Neurosurgery - Subarachnoid Haemorrhage

Introduction

Subarachnoid haemorrhage (SAH) affects a person suddenly and usually without any warning. It is a leakage of blood over the surface of the brain from a major blood vessel.

SAH causes the sufferer to develop sudden and severe headache, which is often accompanied by nausea, vomiting, neck stiffness and sometimes collapse, seizure and loss of consciousness.

In approximately 75% of cases, this leakage occurs from a weak spot in the wall of the blood vessel that bulges outwards to form an aneurysm.

Aneurysms are a relatively common finding and occur in approximately 3% of the population.

Rupture of an aneurysm is unusual, and the risk is increased by smoking, high blood pressure and excess alcohol. Once an aneurysm has bled, there is a high risk of re-bleed in the short term and so it is important to block off the aneurysm so it cannot bleed again.

This is done either from the inside using special coils or from the outside using a surgical clip during an operation.

Diagnosis

SAH is confirmed by CT scan. The cause of the bleed is usually detected by a special type of CT scan requiring injection of contrast (dye) into a vein. In some cases, a catheter angiogram is needed.

If an aneurysm that has bled is found, then an important part of the treatment that follows is to ensure that it does not bleed again.

Non-aneurysmal SAH

In around 20% of cases of SAH, a vascular cause cannot be found. Although initial symptoms are like those of aneurysmal SAH, complications are rare, no treatment is required, and outcome is good.

This is usually an isolated event and so patients are encouraged to resume normal activity as soon as can be tolerated including returning to work.

The common symptoms of headache and fatigue may occur whilst you are recovering and so you will require a period of convalescence to recover from the bleed itself. If you smoke, you should seriously consider giving up and you should ensure your blood pressure is monitored occasionally. You can get help with both these issues from your GP.

All the recovery advice in this leaflet will apply to you.

Treatment options for aneurysm patients

At Salford Royal, the best treatment option is decided in a discussion between clinical staff (surgeon and radiologist) and this is then discussed with the patient and/or family. Based on current evidence from research trials, most aneurysms will be treated by endovascular coiling.

However, there are still several cases when open surgical treatment is the best and safer option. Any treatment method carried out on the blood vessels of the brain carries the risk of serious complications including stroke and death.

Treatment is only considered if the benefits of the treatment are greater than the risks of the treatment to the patient.

Surgical Clipping

Surgical treatment

An open micro-surgical operation on the head is performed under a general anaesthetic in the operating theatre.

During this procedure, a metal clip is placed across the neck of the aneurysm, (see diagram above), sealing the weak spot and excluding it from the circulation.

This is the traditional treatment approach, but research has shown that the same can be achieved in most cases with the non- invasive procedure of coiling.

Endovascular coiling

Endovascular treatment

During endovascular treatment, the aneurysm is packed with small platinum coils.

With the patient under general anaesthetic, a catheter is introduced at the groin into the major artery and navigated, using x-ray screening into the aneurysm.

In this way, coils can then be deposited inside the aneurysm. The aim is to pack the aneurysm with coils so that blood is then unable to enter it.

The diagram above shows this technique. Occasionally other materials other than coils may be used.

Today about three quarters of people with aneurysmal SAH will be treated by endovascular techniques.

Conservative management

Some people, however, have an aneurysm that ruptured to cause SAH, but it was left untreated.

This is usually because the risks to the patient of treatment were greater than the risk if nothing were done.

After six months, the risk of another haemorrhage from a previously ruptured but untreated aneurysm is small.

In this case, it is advisable to stop smoking, drink alcohol only in moderation and ensure that blood pressure is kept within normal limits.

Incidental aneurysms

Approximately 20% of patients have more than one aneurysm. Ruptured aneurysms pose a much greater risk than those that have not ruptured, so there is no urgency to treat an aneurysm that has not bled.

It is not always advisable to treat this kind of aneurysm. The issue will be discussed with you at your follow up appointment.

Complications in hospital

Hydrocephalus

After SAH, there is a chance that fluid around the brain can build up as the fluid pathways get blocked with the blood over the surface of the brain. The build-up of fluid can make someone very unwell. This problem can be relieved by surgically inserting a drain to take away excess fluid. The drain can be placed inside or outside of the body.

It may only be a temporary measure until the problem settles spontaneously, however, in a small number of cases, a drain on the inside of the body is needed permanently (a shunt). If this is required a general anaesthetic will be given and a fine tube is inserted into the fluid chambers of the brain. Further tubing is then attached and passed under the skin down into the cavity between stomach and intestine.

