Providing practical and emotional
support for all people affected
by brain haemorrhage

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    Patient Information - Subarachnoid Haemorrhage


    What is a Subarachnoid Haemorrhage (SAH)?


    It is due to a leakage of blood from a major blood vessel beneath the arachnoid membrane that covers the brain. (see picture below)


    Sub-arachnoid Haemorrhage usually occurs suddenly and without warning.


    SAH causes the sufferer to develop a sudden, severe headache and is often accompanied by sickness, vomiting, neck stiffness, photophobia (dislike of light), sometimes loss of consciousness and/or seizure. There may be slurred speech, disturbance in vision or a weakness in an arm or leg.


    There are 3 membranes covering the brain called the meninges. (The pia, arachnoid and dura) The blood vessels within the brain lie below the arachnoid membrane.


    What Causes SAH?


    Aneurysms


    75% of subarachnoid haemorrhages are caused by a fault (or weakness) in a blood vessel called an ‘aneurysm’. They are “berry” shaped, like a “blister”.


    The ruptured aneurysms require urgent treatment as once an aneurysm has bled there is a high risk of re-bleed in the short term.


    SAH from an aneurysm is most common in people between 30 and 60, although they can occur at any age.


    Occasionally, more than one aneurysm is found. Your surgeon or radiologist will know from the test results which one was responsible for the bleed and treat it. The unruptured aneurysms are not always treated at the same time. It is usual to come back at a later date to have further aneurysms treated or they may be monitored.


    Diagram of Cerebral Aneurysm


    Could it have been prevented?


    NO!


    There is no known reason why a haemorrhage happens at a particular time, but they can rupture at times of physical effort such as coughing, heavy lifting, straining or during sex.


    The risk of rupture of these types of aneurysms can be (but not always) increased by smoking or prolonged untreated high blood pressure.


    Are there any warning signs?


    In most cases the aneurysm goes undetected until it bursts.


    Very rarely an aneurysm can press on a particular part of the brain causing symptoms.


    No vascular Abnormality Found.


    In 15% of cases no vascular abnormality is identified. We do not know why such haemorrhages occur, but we do know that the outlook is good and the risk of a future haemorrhage is very low.

    In cases where no cause is found, no treatment will be required.

    Although your recovery will be quicker, you will still need time to recover from the Subarachnoid Haemorrhage itself and so need to take in the information in the recovery section.

    Other Causes


    Other causes are more rare; these are other vascular abnormalities, the blood vessels, infection, trauma and certain genetic disorders

    Is the Condition Hereditary?


    Generally, aneurysms are not hereditary but appear to be due to familial lifestyle such as smoking. A family can be referred for investigation for hereditary aneurysms once 2 first line relatives have been diagnosed with SAH.

    First line relatives are: 1. Your brother / sister. 2. Your parent. 3. Your child.

    In order to start this process, speak to your consultant neurosurgeon. They will probably advise you to inform your relative to speak to their own G.P. and be referred to the local neurosurgical hospital.

    Diagnosing a Subarachnoid Haemorrhage


    This is usually made by CT scan and occasionally lumbar puncture. If the test appears positive, you will be referred to the Walton Centre for further investigation and treatment if necessary. You may then undergo a Computerised Tomography Angiogram (CTA). This involves a CT scan after injection with contrast which allows a scan of the blood vessels within the brain. Digital Subtraction Angiography (DSA) is a test which involves the injection of dye through a catheter (tube) inserted into an artery in the groin and a series of x-ray pictures taken. This shows the blood vessels within the brain. Treatment options will be made on the results.


    Treatment


    The aim of your treatment is to prevent another bleed.


    Once you have been diagnosed with a subarachnoid haemorrhage, you will be required to undergo bed rest and will be closely observed in the ward environment.


    You will normally be required to have about 3 litres of fluid each day, either by drinking or by a "drip" into the vein.


    You will normally take a 21 day course of tablets called Nimodipine. These have to be taken 4 hourly and help prevent complications due to the haemorrhage.


    You will be given regular pain killers.


    If you have had a number of seizures since your brain haemorrhage, you will be prescribed medication for this. These are called anticonvulsants.


