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Aneurysmal subarachnoid haemorrhage
– Part 2: Post-operative nursing
management diagnosis, complications
and treatment: A composite case study
a

Andrew Scanlon
a

Clinical Nurse Specialist, Neurosurgery Austin Health
Melbourne, Australia
Published online: 17 Dec 2014.

To cite this article: Andrew Scanlon (2004) Aneurysmal subarachnoid haemorrhage – Part 2: Postoperative nursing management diagnosis, complications and treatment: A composite case study,
Contemporary Nurse, 17:3, 274-281, DOI: 10.5172/conu.17.3.274
To link to this article: http://dx.doi.org/10.5172/conu.17.3.274

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Copyright © eContent Management Pty Ltd. Contemporary Nurse (2004) 17: 274–281.

Aneurysmal subarachnoid haemorrhage
– Part 2: Post-operative nursing
management diagnosis, complications
and treatment: A composite case study

Downloaded by [New York University] at 23:32 17 May 2015

ABSTRACT

Patients who have been diagnosed with an Aneurysmal Subarachnoid
Haemorrhage (ASAH) frequently require surgical intervention to prevent further
complications. Due to the complex nature of ASAH it is imperative to be
meticulous in monitoring the patient’s neurological condition.This is even more
relevant post operatively as complications such as cerebral vasospasm peak
incidence is between days four to fourteen and as well as complications of
surgical and medical intervention may become evident.
Received 15 September 2003

Accepted 23 January 2004

CN

Key Words

ANDREW SCANLON
Clinical Nurse Specialist,
Neurosurgery
Austin Health
Melbourne, Australia

INTRODUCTION
atients who have been diagnosed with
an Aneurysmal Subarachnoid Haemorrhage
(ASAH) frequently require surgical intervention to prevent further complications. Due to
the complex nature of ASAH it is imperative
to be meticulous in monitoring the patient’s
neurological condition.This is even more relevant post operatively as complications such as
cerebral vasospasm peak incidence is between
days four to fourteen and as well as complications of surgical and medical intervention may
become evident.
Neurological assessment should be per-

P

274

CN Volume 17, Issue 3, October 2004

post-operative; nursing management; intraoperative; surgical interventions; Glasgow
coma scale; hydrocephalus; external
ventricular drains; cerebral oedema; seizures;
triple H therapy; cerebral balloon angioplasty;
intra-arterial Papaverine

formed prior to the use of the various treatment modalities.This assessment will provide a
baseline to gauge any improvement or deterioration of the patient’s condition. Any change in
conscious state, orientation, motor function,
pupillary function, location and onset of
headache must be noted and reported to the
physician responsible so that early intervention
and diagnostic evaluation can be initiated.
Close monitoring of the patient’s cardiovascular, hepatic, endocrine, renal, and respiratory
and other body systems must be included in
line with parameters set by the managing physician.This not only detects any side effects from

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Aneurysmal subarachnoid haemorrhage – Part 2 CN
the various treatment modalities, but also
determines any underlying conditions of the
patient that may affect their full recovery.
As previously discussed in Part 1, Mrs. X is
a 55-year-old lady who presented to a major
metropolitan hospital with symptoms of headache, photophobia, nausea and vomiting. Her
only relevant past history is of hypertension and
she is a current smoker of 25 years. Her initial
diagnosis of subarachnoid haemorrhage was
made by Computed Tomography (CT) scan and
later confirmed as an ASAH by Intra-Arterial
Digital Subtraction Angiography (IADSA), to
have been caused by an Anterior Communicating
Artery Aneurysm (ACommAA). Surgical intervention was required to treat this condition.