Delayed cerebral ischaemia

Cerebral ischaemia produces stroke-like symptoms. Its onset can be gradual over several days initially producing transient symptoms, which then become permanent. This happens because an area of brain tissue does not receive adequate oxygen.

This problem reaches a peak at 7 days following the SAH but would normally respond to medical management.

Recovery advice

How long will it take for me to recover?

The time it takes to recover is very variable and will be influenced by many factors. However, recovery will take a minimum of 4-6 weeks and may take many months.

On average, individuals will take at least 3 months before they feel capable of returning to their previous level of activity, including returning to work. Don’t be concerned if your recovery period appears to differ from that of others, you will recover at your own pace.

What should I be doing whilst recovering?

You are likely to feel tired for some time, and therefore you should rest whenever you feel the need to. In the first few weeks it is advisable to plan to have a rest period each day. As you begin to feel stronger you should gradually resume your previous activities, building up as you feel able. Try to avoid doing too much too soon. You will have good days and bad days.

What can others do to help?

Following discharge, practical support will be needed such as shopping and transport. Emotional support will also be needed - you must allow yourself time to regain your independent lifestyle as far as possible.

When should I return to work?

You will require a period off work. The exact amount of time will vary according to your individual rate of recovery, and the type of work that you do. However, on average, individuals will need to be off work for at least 3 months, and often longer. Some people who recover quickly, and do very well, may be ready to return to work before this time.

You should return to work when you feel physically and mentally capable of doing so, and ideally following discussion with your GP, surgeon, or specialist nurse. Regardless of the type of job, you are advised to discuss your situation with your employer and where possible you should initially start back on reduced hours and/or lighter duties, and build up, as you feel able.

Will I be able to drive?

Everybody who has a subarachnoid haemorrhage and holds a driving licence must inform the Driver Vehicle Licensing Authority (DVLA), this is a legal requirement. An example of a suitable letter can be found on page 10, or a form can be downloaded from the DVLA website. DVLA contact details can be found in the Useful links.

If you do not inform the DVLA, or continue to drive, you may find your insurance is void and you may be liable to a fine. The DVLA will ask you to complete a form, and collect information from your doctors, before deciding how long you will be suspended from driving.

Everybody will need to refrain from driving for a period whilst they recover, the length of which will vary depending on your specific situation.

Following a subarachnoid haemorrhage, you may experience one or more of the following symptoms:

Headaches

A sudden and severe headache is characteristic of a subarachnoid haemorrhage. Headaches over the first few days will remain quite severe, but constant. This is due to the blood that is present around the brain, causing it ongoing irritation. This blood will be slowly broken down and reabsorbed naturally but may take several weeks to do so.

General frequency and severity of headaches will reduce as time goes by, but many people find that they may be more prone to headaches over the coming months. After the first couple of weeks, headaches may be associated with tiredness or following periods of concentration for example.

Pain killers such as paracetamol can be taken as need. If you still have concerns then you should discuss them with your GP, specialist, or specialist Nurse. Remember, headaches are common for most people; subarachnoid haemorrhage is rare.

Tiredness

Overwhelming tiredness is the most common symptom that people experience following subarachnoid haemorrhage and takes the form of both physical and mental fatigue. In the first few weeks, normal daily activities such as taking a bath, will leave people exhausted.

Tiredness is the body’s way of telling you to rest. As time goes by the amount of rest needed will get less, it is common in the first six weeks or so that a rest period during the day will be required. You may find a worsening of common symptoms, such as headache, when tired, and may cause unnecessary worry.

A gradual return to previous activities is recommended; it is likely that resuming all previous activities will take at least 3 months, and often longer. You may find that you have a reduction in your level of stamina for a year or more.

When in hospital the occupational therapist will complete an assessment of activities of daily living such as meal preparation when you are mobile. Also fatigue management strategies in relation to your activities of daily living during the assessment will be discussed.

Back pain

Following Subarachnoid Haemorrhage some people experience lower back pain and/or shooting pain down the back of the legs.

Your back pain may be caused by blood in your spinal fluid that is irritating the nerves. This is a normal process which will get better with time. Lower back pain may also be due to lying in bed for many days and a lack of activity. This type of back pain usually gets better as you increase your activity level.

These symptoms, whilst uncomfortable, generally settle down on their own. Pain relief provided on discharge will be appropriate to manage these symptoms.

Cognitive (thinking) difficulties

Cognition describes functions such as memory, concentration, decision-making and general thought processes. Some of these functions may be affected to varying degrees after a subarachnoid haemorrhage, some people may find that they have more difficulty learning new skills or information.