    If an aneurysm is found to have caused the bleed then it may be treated by;-


    1. Coil Embolisation
    2. Surgical clip
    3. Conservative management

    The choice of treatment will be made by your neurosurgeon along with the Interventional Radiologist and Multidisciplinary team.


    Coil Embolisation


    This is an endovascular treatment which means it is performed through a blood vessel. Under a general anaesthetic, a small catheter (tube) is inserted into one of the arteries in your groin in the same way as an angiogram. The catheter is fed up to the aneurysm using x-ray screening. The coils are then deposited inside the aneurysm. The size, shape, and position of the aneurysm will determine which type and how many coils are used. The aim is to pack the aneurysm with coils so that blood is not able to enter it and allow the aneurysm to seal over.


    Coiling of aneurysm


    Stent assisted coil embolisation


    Sometimes, a Stent (artificial tube) is used as well as coils to help seal off the aneurysm. This would depend on the type, shape and position of the aneurysm. Sometimes, certain types of stents are used on their own. A stent is a tube placed inside the artery to help seal off an aneurysm.


    Surgical treatment by clipping


    This involves placing a small metal clip around the base of the aneurysm to seal it off and so prevent further bleeding. The operation is done under general anaesthetic and carried out by a neurosurgeon. Part of the hair may be shaven. A cut will be made in the skin and bone to allow access to the brain and the aneurysm. The bone will be replaced after surgery and the skin stitched or clipped up.


    Clipping of aneurysm


    Conservative management


    Depending on your current health, the position and size of the aneurysm and the risks of treatment versus the benefits, it may be decided to manage the aneurysm ‘conservatively’. This means that symptoms will be treated and the aneurysm will be monitored.


    After treatment.


    After your aneurysm is treated, you will often spend the first night in the critical care unit (HDU / ICU) on the ground floor. Depending on how you are and what treatment plan has been ordered by your consultant, your stay in critical care may be longer than 24 hours and will be reviewed daily until you are ready to go back to the wards.


    Once the team at the Walton Centre are happy that you no longer need specialist facilities, you will either go home or to another hospital for local rehabilitation.


    Rare Complications after SAH


    Hydrocephalus


    Hydrocephalus is a condition where there is a build up of cerebrospinal fluid (CSF) in and around the brain and spinal cord. This happens because it may not be able to drain away after the haemorrhage.


    Symptoms include a build up of headaches, problems with balance and possibly worsening vision and memory/concentration (more obvious than when you left hospital) These symptoms must not be ignored. If they are getting worse you must go to your nearest accident and emergency department for a scan. Hydrocephalus can be treated by a shunt (drainage tube) into the CSF. If you have a shunt you should carry a “shunt card” and have information on it. Support and information on shunts is available through the Walton Centre.


    Stroke like symptoms


    This can occur in any part of the body but is usually confined to one part or the whole side of the body following a subarachnoid haemorrhage. This can range from a slight weakness to a complete lack of ability to move. It may be permanent or may get better. If you get any of these symptoms once you go home, you should go to your GP or nearest accident and emergency department immediately.


    Epilepsy or "fits"


    Rarely people who have a subarachnoid haemorrhage develop epilepsy causing "fits" or "seizures". You may or may not lose consciousness when these occur and symptoms can vary. In most cases, the first seizure occurs within the first year of the subarachnoid haemorrhage. After two years, you are unlikely to develop epilepsy as a result of the subarachnoid haemorrhage. Epilepsy is normally treated with medication. You will normally be reviewed by a neurologist to ensure appropriate management.


    Going home


    Medication: Nimodipine


    You will normally be required to complete the 21 day course of Nimodipine at home if it wasn’t completed in hospital. This is just one 21 day course – no more! It is used to reduce the risk of blood vessels in the brain closing after the brain haemorrhage. This risk has passed by 21 days and so the course doesn’t have to be continued. This course of tablets needs to be taken regularly every 4 hours. Side effects of Nimodipine are low blood pressure, flushing, changes in heart rate, headache, feeling sick and feeling too warm. Please read the leaflet inside the box given to you inside the hospital.


    If these side effects occur, seek medical advice.


    You should get your blood pressure checked once the course has finished as your GP will need to make sure it is well controlled.


