Management Of A Patient With A Subarachnoid Haemorrhage Essay Example

The aim of this assignment is to explore the management of a patient with a subarachnoid haemorrhage, which an acute neurological condition. The rationale for the case chosen, pathophysiology and nursing care of the patient will be discussed, ensuring critical thinking and analysis of relevant literature and theory to support decisions made by the multi-disciplinary team. It will demonstrate the complexity of different neurological issues, throughout this assignment the patient is referred to a name called ‘Anne’ to maintain the confidentiality and privacy of the Patient (NMC, 2021).

Anne is a 79-year-old lady admitted to the ward following one week history of headache, nausea, and vomiting. She developed a right sided weakness on the day before admission. On admission a computerised tomography (CT) scan was performed to help identify the cause of the neurological symptoms and it showed subarachnoid haemorrhage (SAH). Initially, she was admitted to the ward however her neurological status deteriorated on the ward and a repeated CT scan showed further bleeding caused by a ruptured cerebral aneurysm. Therefore, she went to the theatre for clipping of the cerebral aneurysm and an external ventricular drainage (EVD) was inserted to manage hydrocephalus. After surgery Anne’s breathing was supported with the help of a ventilator and she was transferred to the intensive care unit. She was extubated after two days and transferred to high dependency unit where she spent five days and then transferred to the ward. This assignment mainly focuses on the management of Anne’s condition while she stayed in the intensive care unit.

Subarachnoid haemorrhage (SAH) refers to the extravasation of blood into the subarachnoid space which lies in the meninges between the arachnoid mater and dura mater of the brain (Rinkel et al, 2011). As a vascular disease with lifelong modifiable risk factors SAH  has been shown to its peak incidence after 70 years of age (Valimaki etal, 2021: okuma etal, 2017 and it can have  along lasting complication in many people Macdonal d etal, andesson etal)  The incidence of this is more common in female as compared to males (Macdonald et al 2016, Am algra etal, 2012). This is because oestrogen and progesterone levels have a protective effect and therefore increased risk in post-menopausal women (Am Algra et al, 2012).  However, in their analysis Turan et al, (2016) found that t the presence of hese hormones might increase the risk of developing SAH. When refers to Anne her age , sex and past medical history of HTN also are the contributing factors in developing SAH ( Anderson etal, Am algra etal,)

There are mainly 3 scales used to grade the severity of subarachnoid haemorrhage (SAH).  The Hunt and Hess consist of 5 scores ranging from minimal symptomatic to coma.  This is useful in forecasting the outcomes among patients with severe neurological impairment or coma.  There are concerns regarding its ability to forecast outcomes WFNS World federation of neurosurgeon’s scale developed Agarwal et al, 2018). In WFNS World federation of neurological surgeons) the scoring is based on the severity of neurological impairment as rated by the GCS (Van Donkelar et al, 2017). Some consultants only use GCS as the main predictor for the outcome of SAH and found that the scores are superior to the Hunt and Hess Score or WFNS. On the other hand, Lagares etal, 2011 concluded  the factors besides the level consciousness has the best predictive function. Smith etal found that The NIHSS score has a robust impact in predicting the hospital mortality in patients with aneurysm, in subarachnoid haemorrhage. In addition to that ,the scales based on the imaging findings are used to help forecast the development of complications of subarachnoid haemorrhage such as vasospasm, ischemic stroke or predict the patient outcomes.

Most of the intracranial aneurysms are slowly growing vascular lesions.  Large population based observational studies shows that increasing age, female sex, arterial hypertension, smoking and a family history associated with higher chances of developing IA and its rupture. Mainly there are two types of aneurysm. Fusiform and saccular or berry type which is the most common type of aneurysm.  Intracranial aneurysm usually occurs at the branching point of the arteries associated with turbulent blood flow in the arteries at the base of the brain called circle of Willis.

