Intracerebral hemorrhage

Admission to hospital

• Tests and diagnosis

  If you are admitted to hospital because the doctors think you have a cerebral hemorrhage, a CT (Computer Tomography) scan of the brain will be taken. This allows the doctor to see what kind of cerebral hemorrhage you have had. The blood vessels can be seen in the CT scan by injecting contrast medium into your arm via an IV, so that the doctor can detect any vascular abnormalities. A cause is often not found on a CT scan of the cerebral blood vessels.
   

  If there is any doubt about the cause of the hemorrhage, the team of vascular specialists may decide to conduct further tests. This is done by means of a vascular examination (angiography).

• Intensive Care or Medium Care

  You will be admitted to the Intensive Care, Medium Care, or Stroke Unit if accurate monitoring and support of important bodily functions is necessary. Examples are respiration, blood pressure support, observation of the pressure in your head, or the heart rhythm. If your situation allows for it and you do not need continuous monitoring or support for bodily functions, you will be transferred to the nursing ward.

• Nursing ward

  If the situation permits, you will be admitted to the nursing ward. You will typically stay in a single room. You will be checked regularly and your bodily functions will be monitored. We offer as much peace and safety as possible. As your situation becomes less pressing, the medical team at the nursing ward will map out the problems that remain after the hemorrhage, and speak with you and your loved ones about how and where you can best recover from the bleeding.
   
  You will be cared for and observed by a specially trained nurse. This nurse is responsible for observation and care, and for the coordination of care.
   
  A doctor is available 24 hours a day for the medical treatment, under the supervision of a medical specialist from the department. The medical specialist and the doctor in the department are in contact on a daily basis to discuss your treatment and policy. Every morning the doctor will visit you during visitation rounds in the ward and they will check with you and the nurse regarding your treatment progress. You will hear the results of the tests during the visit. If new tests are planned, the nurse will give you verbal and written information. If needed, an additional meeting with the doctor can be planned.

• Treatment team

  The effects of the ICH may be different. There may be hemiplegia (paralysis on one side), difficulties with swallowing and speech, and cognitive issues (difficulty thinking). That is why you will meet therapists in the various departments who will map out and treat the consequences of the ICH for your general function.
  The treatment team consists of several professionals. They consult with each other. The goal is for you to receive guidance and information from the same people as much as possible during the admission.
   
  The treatment team consists of:
   

  • Treating neurosurgeon/neuro-intervention specialist: the doctor performing the treatment.
  • Departmental physician: present at the IC, MC, or nursing ward from Monday to Friday from 9:00 am to 5:00 pm. They responsible for the implementation and continuity of daily medical care. A doctor is available 24 hours a day in the nursing ward.
  • Intensivist: the doctor who treats you in Intensive Care. This doctor is available 24 hours a day.
  • Nurse: responsible for the coordination of care, monitors you, assists you in your daily care, administers medication, and carries out actions on behalf of the doctor.
  • Nursing specialists: monitors continuity, helps you think about your recovery process, is your contact person, and performs outpatient check-ups. During these check-ups, they will map out your complaints, discuss the influence of the complaints on your daily activities and, if necessary, refer you to the correct professional.
  • Rehabilitation doctor: coordinates the care of co-treating therapists such as those who assist with speech therapy, physiotherapy, and occupational therapy, and advises you on your recovery process.
  • Physiotherapist: treats problems regarding movement, breathing, coughing, or recovery.
  • Speech therapist: treats problems with swallowing or speaking. You will also be treated by the speech therapist if you have a breathing tube (trachea cannula).
  • Occupational therapist: identifies problems in daily function and can, if necessary, provide adaptive aids (e.g. wheelchair).
  • Dietician: gives advice in the event of problems with nutrition or the nutritional situation.
  • Social worker: provides support when there are social or societal problems, such as problems caused by legal incapacity or possible financial consequences of the disorder.
  • Pastoral care staff: can support you and your loved ones in matters regarding spiritual and philosophical meaning.
  • Transferpunt Zorg: the healthcare referral center, which arranges home care, care aids, or accommodation in a nursing home after hospitalization.

• Safety

  You may be confused and restless because of an ICH and this can lead to unsafe situations. To ensure your safety, it is sometimes necessary to use wrist, ankle, and abdominal straps made of fabric. These measures are generally not considered to be pleasant. If these measures are necessary, we will discuss them with you and your contact person.

• Medication

  After an ICH, all patients receive a number of medications such as painkillers, medication that improves the blood circulation in the brain, and medication to promote bowel movement.
  Home medication such as blood thinners and antihypertensives (blood pressure medications) are usually stopped. You can continue to use other medication.

