David Greer, MD, MA, FNCS, Professor and Chair of Neurology, Boston University and Boston Medical Center; Secretary NCS
Sarah Livesay, DNP, APRN, FNCS, FAAN, Professor and Associate Dean, Rush University College of Nursing; President, NCS
Panos Varelas, MD, PhD, FAAN, FNCS, Professor of Neurology and Chairman, Department of Neurology, Albany Medical College; Immediate Past President, NCS
Paul Vespa, MD, Professor of Neurology and Neurosurgery, UCLA; Vice President, NCS
Susan Yeager, DNP, APRN, FNCS, Neurocritical Care APP Educator; Treasurer, NCS
With the recent news that actor Tom Sizemore was in critical condition from a brain aneurysm, many are wondering exactly what a brain aneurysm is, what a subarachnoid hemorrhage is, how it happens, and how to prevent and treat it. As healthcare providers who commonly care for patients who have survived a subarachnoid hemorrhage, we as leaders of the Neurocritical Care Society wanted to share some helpful information and FAQs to help raise awareness in the community.
Q: What is an aneurysm, and what is a subarachnoid hemorrhage?
A: An aneurysm is a small bubble that forms on an artery—a weak spot that can burst unpredictably and cause bleeding to occur. Not all aneurysms rupture and cause a hemorrhage; some aneurysms are detected and treated before they rupture. But when they do rupture, they cause a subarachnoid hemorrhage, or bleeding that occurs on the surface of the brain. Besides ruptured aneurysms, which usually cause bleeding at the base of the brain, other causes of subarachnoid hemorrhage include trauma to the brain and other malformations of blood vessels in the brain.
Q: Is a subarachnoid hemorrhage serious?
A: Yes. A subarachnoid hemorrhage is very serious and carries a high risk of causing death or serious disability. It is one of the most dangerous forms of stroke, and patients with a subarachnoid hemorrhage need to seek medical attention immediately.
Q: How do you diagnose a subarachnoid hemorrhage or an aneurysm?
A: Usually your clinicians can diagnose a subarachnoid hemorrhage by a simple CT scan, but sometimes an MRI can provide additional information. Sometimes, when a CT scan appears normal but a patient’s symptoms are very suggestive of a subarachnoid hemorrhage (i.e., sudden onset of the worst headache of their life), a lumbar puncture—or “spinal tap”—is performed to see if blood can be detected that way, as approximately 5% of subarachnoid hemorrhages are initially missed on CT scans. However, diagnosing an aneurysm usually requires a separate type of test called an angiogram that specifically focuses on the blood vessels in the brain, often by injecting a kind of dye that makes them stand out from everything around them. This could be done by performing a catheterization, where a catheter on the inside of your body directly injects dye into the blood vessels, but also with a CT or MRI angiogram that could help screen for an aneurysm non-invasively.
Q: How do you treat a subarachnoid hemorrhage?
A: The first steps are for your clinicians to ensure that a person is stable, usually by making sure they can breathe safely and have adequate blood circulating to their body. Then we try to “secure” the aneurysm as quickly as possible to make sure it doesn’t bleed again. This can be done either by placing metal coils inside the aneurysm (using the same kind of catheterization that is used for diagnosis), or by doing a surgery where the skull is opened and a clip is placed on the outside of the aneurysm. In both cases, the goal is to prevent the aneurysm from filling with blood and potentially bleeding again. The kind of treatment chosen often depends on factors related to the aneurysm itself and other medical conditions a patient might have.
Q: Once the aneurysm is treated, are they okay and can they go home?
A: Securing the aneurysm is actually only the first part of the journey after a subarachnoid hemorrhage, and people often need to spend weeks in the acute care hospital getting further treatment from a multi-disciplinary team for complications that can occur. One the most important complications is called “cerebral vasospasm” where the arteries become narrow due to irritation from the blood around the brain. This can lead to strokes which can be very disabling, so detecting and treating “vasospasm” is crucial to prevent patients from becoming disabled or even dying.
Q: What is the prognosis for someone with a subarachnoid hemorrhage?
A: The prognosis can vary quite a bit. Some patients do very well and can resume a normal life after their treatment. Some are left with some level of disability, which can be cognitive (e.g., affecting their speech, thinking, memory, or personality), visual (e.g., loss of vision or double vision), or affect their mobility (e.g., paralysis of an arm or a leg). Some people are left with a severe disability and are dependent on others for their daily life, and sadly some people die from subarachnoid hemorrhage despite our best efforts.
Q: What can I do to avoid a subarachnoid hemorrhage?
A: The biggest risk factors for developing a cerebral aneurysm are high blood pressure and smoking, and sometimes they can run in families due to genetics. Controlling your personal risk factors—and sometimes getting a screening CT scan or MRI—are the most important things you can do to prevent a subarachnoid hemorrhage. If you have a strong family history of aneurysms, you should consult with your provider.