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.
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.
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.
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.
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.
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.
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.
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.
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.
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 treatmentExternal 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.
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/ELDIf 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.
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.
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.
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.