Sub Arachnoid Hemorrhage due to Cerebral Aneurysm

Cecily Ruba

Nurse Educator Kauvery Hospital Trichy Cantonment Tamil Nadu India

Abstract

A subarachnoid hemorrhage means that there is bleeding in the space between the layers of the arachnoid and pia that surround the brain. Most often, it occurs when a weak area in a blood vessel (aneurysm) on the surface of the brain bursts and leaks. The blood then builds up around the brain and inside the skull, increasing pressure on the brain.   This can cause brain cell damage, life – threatening complications and disability. Intra cerebral aneurysm often develops over a long period of time and may not cause any symptoms till it bursts or ruptures. Most aneurysms develop after 40 years of age.

Background

A Subarachnoid Hemorrhage is a complication, a type of hemorrhage inside the brain. This is different from an ischemic stroke which is caused by a blood clot.

Bleeding in the brain can sometimes cut through the brain tissue and leak in to the area outside the brain called Sub Arachnoid space. This is called as Sub Arachnoid Hemorrhage and can be life threatening. The blood from the hemorrhage can compress or displace vital brain tissue. A severe hemorrhage can cause a paralysis or coma.

After aneurismal Subarachnoid hemorrhage, the clinical outcome depends upon the primary hemorrhage and a number of secondary insults in the acute post- hemorrhagic period.

In the last 30 years of the incidence of spontaneous hemorrhage mostly from rupture of intracranial aneurysms has remained at around 6 to 10per 100,000 persons per year.SAH accounts for about 3% of all strokes and about 5% of stroke deaths,

Overall outcome has improved only modestly during the last decades. Case mortality is around 50% including pre hospital deaths and one third of survivors remain dependent.

Case Presentation

A male patient 58 years of age was admitted with H/O unresponsiveness at a bus stand. He was brought to the hospital by a stranger.

Social History

He does not have any social history of cigarette smoking, alcohol Addiction.

Allergies

No known medicine or environmental allergies.

Past Medical History

He was known to have Type 2 DM and was on treatment. He was also earlier diagnosed to hypertension but was not on regular treatment.

Past Surgical history

No known surgical history.

Physical Examinations

Vital signs:

Temp:98 degree fahrenhiet.HR:120/min,RR:18/min BP 130/90mmHg SpO2 :97%

GCS E4V4M6

Initial Evaluation

CT brain:

  1. Sub Arachnoid hemorrhage
  2. Brain stem contusion
  3. Small saccular aneurysm measuring 4*2mm present in the anterior communication artery. The neck of the Aneurysm is facing anterosuperiorly.
  4. Hematoma in the frontal region on inside and near the midline with diffuse Sub Arachnoid hemorrhage. Mass effect brain stem compression
  5. Early obstructive Hydrocephalus

He was diagnosed to have Secular Aneurysm in the ACA with SAH mass effect.

Patient was taken up for surgery Craniotomy +Clipping of Aneurysm done.

Post operatively he was under treatment with anticonvulsants, Low molecular Weight Heparin and other supportive measures and ionotropic support.

Patient was on ventilator support. Later Tracheostomy was done. Trial weaning done.

Post-operative CT scan findings:

  1. Bony defect right Fronto Parieto region
  2. Adjacent Parenchymal changes with aneurysm clip is in situ.
  3. Areas of hemorrhage (Intra Ventricular Hemorrhage)
  4. Minimal mass effect
  5. Obstructive Hydrocephalus

On his early post-operative period patient had sudden bradycardia and Hypotension. Emergency CT scan showed Acute Infarct in left ACA Teritorry.It was a new finding compared with previous CT scan.

Patient developed focal seizure at lower limb, with abnormal flexion response present

Then Decompression Craniotomy was planned but it was not performed,

Patient was on antibiotics, anticonvulsants and anti-hypertensive drugs.

Gradually patient’s vitals improved, Spontaneous eye opening was present. Left upper limb flexion response present to pain. Patients GCS improved. Hence patient was shifted to Neuro HDU for further management

Follow up treatment.

Patient GCS stable, E4VTM6, vital signs improved.

Able to recognize relatives.

Patient was discharged and moved to rehabilitation centre after successful decannulation. Patient was advised to come for regular follow up.

 Skilled Nursing Care:

Regular monitoring of the overall condition and reporting deviations in health status.

  1. Nutritional needs: Tube feeding given.
  2. Positioning:The head end elevation from 30 degree upto 45 degree in order to prevent swelling on the face and orbital edema. And frequent position changing done to prevent pneumonia.
  3. Early ambulation: Ambulated the patient to chair to improve his muscle strength.
  4. Pressure ulcer risk assessment measures taken to prevent bed sore.
  5. Sequential compression device applied in order to prevent deep vein Thrombosis.
  6. Hygienic and grooming measures taken
  7. Physiotherapy exercise given to evaluate the muscle strength balance and mobility. As physiotherapist will train the family the exercise to continue at home.
  8. Speech and swallow therapy given by the swallow therapist.
  9. Chest physiotherapy  offered to help reexpand the lungs and prevent pneumonia.
  10. Tracheostomy  care given and monitored and assisted to prevent complicate and early removal of tube done.
  11. Hygienic and grooming measures taken
  12. Clinical Nutrition:The nutritional requirements of the patient ,type of feed ,frequency and quantity of feed, supplements etc are decided and monitored by dietician on a daily basis .Diet chart is prepared and given when the patient is discharge.

To prevent aneurysm one should take healthy diet, keep the blood pressure level under check, lower high cholesterol, and exercise regularly. Advises to control stress, to treat obstructive sleep apnea and to quit smoking.

Conclusion

The risk of Aneurysm in Cerebral artery is becoming a common health issue in the old age. Immediate clipping of Aneurysm resolves Sub arachnid hemorrhage.

An international Subarachnoid trial study showed that surgical clipping has good outcome at one year. It can stop bleeding and prevent another episode in future. For unruptured aneurysm clipping usually provides an effective resolution to the problem.

However, brain damage that occurred prior to treatment may cause long lasting disability.

Although invasive surgical aneurysm clipping is highly effective in preventing aneurismal recurrence and rupture, in patients undergoing cerebral aneurysm clipping stroke is estimated to be a complication in up to 11.8% of patients. Main reason for acute infarct is due to vaso spasm or it may block normal artery unintentionally.

 

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