patients Cerebral hemorrhage Subarachnoid hemorrhage SAH

About subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) occurs very suddenly, without any type of warning. This hemorrhage is called subarachnoid because of the location in the head: just above the brain below the arachnoid mater.

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About subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) occurs very suddenly, without any type of warning. This hemorrhage is called subarachnoid because of the location in the head: just above the brain below the arachnoid mater. A widening of the artery (aneurysm) or other vascular abnormality in this subarachnoid space can lead to a hemorrhage. The blood that enters the arachnoid mater around the brain can spread to the ventricles of the brain. The leak in the aneurysm coagulates, stopping the bleeding.

How do you recognize subarachnoid hemorrhage?

  • acute, severe headache (lasting more than an hour)
  • nausea
  • vomiting
  • decreased consciousness
  • loss of strength in the limbs
  • stiff neck
Subarachnoid hemorrhage is characterized by the acute onset of severe headaches at the time of the bleeding. Sometimes unconsciousness occurs. There may also be a change in consciousness or acute confusion. Nausea and vomiting are common after the hemorrhage.
Sometimes there are also epileptic seizures in the arms and legs or paralysis symptoms.

About half of all people with a hemorrhage from an aneurysm in the brain die. Some people only have headaches and neck pain, others go into a coma. Most hemorrhages from a brain aneurysm occur in people between 40 and 60 years of age. It occurs more often in women than men.

Causes

In most cases an SAH is caused by an aneurysm in the brain. In rare cases there is another cause or the cause is unknown.

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Causes

Aneurysm

Due to the pressure in the artery, an aneurysm can become larger and its wall becomes thinner. There may be a tear in it that will eventually cause a cerebral hemorrhage. Bleeding from an aneurysm usually takes place between the meninges. This is called subarachnoid hemorrhage. A brain aneurysm is usually located in one of the larger brain arteries, on the outside of the brain, in the arachnoid mater.

Perimesencephalic hemorrhage

Perimesencephalic hemorrhage is a form of subarachnoid hemorrhage that is not caused by an aneurysmal hemorrhage. This is the case for 10-15% of subarachnoid hemorrhages. The cause is a tear in a vein, an efferent (draining) blood vessel at the brain stem. On the CT scan we can then see a blood distribution that matches this location. A patient with perimesencephalic hemorrhage has no loss of consciousness or reduced consciousness. If you do, or if the blood distribution is not typical for perimesencephalic hemorrhage, the doctor will conduct another examination after a few weeks to rule out an aneurysm or other vascular abnormality.
Patients with this type of hemorrhage have a normal life expectancy. The disorder generally has a more favorable course than aneurysmal hemorrhage.
 

Unknown cause

In a small proportion of patients with subarachnoid hemorrhage without trauma, no aneurysm can be found to be the cause of the bleeding. Possible, very rare causes are: a vascular wall rupture (dissection), vascular wall inflammation (vasculitis), a rare connective tissue disease or other vascular abnormalities in the brain such as an AVM or dural fistula. Sometimes the cause remains unknown. There may then be a slight increase in arterial bleeding. Historically, in these patients the risk of a new hemorrhage is very small.

 


Admission to hospital

It is essential that you get emergency care after subarachnoid hemorrhage and get to a hospital where the aneurysm can be treated as soon as possible.

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Admission to hospital

It is essential that you get emergency care after subarachnoid hemorrhage and get to a hospital where the aneurysm can be treated as soon as possible. You can die or suffer serious injury from the disorder. There is a significant chance of a new hemorrhage. Once the aneurysm that has burst has been found, the doctor will try to treat it as soon as possible. Accumulation of cerebrospinal fluid can also be a life-threatening problem. In that case you will be given a shunt in the ventricle of the brain so that the fluid can be drained. The first few weeks after the hemorrhage can be erratic due to regular complications, such as circulatory problems in the brain, metabolic disruption, or infections.


  • If you are admitted to hospital because the doctor thinks you have a brain hemorrhage, a CT (Computer Tomography) scan of the brain is taken first. X-rays are used to make a cross-section of your head. The doctor can see what kind of brain hemorrhage you have had. The blood vessels can be clearly visible with a CT scan by injecting contrast fluid through the vein in your arm (CT angiography). This way, any bulging of a brain artery can be detected.
    If the CT scan does not show any bleeding, you will be given a spinal tap (lumbar puncture) 24 hours after the symptoms have started. This spinal tap removes cerebrospinal fluid. The cerebrospinal fluid tells the doctor if there has been subarachnoid hemorrhage.