The Occupational Therapist will complete a cognitive screening assessment prior to discharge and advise you of strategies to manage any difficulties in relation to your activities or daily living.

Memory problems

Memory problems may be subtle, or more noticeable, temporary, or permanent. You are unlikely to remember a lot of your time spent in the neurosurgical unit, this is normal. Short-term or day- to-day memory can commonly cause people difficulties after subarachnoid haemorrhage.

Memories prior to the incident remain intact for most individuals, but it is day-to-day memory that can be impaired to varying degrees, such as things people tell you, or what you have gone to the shop for.

Memory difficulties are very common during the initial period following the haemorrhage but will improve throughout recovery. You may notice that short-term memory difficulties are more apparent when you are tired. Your memory may completely recover. However, some people find that their short- term memory is never quite as good as it was before. If memory problems persist a referral to a Neuropsychologist may be useful.

Difficulty concentrating

You may find that your ability to concentrate is affected, but again, like memory, this will gradually improve with time. You may find that you can only concentrate for shorter periods of time, and that concentration is more easily broken by distraction.

In the early stages you may find that you need to concentrate more intently when carrying out previously straightforward tasks. If you find concentration difficult, it is advisable to avoid trying to do more than one or two things at one time, and, if possible, avoid distractions or interruptions.

Feeling more emotional and/or anxious

After leaving the security of hospital you may feel a lack of confidence and may feel isolated and fearful of the future. Some fear recurrence of the illness. Men and women alike often find that they are more emotional.

You may experience mood swings, and find that you feel like crying more easily, or for no reason. You may find that you feel quite low on occasions throughout your recovery. Feelings of low mood and depression can be common during recovery, and often occurs during the first few months.

These feelings generally improve with time, but if you are feeling low it may be worth discussing it with your GP. You may also find that you and your family can get quite emotional when thinking about all that you have been through.

Often individuals lose their confidence and generally feel more anxious about day-to-day activities. Confidence will slowly be regained as progress through recovery takes place.

In the early stages you may feel unhappy going out alone or speaking to strangers.
 
You may find yourself feeling stress more easily; when you are experiencing a stressful situation, you may notice more difficulties with memory and concentration, and you may find you are more likely to develop a headache.

You may find it useful attending a support group and speaking to others who have had similar experiences, or you can contact your specialist nurse or neuropsychologist if you need to talk. You can also find relevant helplines details in Useful links.

Physical disability

Occasionally people have a weakness of one or more limb. The severity of the weakness can vary from person to person, as can the response to therapy. You will be assessed by a physiotherapist and offered an exercise programme if appropriate.

Strength in limbs generally improves over the months following the subarachnoid haemorrhage. In the initial weeks after the bleed, it will be difficult to predict the final physical recovery any given individual will make.

Speech/communication difficulties

Some people find that they often have problems with finding the right words, or that speech may be a little slurred, or slowed, particularly when tired. In most cases this gradually improves.

Speech difficulties may vary, and a speech and language therapist will assess those people with serious speech difficulties.

Symptoms specific to surgery (clipping)

Discomfort in Jaw

During the operation the surgeon may have cut the muscle at the temple to expose the skull. This muscle is involved in the movement of the jaw, and many people experience discomfort, stiffness, and a limitation of opening of the jaw, for example, when chewing or yawning. This muscle will slowly heal, and as it does this pain and stiffness will improve.

Facial swelling

The majority of facial swelling will go down in the first week, but sometimes swelling around the temple area may be more persistent. People who wear glasses are often aware that the arm of the glasses seems to dig in a little. Some people also find that for a few weeks their eye(s) may be puffier in the mornings, gradually settling once they have got up. These symptoms may be variable from day-to-day.

Pain or numbness around the scar

The scar will feel more sensitive generally and may feel itchy or have a sensation of pins and needles some of the time. The nerves that supply the sensation to the scalp will have been damaged during the surgery, making the area around and behind the scar feel numb.

This area of numbness will gradually reduce in size, but the scar itself may always be numb. Odd creeping sensations and sharp pains are also common. If the wound becomes tender, red, inflamed, and hot, and/or begin to weep, you should contact your neurosurgeon or specialist nurse. The area around the scar may also feel lumpy and uneven, this is due to the piece of bone that was cut during the surgery, and stitches under the skin.
 
The piece of bone may feel as though it moves in and out slightly on occasions, this is due to normal pressure changes inside the head, and whilst it may feel strange, it is not a problem.