SURGICAL TREATMENT
Surgical treatment of an aneurysmal subarachnoid haemorrhage usually depends on the location, severity and cause of the bleed. Common
techniques used to stabilise blood vessels causing an ASAH include clipping and coiling.
As previously stated in Part 1 Mrs X was
consented for a clipping of her ACommAA.
Clipping has been widely and successfully
used for over 20 years to stabilise cerebral
aneurysms. A craniotomy is performed that
enables the neurosurgeon to access the effected
blood vessel. Once located a surgical clip is
placed at the neck of the cerebral aneurysm
occluding it from the cerebral blood flow and
decreasing the risk of further bleeding (Kaye,
1997).
An alternate method to clipping of cerebral
aneurysms is endo-vascular coiling.This procedure performed with the aid of IADSA to
locate the effected vessel and usually is performed by centres with expertise in this field.
Minute coils are then introduced into the
aneurysm to fill it completely. This causes the
area to thrombise and excludes it from blood
flow, preventing any further bleeding. As this
technique was introduced in the early 1990s
(Bell & Kongable, 1995) it is still not widely

accepted by all Neurosurgeons. However it is
more commonly used in aneurysms that are difficult to locate with a craniotomy, especially
posterior cerebral circulatory vessels such as
the Basilar or Vertebral arteries.

INTRA-OPERATIVE
A craniotomy and clipping of the ACommAA
was performed. Unfortunately due to the complexity of the surgery and Mrs X’s past history
of hypertension her aneurysm burst during the
operation, causing more blood to enter the subarachnoid space. To prevent further complications and to monitor her condition closely an
External Ventricular Drain (EVD) with Intracranial Pressure (ICP) monitor technology was
inserted to prevent acute hydrocephalus and to
monitor her intracranial pressure. A Central
Venous Catheter (CVC) was inserted to monitor Central Venous Pressure (CVP) and to initiate hypervolemic therapy. Mrs X’s blood
pressure was monitored via a left radial arterial
line and an indwelling urethral catheter was
inserted and enabled hourly assessment of urinary output.

POST-SURGICAL NURSING
MANAGEMENT
Again frequent neurological observations (as
per individualised protocol) are performed to
closely monitor any changes in a patient’s neurological status and to provide a baseline to
gauge any improvement or deterioration of the
patient’s condition as well as to plan for appropriate treatment.
Environmental stimulus should be kept to
decrease possible exacerbating factors, such
which may lead to a rise in blood pressure.
Post operatively Mrs X’s Glasgow Coma
Score or GCS decreased to 12. She was now
eye opening to speech, localising to pain and
confused to time and place but orientated to
person. Her condition was routinely monitored
post operatively as pre neurosurgical protocol.
Which includes neurological assessment in

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CN Andrew Scanlon
recovery by the ward nursing staff to ensure
that they are confident to take the patient back
to the ward. On return to ward from recovery
another set of neurological observations must
be attended. Neurological (GCS, ICP and
EVD), cardiovascular (Bp, pulse, Central Venous Pressure or CVP), respiratory (respiration
rate and oxygen saturation) and pain (severity
and position) assessments are then attended,
half-hourly for four hours, hourly for four
hours, one to two-hourly overnight until
review by the Neurosurgery medical staff in the
next morning.Then four hourly until the acute
phase of the patient’s condition is over (which
will be for the entire stay of Mrs. X due to the
potential of cerebral vasospasm). If at any stage
a patient’s condition deteriorates then it must
be reported immediately to the nurse-in-charge
(Crowe et al., 2003).The frequency of the neurological observations will then increase as per
the nurse-in-charge’s instructions on consultation with the medical staff. Mrs. X also had her
temperature taken every four hours. Her indwelling catheter was also emptied/measured
every hour to assess her fluid status.
Postoperatively Mrs. X was recovered in bed
at a thirty-degree angle and was issued with
anti-embolic stockings. Her Nimodipine was
continued (see Part 1) and she was also commenced on Dexamethasone 4mg/6hourly and
subcutaneously Heparin 5000 units twice a day.
Her blood pressure was to be maintained at a
hypertensive level (between 140–180mmHg
systolic) and her combined intravenous and oral
fluid intact was to be keep above 3000mls a day
thus keeping her hypervolemic. Her EVD was
to be maintained 15cm above the tragus and
Cerebro-Spinal Fluid or CSF amounts of less
than 10mls or more than 25mls an hour are to
be reported.