Treatment

There are different treatment options. Your attending physician will discuss these options with you.

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Treatment

Subarachnoid hemorrhage from an aneurysm is, in principle, treated at short notice to prevent new bleeding from the aneurysm.
In some cases, the risk of complications from treatment is greater than a new hemorrhage. For example, the cause of the hemorrhage may be difficult to treat. The neurosurgeon will discuss the treatment plan and the considerations with your contact person.
 
Read more about the treatment of a brain aneurysm. Not all treatments are suitable for the acute treatment of an aneurysm.


  • The procedure of all treatments via the artery is conducted in the same way as the examination via the artery, the angiography. During the treatment you are under anesthesia because you have to lie still for a long time.

    Coil

    A coil is a wire made of platinum that curls up like a coil into the aneurysm. Through a tube in the inguinal artery, a catheter is brought up to the aneurysm and filled with coils until no more blood enters the aneurysm.

    Stent

    A stent is a kind of mesh tube. The tube is pushed through the inguinal catheter into the right place for the neck of the aneurysm, after which the aneurysm can be filled with coils. Treatment by means of a stent is usually done in the case of an aneurysm that has not burst or a wide-necked aneurysm.

    Flow Diverter

    A flow diverter is a finely meshed tube that ensures that the blood does not flow into the aneurysm, instead remaining in the blood vessel. When there is no more blood flowing through the aneurysm, a blood clot forms in the aneurysm after which it shrinks. The flow diverter is slid into place in front of the neck of the aneurysm just like a stent, usually in the case of aneurysms that have yet to burst.

    WEB device

    A Woven EndoBridge, or WEB device, is a finely meshed, cube-shaped net that is inserted into the aneurysm via the tube, after which it is unfolded and closes the entire aneurysm at once.

    E-clips

    An e-clip is a kind of half sleeve which, like a stent, covers the neck of the aneurysm. An e-clip is specifically intended for aneurysms that have not burst, located at a major arterial junction. After the e-clip has been pushed into place, the aneurysm can be filled with coils.

    Closing the vessel

    In some cases, it is only possible to treat the aneurysm by closing off the entire artery. This is done by means of adhesive or coils.


Complications

Complications following a subarachnoid hemorrhage may be very different and depend on the size and location of the bleeding. Read more about the most common complications here.

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Complications


  • The chance of a new hemorrhage is greatest in the first few hours after a subarachnoid hemorrhage. If the aneurysm is not treated, the risk remains higher in the first weeks after the hemorrhage. A new hemorrhage results in acute deterioration, no or uneven response of the pupils, or decrease in consciousness.


Life after an SAH

After a subarachnoid hemorrhage, there are a number of things to consider.

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Life after an SAH

You may continue to have complaints that are not obvious to others. Common examples of this are physical and mental fatigue, problems with processing stimuli, concentration problems, forgetfulness, and headaches. This can be quite a constraint on resuming your daily life again.
 


  • After a subarachnoid hemorrhage and the treatment of a brain aneurysm, there are no special restrictions or everyday rules. 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.


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.

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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
If daily function can be resumed independently and safely, you can go home after your discharge. Your family or friends can pick you up at the agreed upon time. For example, if you still need therapy at home, you will be referred to a practice for physiotherapy or occupational therapy. If you need care, the nurse will fill out a request for home care. An expert from the Centrum Indicatiestelling Zorg (Care Assessment Centre - CIZ) will, after consultation with you, give you advice on the care you need at home.
 


  • Rehabilitation at a rehabilitation center

    For rehabilitation in a rehabilitation center (Medical Specialist Rehabilitation) there must be sufficient capacity and the prospect of a future discharge to the home. If you are chosen for this, 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. 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. 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, you may be transferred to the regional hospital where you were initially cared for during the waiting period. The Transferpunt Zorg (healthcare referral center) assists in choosing from the nursing homes where a long-term stay is possible.
     


Rehabilitation aimed at improving complaints and limitations

Brain damage can cause many different complaints, such as loss of strength, memory problems, difficulty speaking, or spasticity. Rehabilitation is aimed at reducing the symptoms and problems in order to be able to function as well as possible again.

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Rehabilitation aimed at improving complaints and limitations

Brain damage can cause many different complaints, such as loss of strength, memory problems, difficulty speaking, or spasticity. Rehabilitation is aimed at reducing the symptoms and problems in order to be able to function as well as possible again. Depending on the complaints and how they limit a person's daily activities, different therapies are used. For example, physiotherapy for problems with walking and occupational therapy when self-care is difficult.
 