Complications

• Hydrocephalus

  Hydrocephalus is the accumulation of cerebrospinal fluid in the ventricles of the brain. Hydrocephalus can develop acutely if the bleeding causes the passage between the ventricles of the brain close and the cerebrospinal fluid cannot drain out. It can also develop gradually when the relatively large blood cells stop the drainage of the water-thin cerebrospinal fluid. The "drain" then becomes clogged, which causes the pressure in the brain to increase. Due to the high pressure in the brain, the patient is always suffering from drowsiness, and there may be a downward pressure on the eyes or narrow and non-responsive pupils. Usually there is an increase in headache, nausea, and vomiting.

   
  In that case, cerebrospinal fluid drainage is required. You can read more about this under the heading Cerebrospinal Fluid Drainage.

• 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.

  Cerebrospinal fluid looks like water and is produced in the cavities of the brain, which are called the ventricles. There are two side ventricles (lateral), a third ventricle in the center of the brain, and a fourth ventricle at the bottom of the cerebellum. Cerebrospinal fluid is continuously created and absorbed. On average, cerebrospinal fluid is completely renewed about 3 to 4 times a day.

  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. If cerebrospinal fluid accumulates, the doctor must do something to limit the damage as much as possible.

  Treatment

  External ventricular drain
  An external ventricular drain (EVD) is a thin tube (drain) that is surgically placed through your skull into the ventricle. During surgery, the doctor will make a small incision in your 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.
  Because the drainage collection system is attached to your bed, you will be on bed rest. 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, they will place the shunt into the ventricle of the brain and slide it under the skin towards the abdominal cavity. The operation takes about an hour.

  Complications

  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. Your attending physician will discuss the possible complications of this operation with you.
   

• Delirium

  Delirium often occurs after a brain hemorrhage. It is a state of confusion that is accompanied by hallucinations or unrealistic ideas, often with anxiety and fear, but sometimes with apathetic and silent behavior. Characteristic symptoms of delirium are alternating levels of consciousness and worsening of the symptoms during the course of the evening and night. Delirium after a cerebral hemorrhage can be caused by the bleeding, an infection, or disruption to metabolism.

• Infections and fever

  If the cerebrospinal fluid is drained through an external shunt, there is a risk of bacterial meningitis. A urinary catheter also causes rapid urinary tract infections and lying on the bed for long periods of time on the ventilator causes the risk of a lung infection. With a longer hospital stay, resistance is lowered and the risk of infection increases. If there are signs of an infection, for example due to fever or increased inflammation in the blood, then cultures are taken to determine the cause of the infection and to identify the bacteria, so that we can treat you with the right antibiotics. This is done in consultation with the medical microbiologist.
   

  Fever after a cerebral hemorrhage also occurs frequently without bacteria being the cause. We think this occurs because the regulation of body temperature in the brain is disturbed.

• Heart and lung problems

  After an intracerebral hemorrhage, various cardiac dysrhythmias (rhythm abnormalities) can occur, which usually recover on their own. A heart that has already had issues maintaining its pumping function may find it difficult to process the additional amount of fluid being administered after a cerebral hemorrhage. This can cause heart failure. This, or the bleeding, can cause fluid to accumulate in the lungs, making it more difficult to breathe or be taken off artificial respiration.
  
  Lying still in bed can cause thrombosis. If this dislodges, a blood clot can end up in the lungs. This causes acute deterioration and shortness of breath.
  
  In order to avoid the above problems, bed rest precautions are taken: such as pneumatic stockings, cycling in bed, bed mobility, or sitting in a chair as soon as possible.

Discharge from hospital

In the course of admission to the nursing ward, the neurosurgeon's medical treatment gradually tapers off. Your stay will be more about rehabilitation.
During recovery, your medical team will advise you on the best place to recover after hospitalization.

Discharge to home

• Rehabilitation

  Rehabilitation at a rehabilitation center

  For rehabilitation at a rehabilitation center (Medical Specialist Rehabilitation) there must be sufficient capacity and the prospect of a future discharge to the home. If this is chosen, the rehabilitation doctor will register you for this type of rehabilitation. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being.

  Rehabilitation in a nursing home

  If your strength is so limited that you still need a lot of rest between therapy sessions and there is a prospect of a future discharge to the home, you can opt for the Geriatrische Revalidatie Zorg (Geriatric Rehabilitation Care, GRZ) at a nursing home. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where GRZ is possible, and takes care of the registration.

  Long-term rehabilitation in a nursing home

  If there is still a lot of support needed for daily activities and it is uncertain whether discharge to the home is still possible, a long-term stay with rehabilitation at a nursing home is an option (care indication 9b). The patient will have a longer period of time to recover and, if possible, discharge to the home is an option. After completion of the neurosurgical treatment, you may be transferred to the regional hospital where you were initially cared for during the waiting period for the time being. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where it is possible to stay for care indication 9b.

