Subarachnoid haemorrhage

A guide for patients and carers

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Possible treatments

The aim of treatment is to prevent bleeding or re-bleeding. There are different possible treatments and the decision about which particular method should be used is made by a neurosurgeon, an interventional neuroradiologist (a specialist who treats aneurysms via the blood vessels), and other members of the health care team, in discussion with you and your family.

The chosen method will be the one most suitable for your particular situation.

The decision will depend on a number of factors, including the size and position of the aneurysm.

Conservative management

The decision to go ahead with a treatment is made when the benefits are deemed to outweigh any possible risks. Due to the individual nature of SAHs, it might be that a decision is made not to go ahead with any interventional treatment like coiling or clipping (see below).

Instead, you will be managed “conservatively”. Treatment will focus on managing your symptoms rather than treating the aneurysm.

Coiling

In the 1990s, coiling was introduced as a way of treating ruptured and unruptured aneurysms without the need for a craniotomy (see below).

Coiling involves approaching the aneurysm from inside the blood vessel, avoiding the need to open the skull. Small metal coils are inserted into the aneurysm through the arteries that run from the groin to the brain. The coils remain in the aneurysm: they are not removed. They prevent blood flowing into the aneurysm and therefore reduce the risk of a bleed or a re-bleed. Blood then clots around the coils sealing off the weakened area.

Coiling is the most common treatment for SAH.

What happens before the procedure?

Although the coiling procedure is similar to an angiogram, involving a catheter being fed up to the brain via the femoral artery, it is much more complex and is carried out under a general anaesthetic in the radiology department.

This means you must not eat or drink anything for four to six hours before the procedure. The staff on the ward will advise you on this.

Before you leave the ward, a nurse might shave a small area of your groin at the entry site through which the coils will be passed. If you are well enough, and if you prefer, you might be able to shave yourself.

On arrival at the radiology department, an anaesthetist will give you a general anaesthetic and you will be asleep throughout the procedure.

What happens during the procedure?

The room will have several large pieces of high-technology scanning equipment which are needed to perform the coiling.

The radiologist will make a small incision in your groin through which they will insert the small tube into your femoral artery. This is then guided through other blood vessels in your body until it reaches your neck and then into your brain.

Using a guide wire, one by one, the coils are slowly inserted into the aneurysm. The coils are made of platinum, are twice the width of a human hair, and can vary in length. The number of coils needed depends on the size of the aneurysm. The largest coil is inserted first and then smaller coils are inserted until the aneurysm is filled. Usually, several coils will be used.

Each coil has a small electric current passed through it to detach it from the guide wire. This small current also helps the blood to clot and helps to seal the aneurysm.

The radiologist will remove the catheter. Occasionally, the entry point in the groin will need to be sealed or stitched. It might be slightly painful, and there might be some bruising.

Coiling is a complex and delicate procedure that will take at least three hours and often longer.
An aneurysm being packed with platinum coils

An aneurysm being packed with platinum coils

What happens after the procedure?

You will probably spend some time in the high dependency unit – usually at least two hours.

During this time, regular neurological observations will be performed by the nursing staff. This is to check that you are waking up properly from the anaesthetic. It involves asking you simple questions, testing the strength of your arms and legs, and shining a light in your eyes. Your blood pressure, heart rate, respiratory rate, and oxygen levels will also be monitored.

The nurse will check the small wound in your groin for any bleeding and also check the pulse in your foot. This is to ensure that your blood circulation to your legs has not been affected.

It might be that the opening in the artery in your groin is plugged closed after the procedure. This is done with a device called an angioseal which dissolves within a few weeks.

You will have to lie flat, or at an angle of no more than 30 degrees, for at least six hours following the procedure. This helps with your blood pressure and prevents any excess pressure on the artery which could increase the chance of bleeding at the puncture site in your groin. Depending on your recovery after this time, you will be able to sit up gradually. The nurses will assist you with this.

Throughout this time, the nurses on the ward will continue to monitor you and carry out neurological observations. Pain-killers will be given for any discomfort or headaches you might be experiencing.

You are also likely to have a drip to prevent dehydration, and possibly a urinary catheter. Because you are restricted to bed rest, you will have to wear pressure stockings to help prevent blood clots forming in your legs (deep vein thrombosis).

What are the risks of coiling?

It is likely that the benefits of coiling will strongly outweigh any possible risks, and your doctor will have discussed this with you fully before you give your consent to go ahead with the procedure.

However, as with any invasive procedure, there are certain risks associated with coiling. Possible complications include stroke-like symptoms such as weakness or numbness in an arm or leg, problems with speech, or problems with vision. There is also a risk of bleeding, infection or arterial damage at the entry site in the groin.

How successful is coiling?

