When a Headache is More than a Headache: Subarachnoid Hemorrhage

Written By: Dr. Jacqueline Peacher Newel

Brain Injury Headache
Subarachnoid Hemorrhage

Michelle exited her 15th patient’s exam room into the corridor, heading towards the water  cooler at the nurse’s station. She was exhausted from hosting her stepparents for the week,  soccer season had just started for the twins, and her patient load felt heavier every day. As she  gulped some water, she came to the abrupt realization that within the hullabaloo of the last  weeks, she had completely forgotten to refill her blood pressure medication! “For the love,” she muttered to herself, as she leaned against the adjacent wall. Her physician, Dr. Barnes, had  already warned her about the dangers of missing her meds at their last visit…was that 3 months  ago? 4? Her schedule between the hospital and clinic had been packed, and she couldn’t recall  the last time she’d been in. He noted that her that her high blood pressure was not well controlled with her current medication, and she admitted sheepishly that she was so busy she  had been neglecting take it regularly. Dr. Barnes’ words echoed in her head. “145/93?  Michelle! You’re only 36 and your blood pressure is this high? You know better than anyone  this is stage 2 hypertension! You need to take your meds. Seriously. Cut down on work. Relax!  You know this is dangerous.” She groaned and turned to enter the next patient’s room. 

Sudden, “Thunderclap” Headache 

Headache. Sudden, blinding headache. It wasn’t just pain, it was booming, thundering,  unbearable agony, as if Thor himself had pounded her cranium with his hammer several times.  She managed to stumble to the bathroom to throw up, and then she hit the floor, unconscious.  She awoke about a second later, groggy, with a stiffness in her neck.1 Her nurses had already  called an ambulance. She had a sinking feeling that she knew exactly what was happening. She  was grateful to even be alive and hoped she’d stay that way despite the blinding pain, as the  EMTs hustled in and took her to the hospital. 

What Happens Next? 

The medical team performed neurological function and mental status tests on her, which were  normal, but her blood pressure had skyrocketed to 190/97. At the emergency room, they  promptly got her to imaging for a CT without contrast, which hinted that there might be a tiny  buildup of blood inside the spaces in her brain. CT angiography was diagnostic. “Michelle, you  have a ruptured cerebral aneurysm. I’m sorry. We need to get you to emergency neurosurgery  NOW.” 2 Those were the last words she heard before she was raced to surgery, and she prayed  they wouldn’t be the last she’d ever hear. 

CT angiography imaging
CT angiography imaging of similarly located aneurysm, looking at a “slice” taken from the side (A) and front-to-back (B) views.

How did this Happen to Me? What Next? 

“Michelle, you’re really lucky to be alive. This was kind of a crazy occurrence, as this occurs in  only maybe 1% of the population. You only had a grade 2 subarachnoid hemorrhage within the  Circle of Willis, due to a ruptured berry aneurysm at the bifurcation of the right middle cerebral artery and anterior communicating artery. It was about 1.0 cm, so it’s been there for a while.  We performed an endovascular procedure to place a platinum coil to block the blood flow. We  will need to keep you here in the ICU for at least a couple weeks to watch your electrolytes and  blood pressure, and monitor for any re-bleeding, hydrocephalus, seizure, vasospasm, or hyponatremia. We will put you on some fibrinolytics and a DVT protocol. You don’t have any  neurological deficits and you haven’t had any brain swelling or other symptoms. You’re young, Michelle, but you need to keep your blood pressure under control. This could happen again,  and you might not be this lucky next time.”3,4 The physician’s face was grim, and her family’s  confusion, uncertainty, and fear were just about palpable.  

The Circle of Willis
Diagram of “The Circle of Willis,” the artery supply to the brain. Michelle’s aneurysm was located where the middle cerebral artery and anterior communicating artery meet.

“So…what does this all mean?” Jordan, her husband, quietly inquired. “Michelle has had high  blood pressure for years and she hasn’t been taking her blood pressure meds. Certain things, like  high blood pressure, smoking, head trauma, and genetics can affect the blood vessels that supply  the brain. As blood flow gushes through the vessels regularly at a high pressure, the spots where  one blood vessel connects with other blood vessels can weaken and cause a little outpouching to  form.5 In Michelle’s case, her uncontrolled blood pressure started straining the spot right  between two major vessels in the front part of her brain. The longer she didn’t treat her high  blood pressure, the more the walls thinned and pushed outwards until they formed a sac, and with more time and continued high blood pressure, it finally burst. The blood leaked into spaces  in her brain and into the brain itself, which increased the pressure too much inside the skull.  Michelle’s case caused an excruciating headache, brief loss of consciousness, nausea, and  vomiting. In many cases, it’s worse. The bleeding can  press on parts of the brain causing problems like  paralysis, seizures, trouble talking, among other  things.2 We performed a procedure where we put a  sort of tube into a big artery in her groin area to reach  her brain, and put in a metal coil in the aneurysm to  stop the bleeding.6 She is stable now.” He took a deep  breath, and continued in a patient, measured tone.  