HYDROCEPHALUS
Mrs X’s EVD was inserted to prevent acute
hydrocephalus, which may be associated with
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CN Volume 17, Issue 3, October 2004

lating in the cerebro ventricular system. Hydrocephalus as explained previously in Part 1 of
this article could occur through the blockage or
obstruction in the reabsorption of CSF (communicating) or flow of CSF (non-communicating).Treatment for acute hydrocephalus usually
involves the insertion of an EVD. An insertion
of an EVD involves inserting a catheter into one
of the lateral ventricles allowing CSF to flow
into a closed burette system for measurement.
Mrs X’s EVD was draining approximately 10
mls an hour of blood stained CSF, which eventually became straw coloured and clear after
five days.

Nursing management (hydrocephalus/external ventricular
drain)
As always-frequent neurological assessment
should allow for early detection of deterioration in a patient’s neurological state which may
indicate hydrocephalus and or meningitis.
Considerations for EVD’s include hourly
empty/measure (into a burette system) and
observation of CSF as well as daily pathology
tests, which can detect any alteration that may
indicate complications. As the chorioid plexus
of the brain produce approximately 10–21mls
of clear straw coloured CSF an hour, approximately that amount of CSF is drained every
hour but can depend on the patient’s condition
and the activities they are performing. Any
blood can indicate trauma caused by the
catheter or further bleed, abnormal amounts of
protein or glucose or the presence of white
blood cells can indicate meningitis.
After the patient has stabilised (usually a few
days), and the CSF has been constantly normal
(without the presence of blood or signs of
infection). A trail of the cerebro-ventricular
system’s ability to function is assessed. Clamping the flow of CSF to the burette system is
done for a few hours to see if the patient
exhibits any signs of hydrocephalus or leaking
from around the drain’s exit site. If however

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Aneurysmal subarachnoid haemorrhage – Part 2 CN
this test fails, a more permanent solution such
as a Ventricular Peritoneal or a Ventricular Atrial shunt is considered.
Benefits of an EVD include the ability to
allow intracranial pressure monitoring and CSF
sampling. The risks however are infection
(meningitis), over shunting and the patient is
required to stay in bed whilst the EVD is insitu.
Therefore it can only be for short-term use.
Mrs X’s GCS increased over 5 days to be
15/15 and it was decided to remove the
EVD/ICP. The EVD was clamped and the
patient monitored for signs of raised ICP. After
approximately 2 hours of half hourly neurological observation and observation of the exit site
of the EVD, Mrs. X showed no ill effects and
the drain and monitor were removed by a Registered Medical Officer.

CEREBRAL OEDEMA
Mrs X’s ICP monitor was inserted to assess for
any changes in ICP, which may be associated
with cerebral oedema. Dexamethasone was
commenced to prevent this from happening.
A common side effect from any traumatic
event involving brain tissue is cerebral oedema.
In this case cerebral irritation caused by the
blood in and around the brain causes cerebral
oedema. Symptoms are very similar to a rise in
ICP including nausea, vomiting, decreased conscious state, severe headache and alteration in
neurological observations. Cerebral oedema
can be diagnosed through a CT scan, which
would show decreased gyri and sulci and grey
like abnormalities at the peripheries (MacDonald, 1989).

decrease the swelling. A complication of Dexamethasone is steroid induced diabetes so daily
urinalysis should be preformed to detect glucose, if present in the urine or a daily random
blood glucose test for elevated glucose levels.
Another treatment for cerebral oedema in
acute cases is Mannitol (an osmotic diuretic)
which can decrease swelling but urine output
and CVP and blood pressure must be carefully
monitored to insure that the fluid shift is not
too sudden to compromise the patient hemodynamic status.

SEIZURES
As stated in Part 1, isolated seizures can occur
pre or post-operatively. If patients do develop
seizures post ASAH, they are commenced on
anti-convulsant therapy.

