Subarachnoid hemorrhage SAH

Admission to the hospital

It is vital that you receive emergency medical treatment after a subarachnoid hemorrhage and that you are taken as soon as possible to a hospital that can treat the aneurysm. You can die or suffer severe damage as a result of this condition. The risk of a new hemorrhage is high. Once we have found the aneurysm that has caused the hemorrhage, we will try to treat the aneurysm as soon as possible. The buildup of cerebrospinal fluid can also form a life-threatening problem. In that case, a drain will be inserted in the ventricle so that the fluid can drain off. The first weeks after the hemorrhage can be unpredictable as complications regularly occur, such as blood flow problems in the brain, metabolic disruption or infections.

• Examination and diagnosis

  If you are admitted to the hospital, because we think that you have suffered a cerebral hemorrhage, then we will first perform a CT scan (Computer Tomography) of the brain. X-rays are used to produce a cross-section of your head. This allows us to see what type of brain hemorrhage you have had. The blood vessels can be imaged clearly in a CT scan if we inject a contrast agent via the vein in your arm (CT angiogram). This allows us to detect an AVM.
  If there is no hemorrhage visible on the CT scan, then we will perform a lumbar puncture 24 hours after the symptoms started. Cerebrospinal fluid will be collected via this lumbar puncture. We can look for signs of a subarachnoid hemorrhage in the cerebrospinal fluid.

• Intensive Care or Medium Care

  You will be admitted to the Intensive Care Unit or the Medium Care Unit if close monitoring and support of your vital bodily functions is required. Examples include ventilation, blood pressure support, observation of the pressure in your head or your heart rhythm. You will be transferred to a nursing ward once your situation allows for this and you no longer require continuous monitoring or support of your bodily functions.

• Nursing ward

  You will be admitted to the nursing ward if your situation allows for this. You will generally be given a private room. In addition to the regular monitoring of your bodily functions, we will try to give you the rest and safety that you need. As your situation stabilizes, the treatment team on the nursing ward will determine which problems still exist after the hemorrhage and will discuss with you and your loved ones how and where you can best recover from the hemorrhage. 
  
  You will be cared for and monitored by a specially trained nurse. In addition to the monitoring and care, the nurse will also be responsible for the coordination of your care.
  
  A doctor is available 24 hours per day for the medical treatment, under the supervision of a medical specialist from the department. The medical specialist and the doctor on the ward will be in contact on a daily basis about your treatment and the plan of action. The attending physician will visit you during his/her ward rounds every morning and will discuss with you and the nurse how your treatment is progressing. You will be given results of examinations during these visits. If new examinations have been scheduled, then the nurse will give you verbal and written information. If necessary, an additional meeting can be scheduled with the doctor.

• Treatment team

  The consequences of the SAH can vary. You may be paralyzed on one side of the body, have difficulty swallowing and speaking or have problems relating to your ability to think (cognitive impairment). Therefore, you will meet therapists from different departments who can quantify and treat the effects of the SAH on your general functioning.
  The treatment team consists of various professionals. They discuss cases with each other. We try to ensure that you will be guided by the same people as much as possible during the admission.
  
  The treatment team consists of:

  • Treating neurosurgeon/neuro-intervention specialist: doctor who will perform the treatment.
  • Ward doctor (resident): present in the ICU, MCU or nursing ward from Monday to Friday from 9:00 am to 5:00 pm. He or she is responsible for the implementation and continuity of the daily medical care. A doctor is available on the nursing ward 24 hours per day.
  • Intensive care specialist: the doctor treating you in the Intensive Care Unit. This doctor is present 24 hours per day.
  • Nurse: is responsible for the coordination of your care, observing you, helping you with daily self-care, administering medication and performing procedures as instructed by the doctor.
  • Nurse practitioner: Some treatment centers have a nurse practitioner available for your patient group. A nurse practitioner is allowed to carry out medical procedures independently within his or her specialization. He or she usually ensures the continuity of care and the follow-up care.
  • Rehabilitation doctor: coordinates the care offered by fellow treating therapists such as speech therapy, physical therapy and occupational therapy and gives advice about your recovery.
  • Physical therapist: treats problems relating to movement, breathing, coughing or to help you rebuild your stamina.
  • Speech therapist: treats problems with swallowing or speech. You will also be treated by the speech therapist if you have a breathing tube (tracheal cannula).
  • Occupational therapist: identifies problems in daily functioning and can provide aids if necessary (e.g. a wheelchair).
  • Dietician: offers advice for problems with eating or the nutritional status.
  • Social worker: offers support for social problems, such as problems that occur when someone becomes mentally incompetent or the possible financial consequences of the condition.
  • Pastoral caregiver: can support you and your loved ones if you have questions regarding the meaning of life.
  • Care Transfer Point: arranges home nursing care, aids or a stay in a nursing home after the hospital admission.