This can sometimes be with a primary care practitioner, i.e. a therapist in the neighborhood. If there are problems in more areas, treatment by a rehabilitation team led by a rehabilitation doctor is usually necessary. You can then be admitted to a rehabilitation center or follow a day treatment program from home in a rehabilitation center.
 
The rehabilitation doctor may treat spasticity with medication or injections. Speech and language problems are treated by a speech therapist. Cognitive and mood problems are examined and treated by a neuropsychologist. The rehabilitation team often pays attention to resuming work after a stroke at a young age.

Rehabilitation at a later stage

Sometimes problems caused by the brain injury only become apparent after a long period of time. In this case as well, the general practitioner, neurologist, neurosurgeon, or nurse specialist can refer you for treatment by a therapist in the neighborhood, the treatment program Hersenz, or a rehabilitation doctor. Problems that only become apparent after a longer period of time often consist of behavioral changes and cognitive issues, such as difficulty with memory, planning, or dual-tasking and slow thought. This often requires specialized rehabilitation.

Aftercare

In the Netherlands, aftercare is arranged differently for each hospital. In many hospitals this is done at the aftercare outpatient clinic, but it can also be arranged through a home care organization or through rehabilitation.

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Aftercare

In the Netherlands, aftercare is arranged differently for each hospital. In many hospitals this is done at the aftercare outpatient clinic, but it can also be arranged through a home care organization or through rehabilitation. Often, there are regional agreements on this matter. You can contact your therapist for this.
 
In most treatment centers you will be scheduled for an appointment with a nurse specialist or specialized care provider from the aftercare outpatient clinic after the admission. They discuss the questions and problems that have arisen after the hemorrhage. For example, problems with memory, attention, concentration and fatigue, side effects of medication, or new complaints. As a rule, this person is also available for questions. They can give advice or refer you to an organization that can support you in this. Attention is also paid to the presence of risk factors for cerebral hemorrhage such as high blood pressure, smoking, and obesity.

Survivor stories Anita

“By being open about it, people understand me and can take it into account. We regularly make jokes about it. That keeps things light.”

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Survivor stories Anita

1 When did you find out you had an SAH (brain hemorrhage)?

Five years ago, after a visit to the general practitioner, I ended up at the ER in Arnhem, to my great surprise. There, a SAH due to a burst aneurysm was detected. I was transferred for treatment. I had a terrible headache for 10 days, I was nauseous, and I had to vomit. All of this occurred suddenly and severely. I also had a strange feeling in my arms and legs. I didn't see the seriousness of the situation back then. It wasn't until later that I realized that I was really suffering from something serious. In fact, I was actually very lucky, since I am able to tell this story.

2 How did the treatment go?

The next day the neurosurgeon came by to get acquainted and to explain what the next steps would be. The aneurysm had to be coiled. The calmness he radiated and the matter-of-fact, clear explanation, allowed me to face the operation confidently. After the operation I spent a night at the Medium Care and after a period in the nursing ward I could go home. Except for the fatigue, I felt good.

3 How do you look back on your recovery?

The recovery period was trial and error. I greatly underestimated the impact of the SAH. I am the type of person who is used to being busy with all kinds of things all day long. That was no longer possible. I had to deal with a lot of fatigue and irritability. Talking was exhausting; I was yawning and sometimes nauseous. I also got frustrated because I couldn't do everything at the pace I wanted and was used to.
I told my story to the nurse specialist and heard that most people after a SAH have complaints like this. It was nice to hear that there was getting stronger and she gave me tips on how to proceed. I'm still reaching my limits every now and then. Afterwards, I can usually point out the cause of this. In recent years, I have learned that I can do anything I want, as long as I pace myself. But pacing is still the hardest part for me. I am always open about what's happened to me and the consequences of it. This is because, at first sight, my limitations are not obvious. By being open about it, people understand me and can take it into account. We regularly make jokes about it. That keeps things light.

4 What do your check-ups look like?

At the moment I am still being monitored: I undergo an annual MRI scan to check if there is any development in the aneurysm. I don't think that's a problem and I don't find it nerve-racking any more. At my own request, I have been receiving the results over the past few years by telephone. If I want a consultation with the doctor, this is also possible.

5 How did you experience the care?

Five years ago, I was taken care of very well by the nurse. She could tell what I needed and was understanding. I was comfortable in the nursing ward. Doctors, nurses, the nurse specialist, and the nutrition assistants I have dealt with were all professional, clear, friendly, involved, and reachable. I felt supported.