Treatment of Subarachnoid Hemorrhage
Submitted by Heather Miller, RN
Gina Noggle, RN
A subarachnoid hemorrhage (SAH) is often a devastating occurrence. It affects approximately 30,000 U.S. citizens a year. It can either come from a traumatic brain injury (TBI) or a ruptured cerebral aneurysm. Ruptured cerebral aneurysms account for 75-85% of the cases. Even with all the improvement and advances in medical knowledge and technology, subarachnoid hemorrhage still has approximately a 50% mortality rate, with most occurring before they even enter the hospital, and another 30% of patients have some extent of permanent disability. The remainder have a fairly good recovery. In this article we will discuss the treatment for subarachnoid hemorrhage. (D’Souza, 2015).
When a patient presents to the hospital claiming to have, “The worst headache of my life,” doctors and nurses start thinking about a ruptured cerebral aneurysm. This is a common phrase that is used by most patients when they have a SAH. Other symptoms usually depend on the severity of the bleed and include: nausea and vomiting, loss of consciousness, drowsiness, confusion, focal neurological deficits, hemiparesis, neck stiffness, seizures, and even coma. Patients are quickly assessed and taken to radiology for a computed tomography angiography, CTA, of the head (Liebeskind, 2016).
After a patient is diagnosed with a nontraumatic subarachnoid hemorrhage, the talk of intervention and surgery comes up. There are two different types of treatments for a SAH that are typically done to repair a ruptured aneurysm. Either intravascular coiling done in the interventional radiology department or a craniotomy for a clipping of the aneurysm is done in the operating room. In a surgical clipping, the neurosurgeon opens the skull and locates the leaking blood vessel. The surgeon then places a clip across the aneurysm preventing blood from entering the area and causing a further bleed. A coiling is done in interventional radiology under angiogram by an interventional radiologist, neurosurgeon, or interventional neurologist. This is done by threading a tube through the arteries and then identifying the aneurysm. The aneurysm is then filled with platinum wire coils or with latex. This also prevents blood from entering the area and causing further bleeding (Wedro, 2016).
Once a patient has had either a surgical clipping or a coiling, they are admitted to the intensive care unit for close observation. Unfortunately, even if the patient makes it to this point there is still a risk of delayed cerebral ischemia (DCI) and even death. Delayed cerebral ischemia is usually caused by vasospasms which occur in approximately 30% of these patients. As a result, an estimated 14% either sustain major morbidity or die. Vasospasms occur when the large arteries constrict at the base of the brain. This decreases the perfusion of blood to those areas and can cause ischemia and infarctions in those areas of the brain. This usually arises 3 – 7 days after the initial bleed. It is not clearly understood why the vasospasms happen, but they appear in several patients following subarachnoid hemorrhage. There is little one can do to completely keep the vasospasms from occurring, but it is our job as nurses to help the physicians try to decrease the severity of the vasospasms and recognize when further treatment needs to be initiated (Ashley, 2016).
Within a few days of surgery, interventions are started to prevent the effects of vasospasms. The most common test used to detect vasospasm is transcranial Doppler (TCD). TCD is a noninvasive test that detects the intracranial arterial blood flow and thus the likelihood of vasospasm. This test is usually done daily or every other day (Ashley, 2016).
One treatment that is used to prevent vasospasm is the drug Nimodipine. This medication is a calcium channel blocker that has shown the most success in reducing the occurrence and severity of vasospasms. Patients are usually prescribed this drug every 4 hours for up to 21 days after the initial head bleed (D’Souza, 2015).
A treatment referred to as triple H therapy is then initiated. This stands for hypertension, hemodilution, and hypervolemia. Its intent is to reduce blood viscosity and increase the mean arterial pressure to help blood flow to these spasming arteries. One study found that 70% of patients receiving triple H therapy had a marked decrease in vasospasm symptoms. In addition to IV fluid, sometimes medications are used to increase the patient’s blood pressure. Phenylephrine is the the most commonly used medication for this (Ashley, 2016).
If these treatments fail and the patient develops symptomatic vasospasms, the patient is sent to interventional radiology to try an additional intervention. As in the coiling procedure, a wire is threaded into the artery and medication injected into the arteries directly at the source, in an attempt to reduce the severity of the vasospasm. The most common drugs used are Verapamil and Nicardipine. Both of these drugs are calcium channel blockers and both are effective at reducing the severity of vasospasm. This treatment is often done very frequently until the vasospasms subside which can take several days to even weeks following the initial aneurysm rupture (D’Souza, 2015).
In spite of all the attempts and treatments to give these patients a good outcome, that doesn’t always happen. As previously stated, of the patients that survive past the initial hemorrhage and surgery, 14% will still die or have significant morbidity from DCI. Hopefully, in the near future, further studies and research will be conducted to help these patients have a better outcome.
Ashley, W. (2016, July 10). Cerebral Vasospasm After Subarachnoid Hemorrhage Treatment & Management. Retrieved from URL http://www.medicinenet.com/brain_aneurysm/article.htm
D’Souza, S. (2015, July). Aneurysmal Subarachnoid Hemorrhage. Journal of Neurosurgical Anesthesiology, 27(3), 222-240. Retrieved from URL http://journals.lww.com/jnsa/Fulltext/2015/07000/Aneurysmal_Subarachnoid_He morrhage.6.aspx
Liebeskind, D. (2016, August 4). Cerebral Aneurysm. Retrieved from URL http://emedicine.medscape.com/article/1161518-overview
Wedro, B. (2016, February 8). Brain Aneurysm (Cerebral Aneurysm). Retrieved from URL http://www.medicinenet.com/brain_aneurysm/article.htm