| How are aneurysmal subarachnoid haemorrhages managed? |
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| balloon inserted from groin into artery with vasospasm before and after inflation |
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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 Royal North Shore and Dalcross Hospitals in the Intensive Therapy 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 Royal North Shore and Dalcross Hospitals 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 angioplasty.
Following intensive care.
At Royal North Shore and Dalcross Hospitals the normal length of stay in the intensive therapy 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.
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