Nursing management (cerebral
vasospasm)
As discussed in Part 1, frequent neurological
assessment is performed to detect and treat
complications post ASAH. Usually observations
are done no less than 4 hourly to assist in the
early detection and treatment of this condition.
As cerebral vasospasm can occur from day one
to day twenty eight post bleed, peaking around
day seven, treatment considerations post stabilisation of the cerebral aneurysm are mainly
focused in prevention of the occurrence and or
the severity of this potential condition. These
treatments include the use of Nimodipine as
discussed in Part 1 as well as use of methods
employed in Triple H therapy, cerebral angioplasty and intra-arterial Papaverine.

Nursing management (cerebral
oedema)

Nursing management (cerebral
vasospasm)

Treatment for Cerebral Oedema includes the
removal of the noxious stimuli causing the
oedema (i.e. blood in the subarachnoid space)
and the use of anti-inflammatory medications
such as Dexamethasone (4 milligrams 6 hourly
initially then titrated down) can be used to

Triple H therapy
The term triple-H therapy relates to the use of
hypertension, hypervolaemia and haemodilution in the treatment of patients who have the
potential to develop cerebral vasospasm (Rusy,
1996). Hypertension for the prevention of cere-

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CN Andrew Scanlon
bral vasospasm has been used since 1951 when
Denny-Brown described its benefits. Wood et
al., 1984 introduced the use of hypervolemic
haemodilution almost three decades later in
1982. Awad et al., introduced the combination
of all three methods in 1987.Triple-H therapy
or hyperdynamic therapy has been the mainstay
for the prevention of cerebral vasospasm for
well over a decade now (Kopitnik & Samson,
1993). These three therapies may be used in
conjunction with one another or alone with
other treatment modalities, but all must be performed in a specialised monitored environment
so that the patient can be closely monitored for
possible complications (Wood et al., 1984).
Hypertensive therapy as the name suggests
involves inducing a patient to become hypertensive.This assists with the perfusion of brain vessels. Monitoring and treatment of a patient’s
oxygenation allows the hypertensive therapy to
force oxygen rich blood to flow to the brain
cells, preventing possible ischaemia (that may
lead to the release of vasogenic substances). Also
this form of treatment prevents cerebral blood
vessels from contracting due to the increase in
blood pressure.Various inotropic agents such as
dopamine and dobutamine or adrenergic agents
such as Noradrenaline are prescribed to raise
blood pressure (Wood et al., 1984). Once the
blood pressure is at a therapeutic level (between
120–150 mmHg systolic for patients with
unclipped aneurysms and 160–200 mmHg for
patients with clipped aneurysms), it is maintained and monitored closely by nursing staff
(Wood et al., 1984). These values are not
absolute, rather they are based on a patient’s
baseline blood pressure as well as careful and
thorough clinical examination.
Hypertension is normally considered a harmful state. One complication is an increased
workload on the heart. As a result, the use of
hypertensive therapy is contraindicated for
patients with pre-existing heart disease. Also,
cerebral angiography can sometimes miss small
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CN Volume 17, Issue 3, October 2004

my, thus another subarachnoid haemorrhage
may occur (due to rupture caused by the increased blood pressure on the cerebral vessels)
further compromising the patient (Edlow &
Caplan, 2000).
Hypervolemic or hyperperfusion therapy
assists cerebral blood flow through fluid expansion of the intravascular compartment (within
blood vessels). This is done to dilate the cerebral blood vessels so that they cannot contract
(Stewart-Amidei, 1989). The infusion of crystalloids, such as lactated ringer’s solution and
plasma volume expanders such as Gelofusine is
used to facilitate this process (Wood et al.,
1984). Potential complications of this component of the therapy include pulmonary oedema,
congestive heart failure, further cerebral haemorrhage, myocardial infarction and brain oedema caused by the increased intravascular
volume (Miller et al., 1995). Patients with preexisting renal, cardiac or pulmonary dysfunctions must either be excluded or monitored
very closely so as not to further exacerbate
their underlying conditions.
As Mrs. X was closely monitored on day 12
post initial bleed she unexpectantly became
unresponsive dropping her GCS to 10/15. She
was immediately sent to radiology for an urgent
CT scan, which showed no abnormalities. She
then had a transcranial doppler, which showed
severe cerebral vasospasm in both her anterior
cerebral arteries. Her blood pressure had also
dropped below acceptable limits and could not
be maintained above set limits without high
dose inotropic medication, which could only be
administered in Intensive Care Unit (ICU).
Transcranial doppler is routinely preformed
to diagnosis cerebral vasospasm.This procedure
involves the use of non-invasive ultrasound,
which measures the velocity of blood within the
cerebral arteries (Young et al., 1996). If cerebral vasospasm is present an increased velocity
is detected in the effected vessel. This is due
to the vessel in spasm requires higher flow to
move the blood. Other procedures used include