Other causes include arteriovenous malformation (AVM) and head trauma (Rinkel et al, 2011). In the past few years there has been improvements in recovery from subarachnoid haemorrhage due to early diagnosis, aneurysm repair, administration of medication to prevent vasospasm and better intensive care support. As a result the survival rates are increased by 17 % (Macdonald et al, 2016).

The following part contain the anatomy and the pathophysiology related to SAH.

Three layers called the meninges encase the brain and spinal cord. From the top to bottom these layers are duramater, arachnoid mater and pia mater. The duramater is a dense connective tissue that is adherent to the inner surface of the skull and arachnoid mater is the thin impermeable layer and pia mater is the vascular layer. These three layers difines potentilyy clinically significant three spaces.  The epidural space which exist between the skull and duramater, the subdural space which is lies between the duramayer and the arachnoid mater and the subarachnoid space which is between the arachnoid mater and the pia mater . the subarachnoid space consist of cerebrospinal fluid, blood vessels and cisterns. The cisters are the enlarged pockets of csf created due to the separation of arachnoid mater from the pia mater based on the anatomy of brain and spinal cord. A fine network of connective tissue called turbulae connects the arachnoid mater and pia mater and give the SA dspace a  charachteristic spider web  appearance.  The subarachnoid turbulae act as a supportive pillar between the arachnoid mater and and the pia mater and due to the cutain like structure with  the holes it allows the flow of csf. Besides the trabeculae there are major blood vessels that penetrate the nervous tissue within this space,.

The subarachnoid space does not have a uniform depth around the CNS  and it forms extension around the neurovascular structures , spaces and cisterns. Moreover, the SA space surround the arteries and veins of the central nervous system up to the point where they penetrate to the nervouts tissue and devide into arterioles and venules. While the pia mater closely adhere to the surface of the btrain and folloes the contours of cortiacal sulci and gyri, the arachnoid mater only bridges over sulci resulting in formation of triangle shaped spaces. At somes places where the arachnoid mater and pai mater is not in close approximation results in  naturally filled CSF expansions called subarachnoid cisterns. 

The subarachnoid space is susceptible to blood collection secondary to damage to any of the cerebral blood vessel that close to the brain surface beneath the arachnod mater. During the heamorrhage the build up of clotted blood and the fluid within the skull not only irritates the lining of the brain but also increases the pressure on the brain surface which can lead to shift and herniation.  Besides aa part of the brain previously supplied with oxygen rich blood from the affected artery now suffers from ischemia. Moreover, blockage of the normal csf circulation can  cause hyddrocepahus which is the enlarging of the ventricular system and results in symptoms like lethargy, loss of consciousness and confusion. Evidence suggest that sudden onset of severe headache is one of the main symptoms of subarachnoid haemorrhage (O.I and Cowan, 2019). There are many causes for headache related to the subarachnoid haemorrhage such as local inflammation to the cerebral arteries, irritation to the meninges by the presence of blood in the subarachnoid space, and the increase in the intracranial pressure (Palilonis and Jacoby, 2018). The presence of free ion and vasoactive agent leads to cerebral artery constriction; this damage induces the secondary inflammatory state and leads to cerebral vasospasm and likely exacerbating the headache (Macdonald et al 2016). Recent studies suggest that there are involvement of neuro pathic component as well in causing headache in subarachnoid haemorrhage (O.I and Cowan, 2019).

The sheath of optic nerve is continuous with brains subarachnoid space. In the event of increased ICP , the increased pressure is transmitted trough the optic nerve , creating a protrusion and pinching of optic nerve at its head . the retinal ganglion cells fibres at the optic nerve become enlarged and bulge forward . long standing papilledema can lead to permanent visual damage.

Microsurgical clipping and endovascular coiling are the main methods in treating intracranial aneurysm. The craniotomy in surgical clipping may increase the risk of csf leakage and infection, damage to the brain tissue, produce excessive stimulation of brain cells around the aneurysm and cause the corresponding neuroological deficit. Endovasulatr coilin can reduce the mortality and disability rate as compred to the clipping . However the long term effect of coiling of un reputed aneurysm is less favouarablr than clipping.