• Safety

  A subarachnoid hemorrhage can leave you feeling confused and agitated, which can result in unsafe situations. Sometimes it is necessary to use soft restraints on the wrists, ankles and waist to guarantee your safety and that of others. People generally find these measures unpleasant. If these measures are necessary, we will discuss this with your contact person.

• Medication

  All patients receive a standard number of medications following a subarachnoid hemorrhage, such as painkillers, medication to improve blood flow to the brain tissue and medication to promote regular bowel movements. Home medication such as anticoagulants and blood pressure medication are usually stopped. You can continue to use other medication as normal.

• Cerebrospinal fluid drainage

  The brain and the spinal cord are surrounded by cerebrospinal fluid (liquor). The cerebrospinal fluid has various important functions, namely:

  • Protecting the brain. The brain is surrounded by the cerebrospinal fluid and therefore cannot touch the skull. The cerebrospinal fluid also protects us against poisonous substances in the blood.
  • Passing on information from the brain to other cells in our body.

  Cerebrospinal fluid looks like water and is produced in the cavities in the brain. These cavities are called the “ventricles”. There are two lateral ventricles, a third ventricle in the middle of the brain and a fourth ventricle at the base of the cerebellum. Cerebrospinal fluid is continuously being produced and absorbed. On average, the cerebrospinal fluid is completely refreshed three to four times per day.

  Why insert a drain?

  If there is a problem with the circulation of the cerebrospinal fluid, then the fluid can accumulate in the brain. An accumulation of cerebrospinal fluid causes increased pressure in the brain. This can disrupt the functioning of the brain and cause brain damage. When cerebrospinal fluid accumulates in the brain, we need to do something to limit the damage as much as possible.

  The treatment

  External ventricle drain
  An external ventricle drain (EVD) is a thin tube (drain) that is inserted surgically in the ventricle via your skull. During the surgery, the neurosurgeon makes a small incision in your skin. The neurosurgeon will make a hole measuring approximately 1 cm in diameter in the skull. A section of the drain tube is then inserted in the ventricle. The skin is then closed, and the drain tube is fixed in position by means of a suture or a plaster. The collection system for the drain will be attached to your bed and you will be on bed rest. The doctor will determine the level at which the collection system will be attached.
  Ventriculo-Peritoneal drain (VP-drain)
  If the absorption of cerebrospinal fluid is a problem for a longer period, then a Ventriculo-Peritoneal drain (VP-drain) is an option. This drain helps to remove the cerebrospinal fluid. The drain is a tube that the doctor inserts in the ventricle. The drain runs internally to your abdomen, where it is coiled up. The drain has a pressure relief valve. This valve is located under the scalp and can be felt above the right ear. It ensures that cerebrospinal fluid is removed via the drain to the abdomen if the pressure in the head becomes too high. The draining of cerebrospinal fluid will stop once the pressure in your head returns to normal. Surgery is required to insert this drain. It is a fairly simple procedure. The doctor will drill a hole on the right side of the skull. The doctor will insert the drain into the ventricle via this hole and push the tube under the skin towards the abdominal cavity. The operation will take approximately one hour.
  Complications
  There is a risk of complications with any surgical procedure. The most common complication with a VP drain is an infection, or the inadequate functioning of the drain. The neurosurgeon will discuss the potential complications of this surgery with you.
  External lumbar drain
  If the fluid accumulation causes problems several days after the hemorrhage, then an external lumbar drain (ELD) will be considered. An ELD is a thin tube (drain) that is inserted through your skin in the lowest part of your back. The drain will be inserted via a thin needle. You will have to assume a special position with your back rounded as far as possible (lying down or seated) for the needle to be inserted. This position makes the space between the vertebrae as big as possible. The doctor and nurse will guide and support you into this position. The collection system for the drain will be attached to your bed and you will be on bed rest. The doctor will determine the level at which the collection system will be attached.

  Drain challenge closure of the EVD/ELD

  If you have an EVD/ELD, at some point it will be possible to remove the EVD/ELD. The EVD/ELD will first be sealed for 24 hours to test whether your body can cope with this. This is called the drain challenge. Your level of consciousness and your vital signs — such as breathing, heart rate, temperature and blood pressure — will be checked every two hours during these 24 hours.
  
  Pressure measurement
  If your level of consciousness and vital signs remain good, then a pressure measurement will be performed the next morning. During the pressure measurement, the pressure in your brain will be measured to check whether your body is draining the cerebrospinal fluid correctly on its own. If this measurement is good, then your treating physician will be consulted to determine whether the EVD/ELD can be removed.
  
  Increasing intracranial pressure
  Your intracranial pressure may increase during the 24 hours that the EVD/ELD is sealed off. This can cause you to become drowsy, suffer more headaches and become nauseous. If your intracranial pressure increases, then your treating physician will be consulted to determine whether the EVD/ELD needs to be opened again.