treatment, you may be transferred to the peripheral hospital where you were originally admitted during the waiting time for a place in the nursing home. The Care Transfer Point will support you in selecting one of the nursing homes where GRC is possible and will arrange the registration.
Rehabilitation for a longer period in a nursing homeIf you still require a lot of support during daily activities and it is not certain whether discharge to the home situation is an option for you, then a prolonged stay in a nursing home with rehabilitation is an option (indication 9b). You will have a longer period available in which you can work on your recovery and discharge to the home situation if possible. After completing the neurosurgical treatment, you may be transferred to the peripheral hospital where you were originally admitted during the waiting time for a place in the nursing home. The Care Transfer Point will support you in selecting one of the nursing homes where a stay with indication 9b is possible.
Early Intensive Neuro-rehabilitation (EIN)EIN is an intensive rehabilitation program for patients who have suffered severe brain damage and are in a state of reduced consciousness as a result. The EIN program can contribute significantly to recovering consciousness. There are only a few centers in the Netherlands where this program is available. In the southern part of the Netherlands this is available via Libranet, rehabilitation center “Het Leijpark” in Tilburg. The indication is set by the rehabilitation physicians of the institution.
Prolonged stay in a nursing home
If the care staff take over most of your personal care and you are not expected to recover to such an extent that you can be discharged to the home situation, then admission for a prolonged stay is the obvious choice. Experience teaches us that this is rare in younger patients following a cerebral hemorrhage. After completing the neurosurgical treatment, you may be transferred to the peripheral hospital where you were originally admitted during the waiting time for a place in the nursing home. The Care Transfer Point will support you in selecting one of the nursing homes where a prolonged stay is possible.
If you have been discharged and you do not require any nursing care during the journey, then your loved ones can collect you from the nursing ward.
If you are being transferred to another facility and you require nursing care during the journey, then the nurse on the ward will arrange your transport by ambulance.
The nurse will give the medical and nursing discharge papers to the EMT. Your family physician will receive a note explaining which treatment you have received.
There are no strict limitations about what you can do after being discharged from the hospital, but you will notice that you cannot resume all activities immediately without causing your symptoms to worsen.
Often the symptoms will worsen after returning home, because you will be more active and there will be more stimuli from the environment than was the case in the hospital. Even the car journey home can cause symptoms, because everything whizzes past at speed. The visits, phone calls and your own attempts to resume chores at home can also exacerbate your symptoms.
Common symptoms following excessive stimuli are:
- headache or pressure on the head
- fatigue, physical or mental
- drowsiness or difficulty falling asleep
- nausea, vomiting
- dizziness and balance problems
- hypersensitivity to activity, light or sounds
- irritable or emotional reactions to your surroundings
Tips to limit symptoms
- Increase your activities gradually. If the symptoms increase, then this is a sign that you should slow down a little.
- Create a regular and repetitive daily routine in which you alternate activity and rest. Do not let your moments of rest be dependent on your developing symptoms.
- Try to do one thing at a time. For example, switch off the radio or television in the background and put your cellphone away and only check it at set times each day.
- When you perform an activity for the first time, do this in a way that allows you to have control over the situation and stop if you want to. For example, doing the shopping or riding a bicycle. Take someone with you who can help you if it becomes too much.
- Always carry sunglasses and earplugs in your bag to use when you encounter unexpected environmental stimuli.
- Try not to do everything in one day. This is a trap that many people fall into on a good day and often results in a “harmonica effect” in which you suffer a setback in the following days.
- Schedule strenuous activities — or activities for which you need to be fit — in the morning when your energy levels are highest.
- Schedule adequate recovery time after strenuous activities. For example, ensure that you can take it easy the day after a birthday party.
- Avoid time pressure. Do not be tempted to finish a task quickly. Do not set any deadlines for yourself about when you should have recovered to perform an activity.
- Tell those around you what your limits are and explain to them that you cannot do everything the way you used to. If you find that explaining this often takes a lot of energy, you could send friends and family a message to explain this.
- Your symptoms can actually get worse if you do not exercise enough (for fear of making your symptoms worse). Try to get some gentle physical exercise on a daily basis, for example go for a walk or ride a bicycle if possible.
The mRS PROM study is a study that we are performing to improve the care for people who have suffered a subarachnoid hemorrhage (SAH). We want to do this by creating a good overview of the patient’s symptoms or problems. The improvement entails asking the patient and their loved ones to complete a questionnaire before the appointment, stating what they want to discuss with the specialist.
The study consists of three phases:
- Phase 1: we want to study how best to organize the care after a SAH by interviewing healthcare providers and patients. For example, we want to know what symptoms patients suffered, their limitations they encounter in daily life and what affects their quality of life. In addition, we will give them a number of questionnaires, so that we can discuss whether the questions are important to them and whether the questions were asked correctly.
- Phase 2: the questionnaire will be implemented in practice and the reliability of the questionnaire will be determined (for example, we will determine whether the questionnaire actually measures what we think it does).
- Phase 3: we will evaluate together with the patients and healthcare providers what the benefits — or possibly the disadvantages — of completing and discussing the questionnaire are and we will evaluate whether we can make changes or improvements.
Following a cerebral hemorrhage, it is often necessary to drain cerebrospinal fluid (liquor), which we also refer to as external liquor drainage. In the past, a patient with an external cerebrospinal fluid drain had to remain in bed in order to keep the pressure on the brain within set limits.
The LiquoGuard® is a device that is attached to the drain and ensures that the external liquor drainage is regulated and controlled. It offers you the option to get out of bed in the early stages of your recovery process.
We expect that the use of the LiquoGuard® will result in fewer complications and you should be able to leave the hospital sooner.
In order to test our expectations, we have set up a study to compare the number of complications, time in bed, etc. with and without the LiquoGuard®.
The bleeding following an aneurysm can cause brain damage. This damage is caused by a lack of oxygen in the brain and is also referred to as Delayed Cerebral Ischemia (DCI).
DCI occurs in approximately one in three people who suffer a SAH. It is one of the most important causes of permanent damage in these patients. DCI can be life-threatening and can result in the death of patients. It can also cause permanent neurological damage, such as symptoms of paralysis and problems with speech (aphasia). Patients who suffer damage due to DCI often need a long period of rehabilitation and sometimes end up in a nursing home despite their young age.
A medicine was developed in the 1980s that can prevent some cases of DCI. However, this medicine only works for a small group of patients. No significant improvements have been made in the past 30 years. It has recently been demonstrated that iron released from red blood cells during the hemorrhage plays an important role in the occurrence of brain damage. Therefore, we want to test a medicine that can remove iron and thereby prevent brain damage caused by lack of oxygen.
We hope that — as a result of this study — fewer patients will develop brain damage after a subarachnoid hemorrhage (SAH). Iron is released in the brain during the hemorrhage and this causes damage. We hope to reduce this damage using a medicine that captures this iron. The brain damage resulting from a SAH can cause death or permanent neurological loss of function. This means that patients often suffer symptoms of paralysis or problems with speech (aphasia). They often require lengthy rehabilitation and despite this, young patients are no longer able to go home and need to move to a nursing home. Many people who have suffered a SAH are also no longer able to work. We hope that the medicine that we want to test will result in less severe brain damage occurring. We also hope that this medicine can prevent damage from occurring altogether in a number of patients.