Symptoms specific to coiling

Bruising/tenderness in the groin

You may experience some discomfort in the groin area where the catheter was inserted into the artery. This will settle down over a couple of weeks. If pain persists, or gets worse, or you notice the area to be red, hot, inflamed or weeping, then you should contact your neurosurgeon, or specialist nurse.

Patchy hair loss

Some patients have reported a patch of hair loss following coiling treatment. This is because of the x-rays used during the procedure. This usually is a temporary symptom and resolves after a few months. Please feel free to discuss this further with your consultant or specialist nurse.

Useful contacts

Hospital professionals that you may have contact with as an in- patient or an outpatient:

The Neurosurgeon will be responsible for your in-patient care and management. He or she will also carry out any surgical procedures that are carried out when you are acutely ill.

The Neuroradiologist is the consultant Doctor who will carry out radiological treatments such as coiling.

The Physiotherapist is involved in rehabilitation. He or she can help the person to gain mobility, confidence, and independence as far as possible. The aim of physiotherapy is to promote independence as far as possible.

The Occupational Therapist (OT) may also be involved to help gain independence as far as possible with activities of daily living.

The Speech Therapist will assess language problems that may be encountered after a haemorrhage and offer a programme of therapy.

Your General Practitioner (GP) is your first point of medical contact once home. For example, if you need a sick note, a review of your medication or blood pressure monitoring, you should attend your GP surgery. Your GP should be your first point of contact for the prescription of drugs and the specialist nurse can advise you.

The Specialist Nurse can give you vital information about your illness and treatment, advice, and reassurance that you will find helpful once you are home following your brain haemorrhage. She is your link to the team at the Specialist Neuroscience Centre. The specialist nurse may be able to assist you in managing symptoms that you experience in recovery and advise on the issue of return to work.
 
The Neuropsychologist can help if you experience emotional distress such as symptoms of panic, depression, or anxiety. If you have persistent problems with your day-to-day memory, attention or difficulty with the planning and organising yourself, again, it would be appropriate to see a neuropsychologist in this instance.

The Social Worker can provide information and advice on benefits and services that are available in your local area. They can be contacted through your local Social Services Department or through the hospital where you were an in-patient.

The Welfare Rights Officer can give advice regarding benefits and services. Again, they can be found within the local hospital or Citizen’s Advice Bureau.

The Community Rehabilitation Team is a team of therapists in your local area that may continue working with you if necessary after you are discharged home from hospital

Frequently asked questions

Could I have prevented it?

It is unlikely that there is anything you could have done to prevent it or predict it. There are no known links between stress and subarachnoid haemorrhage.

Those people with high blood pressure, and those who smoke have a greater risk of having a subarachnoid haemorrhage.

Why me, why now?

It is not known why some people have subarachnoid haemorrhage rather than others, and for the majority, it is difficult to predict who is at risk. It is also not known why the haemorrhage occurred at the time it did and not at any other. Whilst a subarachnoid haemorrhage can occur during periods of exertion, it can also happen at any time, during any normal daily activity such as work, rest, or sleep.

My hearing seems different – is this normal?

Often people describe being more sensitive to noise, finding it more difficult to cope with. Everyday noise such as the television, or the sound of conversations in a pub can be just as difficult to cope with as loud noises. Equally some people describe their hearing as muffled as if they are under water.

My vision does not appear to be as good – is this normal?

You may experience a slight change in your vision. You should discuss any visual difficulties with your doctor or specialist nurse, however, for the majority, vision settles down and improves over the first few weeks. It is advisable to wait about 6-8 weeks after the bleed before having your eyes tested, as your vision may be changing during this period.

What effect can my illness have on my family

Subarachnoid haemorrhage is a sudden and sometimes life changing event that mostly occurs without warning, and effects not just the individual who has had the bleed, but the whole family. It is a very worrying period for all involved and often more so for your family who are completely aware of all that is going on during the acute stage of the illness. During the recovery period, whilst you will need a lot of rest and care from your family, you will also need to slowly return to your normal activities and build up your strength. Family members need to take care of themselves as well, and although they may be worried about you, they should avoid being overprotective.

Family members can often experience feelings of anxiety and go through low periods. Spouses or partners will need support themselves and may benefit from attending a support group and/or speaking to others who are experiencing or who have experienced a similar situation. The family needs to take time to relax.

Can I pass the risk of a subarachnoid haemorrhage on to my children?

There are a very small number of families who appear to have a familial tendency to develop aneurysms in the brain; these families are identified by having 2 or more first degree relatives who have had a proven subarachnoid haemorrhage due to an aneurysm. A first degree relative is a parent, a child, or a sibling. For most people who have a subarachnoid haemorrhage an inherited risk is not of concern. If you are worried about this then you should discuss this with your specialist or specialist nurse. To date there is no evidence that aneurysmal subarachnoid haemorrhage is genetically inherited.