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Aneurysmal subarachnoid haemorrhage – Part 2 CN
Magnetic Resonance Angiography (MRA),
Computed Tomography Angiography (CTA) &
IADSA, which have been discussed previously in
Part 1 of this article.
Her blood pressure was eventually stabilised
in ICU with high dose inotropic therapies. Frequent transcranial doppler’s however showed
no improvement to her cerebral vasospasm
despite intensive hypertensive and hypervolemic therapy combined with Nimodipine. It
was decided that more aggressive treatment
was required to prevent any further deterioration in Mrs. X’s condition. Mrs. X was sent for
further IADSA with cerebral balloon angioplasty and intra-arterial Papaverine.

Nursing management (cerebral
vasospasm)
Cerebral balloon angioplasty
Zubkov et al., first reported the use of cerebral
balloon angioplasty for the treatment of cerebral vasospasm in 1984. Although this is not a
commonly used technique, research into its use
has shown it to be quite effective (Cook, 1990).
Cerebral balloon angioplasty is a procedure
performed under fluoroscopy. A balloon
catheter is inserted via the femoral artery into
the cerebral arteries. The area of cerebral
vasospasm is identified and the balloon is then
inflated to dilate these contracted arteries
(Newell et al., 1989). Cerebral balloon angioplasty is not a preventive treatment and
although it is highly successful, it is only used
after other preventive treatments have been
explored (Firlik et al., 1997). Various drug
interactions, which can be associated with pharmaceutical treatment of cerebral vasospasm, are
kept to a minimum, due to the treatment being
mechanical in nature.
There are certain drawbacks to the use of
cerebral balloon angioplasty. One such drawback is its inability to dilate small (usually) distal arteries, which may be involved in cerebral
vasospasm due to the size of the vessel being
smaller than the balloon catheter. Complica-

tions include anaphylaxis and decreasing renal
function (from the contrast medium), thrombosis, embolism, dissection of the arteries at
cerebral or insertion site origin, further haemorrhage from heparin and death (Grimes,
1991). Being a reactive rather than a preventative treatment, signs and symptoms of cerebral
vasospasm must occur before treatment is initiated. This delayed response time can cause an
increased morbidity and mortality rate. The
need for specialised equipment and expertise
makes this treatment limited to major metropolitan hospitals.

INTRA-ARTERIAL PAPAVERINE
As cerebral balloon angioplasty cannot dilate
small blood vessels, intra-arterial infusions of
Papaverine have been effectively used to produce this effect. Papaverine is an opium alkaloid, which relaxes smooth muscle (Clyde et
al., 1996). It is injected into an affected artery
by cerebral angiography. Once injected, it
exerts a vasodilatory effect on these small arteries (Clouston et al., 1995).This form of angiographic intervention has been shown to have
less risk of thrombosis, embolism, vessel rupture or intra-cranial haemorrhage than cerebral
balloon angioplasty (Clouston et al., 1995).
Complications such as unexplained monocular blindness and seizures and a paradoxical
affect on cerebral vessels causing vasoconstriction instead of vasodilatation have been reported
(Clyde et al., 1996). Although there is a
decreased incidence of complications associated
with cerebral balloon angioplasty, this procedure still runs the risk of any angiographic technique. Other complications include dye-induced
anaphylaxis and decreasing renal function,
thrombosis, embolism, dissection of the arteries
of cerebral origin at the catheter insertion site,
further haemorrhage from heparin and death
(Grimes, 1991).
Intra-arterial infusion of Papaverine is another measure that has only recently been developed (Clyde et al., 1996). Further studies,

