How are aneurysmal subarachnoid haemorrhages managed?
This is a serious
problem and requires intensive treatment in order to monitor, prevent and treat
the effects of the haemorrhage (including the risk of vasospasm and
hydrocephalus) and the prevention of further haemorrhage.
Prevention of a rebleed.
Insertion of coils or treatment by microsurgery
is performed early in the treatment to prevent further bleeding. Approximately
50% of aneurysms are best treated by coiling and 50% by microsurgery. A small
percentage is best not treated at this stage because of co-existing medical
problems or the extreme devastation of the initial haemorrhage. In the case
where treatment is planned the best treatment is determined by aneurysm size,
shape, location, patient age, the presence of calcium within the neck of the
aneurysm, neurological condition, other co-existing health problems and the
availability of the expert surgeon or interventional neuroradiologist.
Prevention and treatment of hydrocephalus.
When there is an excess of CSF accumulating
within the cavities of the brain the extra pressure can lead to neurological
compromise. The prevention of this build up of fluid is to insert a fine bore
tube into these fluid filled space and allow it to drain externally. This is called
an external ventricular drain. Although this procedure carries a risk of
infection and bleeding into the brain, these risks are small when compared with
the risk of irreversible damage to the brain in the absence of relieving the
pressure. Occasionally the brain fluid circulation never returns to normal even
after the blood clot has been reabsorbed. In such cases, instead of having the
fluid drain externally, a shunt can be inserted allowing the CSF to drain away
from the brain into another body space by an internal insertion of tubes with a
valve. Again, the risk of such a procedure when recommended is small in
comparison with the potential damage caused to the brain from the build-up in
pressure in the absence of such a shunt.
Prevention and treatment of vasospasm.
This narrowing of segments of brain arteries is
potentially the most common cause for patients doing badly after a subarachnoid
haemorrhage. Fortunately, many cases can be prevented and reversed. The initial
preventative measures include extremely closely supervised fluid, blood
pressure, oxygen and temperature management. This is normally performed at
Macquarie University Hospital in the Intensive Care Unit where medications may
need to be given in addition to fluid in order to tightly control these
parameters. Medications that might reduce the chance of developing vasospasm
are also given in these units such as nimodipine and magnesium. At Macquarie
University Hospital an angiogram is performed at a time that vasospasm might be
at its early stages (usually between days 5 and 7 following the subarachnoid
haemorrhage). If vasospasm is confirmed the interventional neuroradiologist can
enlarge the narrowed artery by inflating a balloon across the narrowed segment
or injection of a drug directly at the time of the angiogram. This is known as
Following intensive care.
At Macquarie University Hospital the normal
length of stay in the Intensive Care Unit is 10 to 14 days (depending on the
medical course) after which the patient is transferred to the neurosurgical
ward. During this time further recovery occurs and an assessment made of
whether the patient will be well enough to go straight home or may benefit from
further specialised rehabilitation. The neurosurgical, nursing and allied health
team co-ordinate the plan for future management. On average, from the start of
the subarachnoid haemorrhage to discharge normally takes an average of 21 days.