    Aspirin:


    You may go home with a course of Aspirin but only if you have had your aneurysm coiled. Aspirin can sometimes worsen indigestion or heart burn, and may make breathing worse in those with asthma. Occasionally, it can cause bleeding or skin reactions.


    If these side effects occur seek medical advice.


    Pain Relief:


    You may go home with pain killers. You should take these regularly to begin with if you need them. They should be cut down as soon as tolerated as taking them for too long may make headaches worse not better!


    Certain types of pain killers can cause constipation so please take the laxatives if they are given to you and eat a diet that is high in natural fruit and fibre.


    Recovery


    Sight


    Problems with vision such as blurring, blind spots, black spots and double vision can occur following a brain haemorrhage. If this occurs, you should tell someone so that your vision can be checked. If you do experience double vision, you may find it more comfortable to wear an eye patch over one eye.


    Communication Problems


    The processes in the brain that control communication (i.e. speaking, listening and understanding) may be disturbed following a brain haemorrhage. If this happens, and is problematic, you will normally be referred for speech therapy. Sometimes, but not always, your speech and ability to understand improve with time.


    Memory


    It is not unusual to be left with poor memory following a brain haemorrhage. Your memories before the haemorrhage will be less likely to be affected. This may improve with time but recovery can be frustrating as often your memory and concentration never return to their pre haemorrhage levels. Try breaking down tasks into smaller steps and using ‘post it’ notes or a notebook to help you. If this problem is affecting your day to day life, you may need to be referred for psychology screening.


    Personality Change


    Anything going wrong in the brain can cause a change in character or personality. This is especially so with certain aneurysms. Character changes often settle down or are adapted to with time. If they are ongoing and troublesome, you should be referred to a psychologist for an assessment and treatment plan to help you cope. However, because recovery from any brain injury can take up to 1 -2 years, this will not normally be done until you have been given time to recover. (usually about 3-6 months after).


    Extreme tiredness


    You will probably need plenty of rest once you get home particularly if you are having a lot of visitors or your house is very busy. Even simple tasks such as a walk to the local shop may leave you feeling exhausted. This will improve with time but may not go completely. You will know if you have done too much as you will be exhausted and may experience more headaches. This often happens the next day and means you have to rest!


    Headaches


    Headaches are common after a subarachnoid haemorrhage. They usually ease with time. You should take simple medication for them such as paracetamol. Headaches can be triggered by dehydration, stress, too much or too little sleep and missing meals. Drinking 2-3 litres of water a day should help reduce the frequency and severity. Also, try and get back to a normal sleep pattern as soon as possible. Try putting some structure into your day, including meal times as this will help with headaches and recovery. Stopping smoking and reducing the amount of caffeine you take in should help reduce the severity of headaches. Headaches can be persistent after a brain haemorrhage. They are often worse if you have done too much that day or the day before. So, always take notice of the symptoms and rest when you feel tired.


    Pacing


    You must pace your activity for the first 4 weeks following going home. Take a daily rest as well as some gentle exercise. Build up activity as you feel able to and try to go outside for regular walks if you are able, otherwise you may lose your confidence.


    Unusual sensations


    Some people experience unusual or strange sensations in their head following a brain haemorrhage. We are not sure why this occurs, but do not worry about them and they should ease with time.


    Fear of rebleed


    This is a very common fear for all patients, especially those who have had a coil occlusion. Unfortunately the risk is real but it is very small. However, because the aneurysm cannot be taken away, it is important to learning a coping strategy as this fear may prevent your recovery progressing. Remember, you will be followed up and scanned regularly once you have gone home. You will only be discharged from the Walton Centre when we think it safe to do so.


    Recovery is dependant on how you feel. You will need to pace yourself for the first month or more after going home because of tiredness and headaches. Feelings of anger, frustration and sadness are not uncommon following a brain haemorrhage. This may be due to the condition but could just as well be due to post traumatic stress following a sudden life changing event and so will pass. If you are affected, you should talk to your GP. You may need to be referred to a psychologist in order that you are able to manage. Enlisting the support of the “Brain Haemorrhage Support Group" affiliated to the Walton Centre may help in that they can offer emotional support and recovery advice.


    However, not everyone is affected this way; some see this as a new beginning; a time to re-evaluate their life following the trauma.


