Subarachnoid haemorrhage no cause found
What is a subarachnoid haemorrhage (SAH)?
A subarachnoid haemorrhage is caused by a leakage of blood from a blood vessel that lies beneath the arachnoid membrane covering the brain. Subarachnoid haemorrhage occurs suddenly and usually without warning. Symptoms are a sudden, severe headache and often accompanied by sickness, vomiting, neck stiffness, photophobia (dislike of light). In some instances there is also loss of consciousness and/ or a seizure (fit). There may be difficulty with speech, disturbance in vision or a weakness in an arm or leg. There are three membranes covering the brain known as the meninges; (the pia, arachnoid and dura) The blood vessels within the brain lie below the arachnoid membrane.
Could it have been prevented?
Diagnosing a subarachnoid haemorrhage
This is usually made by your history, head scan and occasionally lumbar puncture. If the tests appear positive, you will be transferred to The Walton Centre for further investigation. You may be required to undergo bed rest and will be closely observed in the ward environment. You will be given regular pain killers and medication to help prevent sickness. Laxatives will also be offered as the pain killers can cause constipation. You are usually required to have about three litres of fluid each day for about two weeks if you are able. This is either by drinking or by a “drip” into the vein. It is important your urine output is measured every time you go to the toilet. Plenty of fluids help keep a good blood flow to the brain. You may be required to take a 21 day course of tablets called Nimodipine. These have to be taken every four hours and help prevent complications due to the haemorrhage.
Investigations to find a cause
You will undergo a brain scan after injection with contrast which shows the blood vessels within the brain. This is called a CTA (Computerised Tomography Angiogram) if no cause can be found then after the doctors review your case you may require a more formal angiogram – DSA (Digital Subtraction Angiogram). This is a test which involves the injection of dye through a catheter (tube) inserted into an artery in the groin which is then passed up to the brain through major blood vessels and a series of x-ray pictures are taken. This shows very clear pictures of the blood vessels within the brain. You may be given provisional results immediately but formal results are given once these pictures are reviewed in depth by your medical team. There is a separate information leaflet regarding the angiogram which you should get when you sign consent.
No vascular abnormality found
In many cases a cause is found such as an aneurysm (or blister) on the blood vessel. However, in approximately 15% of cases no vascular abnormality is identified. It is not always known exactly why such haemorrhages occur, but it is known that the risk of a future haemorrhage is extremely low and the outlook for recovery is positive. These cases are reviewed and discussed by a panel of experts called the multidisciplinary team if needed. When no cause is found, no treatment will be required other than to support through illness by managing symptoms. Whether a cause is found or not you will still need to recover from the subarachnoid haemorrhage itself.
In certain cases further tests are necessary. These are specific to each individual case. They may include further blood tests whilst you are still in hospital. It may be decided you need a delayed angiogram or an MR scan of your brain as an inpatient or after you go home. You may require review and your care to be taken over by other doctors who are specialist in cases where no cause such as an aneurysm is found (vascular neurologists).
Once it is decided that no further investigation is needed as an inpatient and your medical team are happy that you are recovering you will be allowed home. You may need further investigations as an outpatient. The tests you will need should be discussed with you before you go home. It is advised that you get your blood pressure and cholesterol checked by your GP about a month or two after going home.
You will normally stop this but some may be required to complete the 21 day course of Nimodipine. It is used to reduce the risk of developing complications with vasospasm (a process where the blood vessels close after a brain haemorrhage as a reaction to the blood). This risk has passed by 21 days and so the course doesn’t have to be continued. The tablets need to be taken regularly every four hours.
Side effects of Nimodipine are low blood pressure, flushing, changes in heart rate, headache, feeling sick and feeling too warm. Alcohol and grapefruit juice shouldn’t be taken along with Nimodipine as these may make side effects worse. Please read the leaflets accompanying the medicines given to you to take home from hospital.
You may go home with pain killers. You should take these regularly to begin with if you need them. They should be cut down as soon as tolerated as taking them for too long may make headaches worse not better! Certain types of pain killers can cause constipation and so laxatives are usually given to you. Eating a diet that is high in natural fruit and fibre helps too. If medication side effects occur, seek medical advice.
You will probably need rest once you get home particularly if you are having a lot of visitors or your house is very busy. Even simple tasks such as a walk to the local shop may leave you feeling exhausted. This will usually improve with time although doesn’t always completely go away. You will know if you have done too much as you will be exhausted and may experience more headaches. This often happens early evening or the next day and means you have to take a rest!
You may benefit from pacing your activity for the first four weeks following going home. Take some gentle exercise. Build up activity as you feel able to and try to go outside for regular walks if you are able; otherwise you may lose your confidence and fitness. Aim to build up to half hour walks five days a week. You will probably need to take a rest each afternoon in the first few weeks of recovery.
Some people experience unusual or strange sensations in their head following a brain haemorrhage. These are common symptoms and we are not sure why they occur. Do not worry about them as they should ease with time.
Sensitivity to noise
This is not uncommon following a brain haemorrhage. Everyday noise such as television or background conversations can be just as difficult to cope with as loud noises. This usually settles down with time as you recover.
Headaches are common after a subarachnoid haemorrhage and usually they ease with time. They may, however, persist. Headaches can be triggered by dehydration, stress, illness, too much or too little sleep and missing meals. Prolonged or regular use of analgesia (paracetamol, ibuprofen, codeine, morphine etc.) may also worsen or prolong headaches so should be used sparingly and stopped if no longer required. Drinking two to three litres of water per day, regular meals, ensuring a good sleep pattern and in some instances avoidance of certain triggers (caffeine, alcohol, cheese etc.) can help reduce the frequency and severity of headaches. There are also some non-invasive treatment options such as menthol sticks to rub on the forehead which may help. Drinking more water and using pain relief at the start of a headache may also help. If headaches persist and are troublesome despite this, you may need specialist management. If your headaches persist or get worse, seek advice from your GP.