When is it safe for me to have sex?

Many people are nervous about returning to a normal sex life, and for some, libido, or sex drive can be reduced. Anxieties may be increased if the bleed occurred whilst having sex. It is safe for you to have sexual intercourse as soon as you feel ready. Having sex in the future will not increase your risk of having a subarachnoid haemorrhage.

When can I recommence HRT/oral contraceptive?

This type if medication can usually be recommenced once you are recovered and a resuming normal mobility again. You should contact your GP for advice on this issue.

Is it safe to get pregnant?

For most young women who have had a subarachnoid haemorrhage, it is still safe to become pregnant and have a normal childbirth. If you are thinking of becoming pregnant, then it is advisable to discuss this with your doctor or specialist nurse.

Can I fly?

There is nothing to stop you flying once you are fit enough to do so. You should take the usual precautions, such as adequate fluid intake and keeping mobile during the flight. You may feel particularly tired and should allow for this. It is also important that you inform your travel insurance provider of your recent hospital stay.

Will I be entitled to any benefits?

When off sick from work for a period, you will either be entitled to sick pay from your employer, or you are likely to be able to claim benefits appropriate to your specific situation. You should contact an agency such as the Citizens Advice Bureau, or Welfare Rights to discuss your individual circumstances, and the benefits you may be entitled to. The telephone number for local offices will be in the telephone directory. Your spouse, or partner may also need to take time off work while you are in hospital, and for a period when you come home. If you think that income might be a problem, you should speak to your bank or building society early on to explain the situation, particularly if you have loans and/or a mortgage.

Useful links

Here are a selection of agencies and organisations that you may find useful:

Sub-Arachnoid Haemorrhage Website
Devised by Salford Royal in collaboration with the Wessex Neurological Centre.
To navigate our website, visit the Hospital website:
Website: www.nca.nhs.uk/about-us/depts/sub-arachnoid- haemorrhage/

A.C.A.S.
Help and information regarding employment issues
Telephone: 01252 811 868
Website: www.acas.org.uk

B.A.S.I.C. Brain & Spinal Injury Charity
Address: The Neurocare Centre, 554 Eccles New Road, Salford, M5 1AL
Telephone: 0870 750 0000
Email: enquiries@basiccharity.org.uk
Website: www.basiccharity.org.uk

Department of Work & Pensions
Government agency responsible for benefits
Public enquiries Office:
Telephone: 020 7712 2171
Website: www.awp.gov.uk
For local offices see telephone directory
 
British Brain & Spine Foundation Charity
Organisation providing information and a helpline
Telephone: 0808 808 1000
Website: www.brainabdspine.org.uk

British Epilepsy Association Charity
Organisation providing information and support about epilepsy
Telephone: 0808 800 5050
Email: helpline@eplipesy.org.uk
Website: www.epilepsy.org.uk

Carers UK
Information and support for people who are caring at home
Telephone: 020 7940 8818
Email: info@carersuk.org
Website: www.carersuk.org

Citizens Advice Bureau
Independent advice on issues such as benefits, employment, debt, etc.
Local office numbers in telephone directory (National Association of CAB).
Telephone: 0207 833 2181
Website: www.citizenadvice.org.uk
 
CRUSE
Bereavement care charity offering bereavement counselling and support.
See telephone directory for local branch
Telephone: 0870 16 1677
Email: helpline@crusebereavement.org.uk
Website: www.crusebereavement.org.uk

Different Strokes
Support for younger stroke survivors
Telephone: 0845 1307 172
Website:  www.differentstrokes.org.uk

DVLA
Address: Driver Vehicle Licensing Authority, Drivers Medical Group, DVLA, Swansea, SA99 1DL
Medical Enquiries:
Telephone: 0300 790 6806
Website: www.dvla.gov.uk

Relate
Charity providing relationship counselling
See telephone directory for local branches.
Website: www.relate.org
 
Headway
Charity providing information and support for individuals with brain injury
See local telephone directory for local branches
Telephone: 0808 800 244 Freephone
Email: enquiries@headway.org.uk
Website: www.headway.org.uk

The National Society for Epilepsy (NSE)
Address: Chesham Lane, Chalfont St Peter, Bucks, SL9 ORJ
Telephone: 01494 601 400
Website: www.epilepsynse.org.uk

The Stroke Association
National Charity providing support and information
Telephone: 0207 566 0300
Website: www.stroke.org.uk