Aftercare and Monitoring 

“We really need to keep an eye on her for the next week in case the aneurysm re-bleeds, or if the blood  vessels spasm or clamp closed, which can cause areas  of the brain to lose oxygen and she will show  symptoms of having a stroke. We will keep her on a  medicine called nimodipine that will decrease the  chance of this happening. Hydrocephalus is another  possible complication, which means buildup of blood or cerebrospinal fluid in the spaces of her  brain, which can cause a lot of problems with thinking, moving around, vision, and headache.  We will keep her blood pressure under control, watch her heart, keep her blood thinned so she doesn’t get deep vein thrombosis (DVT) in her legs, and make sure she doesn’t get  hyponatremia, or low sodium.2 Low sodium can happen because the stress of the bleeding and  repair can cause issues with a hormone called anti-diuretic hormone, or ADH. Too much ADH  release is called a syndrome of inappropriate anti-diuretic hormone, or SIADH, and this makes  the kidneys increase water intake and promote salt exit, which causes seizures and other  problems.” 7 

“So…will she be OK? Will this happen again?” Jordan’s face was wan.  

“She really is as fortunate as she can be in her case. She only had a grade 2 hemorrhage with no  corresponding symptoms which has a good prognosis.2 Patients with grades 3 and 4, who have a  lot of neurological symptoms, have up to an 80% chance of not making it.8 A quarter of patients  don’t survive the first day because of re-rupture, but we need to be careful as there is still a risk  in the first month. We need to keep a close eye on her for complications, too, as about a quarter  

of patients don’t make it in the next 6 months. She doesn’t have any neurological problems,  hasn’t had seizures, her blood pressure and blood salts are normal, and she is pretty young and  healthy.2 She will need to come in every so often to make sure the coil we placed is still working  as it should, but overall, she has a really good chance.” The physician managed a comforting  smile.

One Of the Lucky Ones 

Michelle recovered in the next couple months and made sure she kept ALL her doctor’s appointments and diligently took her medications. She was back to work, but took a half-time schedule, and implemented an  exercise program. She felt healthy and renewed, but still held her breath for any hint of recurrence or issues  for the next 6 months. Almost a year later, Michelle spent her 37th birthday enjoying a normal life, symptom  free. 

Subarachnoid Hemorrhage: What you Need to Know: 

  • Some aneurysms may get tiny tears that cause small bleeds resulting in “sentinel headaches,” which  are ominous for full rupture. Any onset of SUDDEN UNEXPLAINED SEVERE headache should be  investigated. Go to the ER! 
  • RISK FACTORS: High blood pressure, collagen or connective tissue disease, vascular disease,  head trauma, smoking, genetic predisposition. 
  • 85% occur in the anterior circulation of the Circle of Willis, the blood supply to your brain. Subarachnoid hemorrhages are most commonly caused by rupture of saccular, or “berry”  aneurysms (80%), that look like little outpouchings, such as the aneurysm described in the story.  Though they can occur in any demographic, they are more common in women under 50. Other  causes can be due a form called a “fusiform aneurysm,” where the circumference of an area of a  blood vessel balloons out, or from blood vessel malformations. There may also be an infectious  cause. 
  • About 2% of the population have intracerebral aneurysms and don’t have any symptoms at all. A  fraction of them become large enough to burst.  
  • Small aneurysms <0.10 mm have only a 0.1% risk of rupturing. Aneurysms >10mm should be  watched carefully as they are more precarious. Giant aneurysms greater than 2.5 mm have at least a  5% risk of rupture and require regular follow-up and medical treatment. 
  • CT/CT angiography are diagnostic. 
  • Subarachnoid hemorrhages are graded by symptom severity by the Hunt-Hess Scale. Scores of 1-2  have headache with little to no changes in mental status or motor deficits and have a good  prognosis. Scores of 3-4 have severe deficits or coma and have an 80% survival rate. 
  • Post-rupture, there is a 45% survival rate in the first month, and more than half suffer from the  effects of vasospasm, re-bleeding, hydrocephalus, and the other complications described. 20% have  seizures. Rebleeding occurs at a rate of 30% in the first month and drops to 3% after the first year. 
  • Endovascular coil placement, or a brain surgery where a metal clip is placed at the aneurysm, are the  most common treatments. Speak with your doctor to figure out which is best for you. Keep in mind they do need to be checked regularly to ensure they are in proper working order. 
  • Monitoring in the ICU is essential for at least the first week. Complete recovery time may be weeks to months depending on the age and health of the patient, and the severity of damage caused by the initial  bleed and any aftereffects. 9

Meet the Author Dr. Jacqueline Peacher Newel
Dr. Newel is a medical and science writer, editor, and artist who graduated from the Loma Linda School of Medicine in Loma Linda, CA, where she also completed a competitive post-sophomore fellowship in pathology (equivalent to a year of residency) between her second and
third years of medical school. Learn More About the Author.


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