Fear of re-bleed
This is a very common fear for all patients, particularly if no cause was found. The chance of another bleed is extremely rare and is usually no higher than everyone else in the general population. It is important to learning a coping strategy as this fear may prevent your recovery progressing. In the unlikely event that you get the same symptoms as you did when you had a brain haemorrhage you need to go to your local accident and emergency department.
Recovery is dependent on how you feel. You will need to pace yourself for the first month or more after going home because of tiredness and headaches. Save your energy for the things you have to do and those you want to do. Looking after yourself in the early days of recovery is beneficial to your wellbeing in the long term. Feelings of anger, frustration and sadness are not uncommon following a brain haemorrhage. This may be due to the condition but could just as well be due to the sudden life changing event and usually passes with time and support. If you are affected, you should talk to your GP as you may benefit from being referred for talk therapy or a psychologist to help you through this stage of recovery.
Family and friends
Enlist the support of your family and friends whilst you recover. They will be a great help with shopping, transport and support and will be the biggest influence in your successful recovery. It is advised to have someone stay with you for the first week or so after going home. The “Brain Haemorrhage Support group” affiliated to The Walton Centre also offer emotional support and practical (not medical) advice from personal experience (details below).
You should not drive for the first month following your subarachnoid haemorrhage or until you have recovered. This is because driving involves many different cognitive and physical skills as well as multitasking, decision making and problem solving. You cannot drive if you have new visual problems, cognitive problems or stroke like symptoms. You cannot drive if you have had a seizure (or fit) as a result of the subarachnoid haemorrhage. Following a subarachnoid haemorrhage, if you hold a driving licence, you are legally required to notify the Driver and Vehicle Licensing Agency (DVLA). In your case they will need you to confirm that you have had a confirmed subarachnoid haemorrhage and no cause was found after a “comprehensive angiogram”. Speak to your neurovascular nurses to confirm this and gain advice regarding driving. Driving restrictions are enforced by the DVLA and each case has to be approved individually. You must speak to your medical team or nurse to clarify driving restrictions.
Returning to work
You can return to work as soon as you feel able from about six weeks following your brain haemorrhage. It will not make you ill to return sooner if you recover sooner and want to or have to for financial reasons. Most people, however, need about three months to recover. (Occasionally longer if there have been significant problems.) You should go back to work on a phased return. This means you build up your working days and hours according to how you are feeling. A phased return is often graduated over four weeks or longer and your employer has an obligation to adhere to it. The Brain Charity will help you if you are having problems with returning to work. The number is printed at the back of the booklet.
Will I be entitled to any benefits?
You may be entitled to sick pay from your employer, or you may be able to claim benefits appropriate to your specific situation. You should contact an agency such as Citizens Advice Bureau or Brain Charity to discuss individual circumstances and what you are entitled to.
If you are taking Nimodipine, do not drink alcohol until the 21 day course is completed and you have reduced the number of pain killers you take. However, most people find they are not able to tolerate large amounts of alcohol. The government suggests no more than 14 units a week. Details of an information website on alcohol awareness is printed below.
It is advisable that you give up smoking completely. A free helpline number is printed at the end of this booklet.
You can resume sexual activity as soon as you feel able.
Starting a family
You can start a family as soon as you have concluded investigation and have results that all is well. You will benefit from taking a few months to recover your physical fitness before planning a family. You will not normally be prevented from a normal delivery but this will depend on your obstetrician.
Sport and swimming
Exercise is encouraged as it improves stamina and wellbeing. Most sports can be resumed once you feel able. However, you should build up your fitness slowly as soon as you feel able. It is advisable to go swimming with somebody during the first year following your brain haemorrhage. Extreme exercise should be avoided until all delayed investigations are complete and results have been given.
Dental treatment is safe after a subarachnoid haemorrhage. Your dentist may need to seek advice from your consultant or GP if you are taking aspirin.
If you have had a subarachnoid haemorrhage with no vascular abnormality found, you should be able to fly as soon as you feel able.
If you have more specific questions please ask your neurovascular nurse specialists, medical team or ward nurses.
Going home information
Date of subarachnoid haemorrhage……………………………………
Medicines to take home:
Follow up advice:
Follow up (clinics):
Information for self help
Brain Haemorrhage Support Group offers practical advice and emotional support for all patients and their families/friends that have had a subarachnoid haemorrhage. A diary is available from them for you to watch your progress.
The Brain Charity– Information and support for people with neurological Conditions (Leaflet available at the helpdesk on the ground floor of the main hospital building).
- Information is available for all patients who have had shunts inserted as a result of brain haemorrhage. (Through your ward staff, neurovascular nurse specialist, hydrocephalus nurse specialist.)
- Information is available for all patients who have epilepsy as a result of brain haemorrhage. (Through your ward staff, neurovascular nurse specialist, epilepsy nurse specialist.)
- ‘A Dented Image’ Alison Wertheimer. This is a self-help book with stories of recovery from patients who have had a Subarachnoid Haemorrhage (ISBN; 978-0-415-38671-5)
- “Road to Recovery.” This is a voluntary information course organised and run by the neurovascular nurse specialists/Walton Centre and supported by the Brain Haemorrhage Support Group. It usually runs once or twice a year depending on resources and need. It is for those people and family/friends who have recently been affected by subarachnoid haemorrhage. Information about the course is available through your neurovascular nurse and customer care team. You can request an invitation to this course at any time if you think you may benefit.
- Last Updated:01 May 2021
- Review Date:01 May 2023
- Author:C Stoneley
Diagnosis and treatment for a subarachnoid haemorrhage