  Vroege Intensieve Neurorevalidatie (Early Intensive Neurorehabilitation - VIN)

  VIN is an intensive rehabilitation program for patients who have suffered serious brain damage and are therefore in a state of impaired consciousness. The VIN program can make a significant contribution to the restoration of consciousness. There are only a few centers in the Netherlands where this program is employed. In the south of the Netherlands this is Libranet, the Leijpark location in Tilburg. The care indication is determined by the rehabilitation physicians of the institution.

  Long-term stay in a nursing home

  If self-care is largely taken over and your doctors expect that you will not recover sufficiently to return home, you may be admitted to a nursing home for a long period of time. This is rare in younger patients with a brain hemorrhage. After completion of the neurosurgical treatment, it is possible that you will be transferred during the waiting period, for the time being, to the regional hospital where you were initially taken care of. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where a long-term stay is possible.

   

• Transfer and transport

  If you are discharged and you do not need nursing care during the transport, your loved ones may pick you up from the nursing ward.
  If you are transferred to another institution and need nursing care during your trip, the nurse in the department will arrange for you to be transported by ambulance.
  The nurse gives the medical and nurse transfer to the ambulance attendant. Your general practitioner will receive a letter stating what treatment you have had.

Life after intracerebral hemorrhage

Mogelijk blijft je voor anderen onzichtbare klachten houden. Veelvoorkomende voorbeelden hiervan zijn: (mentale) vermoeid, problemen met het verwerken van prikkels, concentratieproblemen, vergeetachtigheid en hoofdpijn. Dit kan een behoorlijke beperking zijn voor het oppakken van je dagelijks leven.

• Daily activities

  After recovery from intracerebral hemorrhage, there are no special restrictions or rules to follow. Questions often arise about heavy physical labor, pushing, flying, visiting a sauna, roller coaster, or sexual activity. There is no scientific evidence that these activities increase the risk of a new hemorrhage. However, existing complaints may very well increase as a result of these activities. The advice is that all activities can be resumed as long as this is possible without issue.

• Common symptoms

  Intracerebral hemorrhage has a major impact on your daily life, not only for you, but also for your partner and family members. You may not be able to remember a period of time during your admission once you have been discharged. The majority of people continue to suffer from issues after the hemorrhage. The most common symptoms after six months are:

  • fatigue
  • headache or pressure on the head
  • changes in mood (anxiety, rapid anger, depression, stress)
  • memory problems
  • problems with concentration
  • acting and thinking more slowly
  • reduced or absent sense of taste and smell
  • poorer hearing
  • poorer vision

  It is important that you receive guidance from professionals for these symptoms and their consequences for you and your environment.
  Aftercare is organized differently for each treatment center in the Netherlands.

• Lifestyle advice

  Smoking

  Smoking is a significant risk factor for the development of intracerebral hemorrhage. In the presence of psychological issues, such as depression, stress, or anxiety, it may even be more difficult to stop smoking or to continue not smoking. It is important that you seek professional guidance from your general practitioner or nurse practitioner if you find it difficult to stop smoking. It is also known that the chance of success in quitting smoking is many times greater if family members stop smoking out of solidarity and for their own health as well.

  Blood pressure

  Another significant risk factor for developing an intracerebral hemorrhage is high blood pressure. Have your blood pressure checked regularly by your general practitioner and treated with medication if it is too high. Symptoms of high blood pressure may include headaches, palpitations, or tinnitus. It may also be discovered by chance. High blood pressure is more common in people who are stressed, overweight, who smoke, eat a lot of salty food, or are experiencing a stressful situation in the family. It also occurs with kidney problems.
  
  In addition to medication, it is important to change your lifestyle. Consult your general practitioner or nurse practitioner for advice and guidance on these lifestyle changes.

   

• Pregnancy

  There are no recommendations restricting pregnancy after intracerebral hemorrhage.

• Driving

  After an intracerebral hemorrhage, a 6-month driving suspension is required. If, after this period, there are any residual symptoms that affect driving ability, a specialized report from your specialist is required. On the basis of this report, the Dutch central driver licensing office (CBR) can decide whether an additional independent medical examination or a driving test is required. Your medical specialist will write the specialized report in addition to the health certificate issued by the CBR.
   
  In the case of epilepsy as a result of intracerebral hemorrhage, you can be declared fit to drive for a certain period of time after the end of an attack-free period. The duration of the seizure-free period depends on several factors. Discuss with your specialist what applies to you.

Rehabilitation aimed at improving complaints and limitations

Rehabilitation at a later stage

Aftercare