Research is still being conducted to explore the benefits and risks of coiling. Various studies have been published. The largest is the International Subarachnoid Haemorrhage Trial (ISAT) which was established to explore the effectiveness of coiling compared to clipping (see below) of ruptured aneurysms. The trial involved different neurosurgical centres and a total of 2,143 patients participated. The ISAT trial showed that the long-term risks of further bleeding are low for both coiling and clipping, and the results positively supported coiling as a treatment for ruptured aneurysms, both in terms of survival and in the reduction of long-term disability.

The National Institute for Health and Clinical Excellence (NICE) have approved coiling as a treatment of ruptured aneurysms and have published guidelines on the procedure.

Can the coils move?

Once the coils are securely in place they will not move out of the aneurysm.

Will I need more coils?

Although the coils do not move, they might settle into the space within the aneurysm. This might mean that more coils are required to block off the aneurysm fully. This is why you will have a follow-up angiogram. Around one in five patients will require further treatment.

Craniotomy

A craniotomy is an operation to open the head in order to expose the brain. The word craniotomy means making a hole (-otomy) in the skull (cranium). The operation is carried out by a neurosurgeon who specialises in surgery of the brain and spine.

What happens before the operation?

The general state of your health and condition you are in can affect when you have the surgery. The surgeon and anaesthetist might delay the operation if you are very ill as a result of the haemorrhage, or another medical condition, because this can increase the risks of surgery.

The operation is carried out under a general anaesthetic which means you will be asleep throughout and will not feel anything.

A small horseshoe-shaped area of your hair is shaved over the point at which the aneurysm can be reached.

What happens during the operation?

An incision (cut) is made in the scalp, a skin flap is peeled back, burr holes are drilled in the skull, and then a piece of bone (“bone flap”) is cut out like a trap-door to reveal the brain underneath. The surgeon then looks for the aneurysm and permanently closes the connection between the blood vessel and the aneurysm using a small plastic or titanium clip.

The bone flap is then replaced and the scalp is stitched together. The bone flap is usually fixed into place with small metal screws to prevent movement and encourage better healing.

The operation takes approximately four to six hours. This includes the time taken to transport you from the ward to the operating theatre, give you the anaesthetic, the operation itself, and the time you spend recovering from the anaesthetic.
Craniotomy incision and replacement of the bone flap

Craniotomy incision and replacement of the bone flap

What happens after the operation?

You will usually be woken up as soon as the operation is over. You will regain consciousness in the recovery area where specialist nurses monitor your progress very closely. Occasionally, intensive monitoring is required, and you might be transferred to an intensive therapy unit or a high dependency unit. You might then be kept asleep on a breathing machine for a period of time after the operation to allow your brain to recover. If this is likely to be necessary, your surgeon will discuss it with you before the operation.

Once you have been transferred back to the ward you will be carefully observed and monitored. You will be given fluids through a drip into your vein. You might also have a drain to remove any fluid oozing from the wound. Sometimes a fine tube (catheter) is placed into the bladder to help you pass urine. All of these tubes will gradually be removed as your condition improves.

What problems might I experience after the operation?

Very rarely, a blood clot might form on the surface of the brain at the site of the operation. If this happens, depending on the size of the clot, you might need a second operation to remove it. Otherwise, the doctors and nurses will monitor your condition.

During a craniotomy, a small cut is made in the muscle that helps with chewing. As it heals after the operation, the muscle can be slightly shortened causing the jaw to feel stiff. You might have difficulty in opening your mouth. This problem usually begins to clear up after a couple of months. Chewing gum can help to resolve this problem.

It is common for there to be swelling and bruising to your face. Your eye might be closed for a day or two. The nurses will bathe your eyes for you.

As the wound in your head heals, it might feel painful and you will be offered pain-killers to help relieve any discomfort. This gradually improves and is usually better by the time the stitches are removed, three to five days after the operation. Some surgeons use stitches that dissolve and so do not need to be removed.

The skin around the edges of the wound might feel a bit numb until the healing is complete. This numbness might be painful or unpleasant and the wound might also feel itchy, or very cold. This might persist for a few months.

Wound infection is not usually a problem. Antibiotics are often given around the time of the operation as a preventative measure. Lumps or indentations around the wound are common.

The bone flap (the piece of bone cut out during the operation) might feel like it moves. Because the pressure in your head can vary, the flap of bone can move in and out very slightly. You might experience a “clicking” sensation. Although this feels strange, it is not dangerous. The bone flap is not loose: it is secured when it is replaced and will heal back into place.

Headaches are common and might last for several months before they gradually settle down. Some people find that their headaches persist for a longer period of time.

Can the clip come off?

The risk of the clip coming off is extremely small. Modern clips are not affected by airport security systems. Most people are also safe to have MRI scans, but you should discuss this with your doctor or nurse.