    However, not everyone is affected this way; some see this as a new beginning; a time to re-evaluate their life following the trauma.


    Using a diary from when you are in hospital and for the following months can be very useful. By charting good and bad days, you will be able to mark your progress; this will help a lot when you have ‘bad days’ and will mark how far you have come with recovery.


    Everyday Activities


    Driving


    Following a subarachnoid haemorrhage, if you hold a driving licence, you are legally required to notify the Driver and Vehicle Licensing Agency (DVLA). You will not be able to drive until you have received DVLA approval and your doctor has confirmed you are recovered. If you drive without telling the DVLA, then your insurance becomes invalid.


    Flying


    If you have had a coil occlusion of your aneurysm, you should be able to fly as soon as you feel able. However, if you have had surgical treatment then current advice is to wait for 3 months unless your doctor advises you otherwise. It is safe to go through the metal detectors in the airport. They will not affect the coils or clips.


    Drinking Alcohol


    Don’t drink alcohol until the 21 day course of Nimodipine is completed and you have reduced the number of pain killers you take. However, most people find they are not able to tolerate large amounts of alcohol following a brain haemorrhage.


    Smoking Cigarettes


    As cigarettes are one of the biggest risk factor in causing an aneurysm to rupture, it is advisable that you give up smoking completely. A free help line number is printed at the end of this booklet.


    Returning to work


    You can return to work as soon as you feel able from 6 weeks following your brain haemorrhage.


    However, most people need about 3 months, to recover. (Occasionally longer if there have been significant problems). It is advisable to go back to work on a phased return. This means you build up your working days and hours according to how you are feeling. A phased return is often graduated over 4 weeks or longer and your employer has an obligation to adhere to it.


    The working life service at Neurosupport will help you if you are having problems with returning to work. The number is printed at the back of the booklet.


    Sexual Activity


    You can resume normal sexual activity as soon as you feel able.


    Starting a family


    It is advisable not a start to a family for the first 6 months following your brain haemorrhage as it takes this time to recover. You will not be prevented from a normal delivery but this will depend on your obstetrician. You will not have M.R.I. scans whilst you are pregnant.


    Sport and swimming


    As long as wounds have healed, there is no problem with swimming. However, it is advisable to go with somebody whilst you are at increased risk of seizures in the first year following your brain haemorrhage. Most other sports can be resumed once you have recovered.


    Hair Washing


    If you have a head wound, this can be done after 48 hours. If your aneurysm has been coiled then as soon as you feel up to it.


    Family and friends


    It is essential that you enlist your family and friends support whilst you recover. They will be a great help with shopping, transport and support if you feel down. Family and friends support is essential to you in the first 4 weeks after you go home and will be the biggest influence in your succesful recovery.


    Information for self help


    Brain Haemorrhage Support Group offers practical advice and emotional support for all patients and their families/friends who have had a subarachnoid haemorrhage (Leaflet available at the helpdesk on the ground floor) A diary is available from them for you to watch your progress.


    Neuro Support – Information and Support for people with Neurological Conditions (Leaflet available at the helpdesk on the ground floor).


    Information is available for all patients who have had shunts inserted as a result of the brain haemorrhage. (Through your ward staff, neurovascular nurse specialist, hydrocephalus nurse specialist or customer care team.)


    Information is available for all patients who have epilepsy as a result of the brain haemorrhage. (Through your ward staff, neurovascular nurse specialist, epilepsy nurse Specialist or customer care team.)


    'A Dented Image' Alison Wertheimer.


    This is a self help book with stories of recovery from patients who have had a Subarachnoid Haemorrhage (ISBN; 978-0-415-38671-5)


    Road to Recovery


    This is a voluntary information course run by the Walton Centre and supported by the Brain Haemorrhage Support Group. It usually runs twice a year in March/April: September/October.


    It is for those people and family / friends who have recently been affected by Subarachnoid Haemorrhage.


    Information on this course is available through your neurovascular nurse, the brain haemorrhage support group or customer care team. You can request an invitation to this course at any time if you think you may benefit.


    Produced by: C. Stoneley (Neurovascular C.N.S.)

    Reviewed: Jan., ‘11

    Review Date: Jan., ‘13