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CN Andrew Scanlon
including those into the long-term side effects,
should be performed to evaluate the use of
intra-arterial infusions of Papaverine.
After the IADSA with cerebral angioplasty
and intra-arterial Papaverine Mrs. X spent four
more days in ICU until her condition stabilised.
Her GCS was 14/15 and blood pressure was
kept within acceptable limits without the use of
high dose inotropic medication. She was transferred to the Neurosurgery HDU and to the
general Neurosurgery ward shortly after.
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NURSING MANAGEMENT
GENERAL ISSUES OF CARE
Although the following issues of care may seem
evident they are still pertinent in the care for
any postoperative neurosurgical patient.

Respiratory
Issues such airway maintenance and the monitoring of oxygenation levels are vital to maintain
adequate oxygenation.This is especially important after a neurological insult like ASAH. As the
adequate oxygenation of the patient’s brain cells
maybe already compromised by the ASAH.
Limits on oxygen saturation are usually set well
above dangerous levels (below 90%) at 95% to
allow early detection and intervention and to
ensure that the patient is receiving oxygen rich
blood to the brain.

Musco-skeletal
Adequate rest is also important after surgery,
but extended bed rest is not encouraged. As
patient’s with restricted mobility is can develop
deep vein thrombosis. To prevent this use
anticoagulants such as sub-cutaneous heparin
and the use of anti-embolic stockings are
routine for all post neurosurgical patients.
After ASAH it is not uncommon for patients
to have deficits such as hemiplegia, paralysis,
ataxia etc. Assessment of a patient’s posture,
gait and limb function for any neurological,
muscular or skeletal abnormalities can identity
rehabilitation needs early as well as preventing
related complications.
280

CN Volume 17, Issue 3, October 2004

Pain
Pain is associated with any surgical procedure.
It’s monitoring through position, pain score and
sensation.Treatment through analgesia and the
effectiveness of said treatment can dramatically
effect not only a patient’s recovery and perception of hospital stay. It can also decrease further
complications associated with pain such as an
increase in blood pressure.
Usually Paracetamol and Codeine are used to
treat headache associated with ASAH. As Morphine and Pethidine have a sedating effect that
can mask a patient’s deteriorating conscious
state.

Psychosocial
Psychosocial issues for the patient should
always be considered during any hospital stay. It
cannot be underestimated the effect that the
support for the patient their family and significant others assists with the recovery of a compromised patient. Psychosocial support through
the use of social work referral etc will hopefully
relieve any contributing or exacerbating factors
that may further distress the patient and their
significant others exerted on the patient in a
particularly difficult time.

Discharge
Mrs. X was discharged 20 days after her initial
bleed with no significant morbidity and was
seen in Neurosurgical outpatients 6 weeks later
and was recuperating well and without any
obvious neurological deficit.

CONCLUSION
An aneurysmal subarachnoid haemorrhage is a
very traumatic experience. As the exact aetiology of ASAH and complications such as cerebral
vasospasm are unknown, it is difficult to prevent and treat these conditions. ASAH is a condition that requires high-risk treatment that can
result in complications that are difficult to prevent or predict. As such, careful consideration
of the patient’s past and present medical condition is vital when weighing up all options for
a patient’s care and management. High levels

Aneurysmal subarachnoid haemorrhage – Part 2 CN
of post-operative monitoring are essential to
ensure timely response to any complications
thereby preventing further harm to the patient.

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CN ERRATUM
Contemporary Nurse 16/1–2 (2003/04) 145–150: Middle Ear Problems in Aboriginal School
Children Cause Developmental and Educational Concerns, Judith A Thorne
Page 147, column 1 Results subtitle ‘Horoscopy’ should read: Otoscopy

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