What is a Subarachnoid Haemorrhage (SAH)?
A subarachnoid haemorrhage (SAH) is an uncommon type of stroke caused by bleeding on the surface of the brain. It is a very serious condition and can be fatal (NHS 2019). SAH after the rupture of a cerebral aneurysm is the cause of approx. 6% - 8% of all cerebrovascular accidents, affecting approx.10 per 100,000 people each year (Castanares-Zapatero et al 2011). Due to the bleeds nature, symptoms that could relate to a SAH diagnosis should be treated with urgency and warrant a 999 call.
- Sudden severe headache
- Neck stiffness
- Visual disturbances - double vision, blurred vision, light sensitivity
- Nausea or vomiting
- New limb weakness
- Slurred speech
The bleed may be categorised in hospitals as either Traumatic or Aneurysmal; dependent on the type of SAH will depend on treatment options available.
Aneurysmal SAH
An aneurysm is a weakness in the arterial wall that bulges out like a 'balloon' to cause an aneurysm. This aneurysm can occur at any point in a persons life for unknown causes. Factors increasing someones chances maybe family history, high blood pressure or smoking.
Traumatic SAH
Usually caused through head injury such as a fall or road traffic accident.
No cause identified
In up to 20% of patients no abnormality is identified and the bleeding is thought to originate from a small vein and is referred to as a non-aneurysmal SAH. Patients will still experience symptoms and will need to take time to recover.
Diagnosis
Once a SAH has been diagnosed, a CT angiogram (CTA), this is a CT scan with intravenous injection of X-ray dye, is performed to look for abnormalities of the intracranial blood vessels such as an aneurysm or an arteriovenous malformation. If a CTA does not show a vascular abnormality, a cerebral angiogram (DSA) may be performed to assess the intracranial blood vessels in greater detail. This involves a catheter being inserted into an artery in the groin (femoral artery). Dye is injected into the blood vessels in the brain and digital X-ray images are taken.
Angiogram of the brain
If the CTA and DSA do not reveal an abnormality the diagnosis of non-aneurysmal subarachnoid haemorrhage (NASAH) may be made.
Treatment
The aim of treatment for SAH is to prevent rebleeding. Treatment will depend on whether an abnormality is found or not. Treatment options will be discussed with you and your family. Options are as follows:
Embolisation
Embolisation is a way of treating your aneurysm so that it is no longer at risk from bleeding. Aneurysms are embolised using specially designed platinum coils, which are used to pack the aneurysm to prevent it from bleeding. This procedure is performed in the Angio suite. This involves treating the aneurysm from inside the blood vessels.
Coiling of aneurysms.
Surgical Clipping
Aneurysms that are not suitable for coiling or other similar forms of treatment, may be treated with a surgical clip. This is a neurosurgical procedure where an opening is made in the skull (craniotomy) and a metal clip is placed at the base of the aneurysm.
Craniotomy
Conservative management
This option is when the risks of any treatment far outweigh the benefits. This will be discussed with you and your family in more details.
How long will I need to stay in hospital?
You will stay in hospital until your symptoms have settled and you are well enough to return home. Length of stay varies according to the severity of the initial bleed. Most patients will be discharged home after approx 10 days.
Going home and recovery
There can be many symptoms you may be experiencing when you are going home. You are advised to take plenty of rest, as fatigue is very common following SAH. It is recommended that you pace your return to your normal levels of activity. You may have days where you may be able to do more than others.
You may suffer with ongoing headaches. They are a normal part of the recovery process and should settle with time. Simple pain killers may help. You may find you also have some back discomfort, again this is normal and usually resolves itself over time.
If you experience worsening headaches that become severe, you should seek medical assistance.
Cognition
Some patients experience difficulties with short term memory and concentration (cognitive changes) following SAH. Many patients may also experience changes in mood and emotions. Anxiety is common. These symptoms improve over time. If you are concerned about cognitive or emotional changes please speak to your specialist nurse or your GP.
Confidence
When you are just out of hospital, not having a routine or regular support of a nurse or other professional can seem daunting. Family and friends are an excellent point of support but sometimes you may feel different to the person you were before the injury.
Regaining your confidence in relationships, finances and a wide range of daily interactions. Adjusting to life after the injury can have devastating consequences for the individual and their family. All of us with or without brain injury have difficulty making decisions from time to time.
Further advice
In hospital you will be seen by a neurovascular nurse practitioner (NNP) who will discuss your diagnosis and progress and will provide you with advice on your discharge and recovery. You will also receive a telephone consultation with the NNP 6-8 weeks after discharge.