Steptoe Posted December 4, 2022 Share Posted December 4, 2022 This forum has been very useful, providing me with information which is difficult to find in the published medical literature. I thought it would be worth posting my experience and observations in case someone else finds something in them of value. I apologise in advance for the prolixity. I am a 60yr old recently retired former Consultant in a hospital specialty (not neurosurgery, neurology, ICU or acute internal medicine) so, apart from learning about SAH at medical school and occasionally coming across cases with a poor outcome during my career I had no particular interest in, nor special knowledge of SAH. Of course, nothing I say should be construed as advice. I will give my commentary as follows: History of my case to date. Observations: 1) Rarity of perimesencephalic non-aneurysmal subarachnoid haemorrhage (PMNASAH). 2) New National Institute for Health and Care Excellence (NICE) guidelines on (Aneurysmal) SAH. 3) Loss of driving licence and DVLA. 4) Lower back and leg pain. 5) Proportion of us who are athletes. History: I joined our very exclusive club 12 days ago when I was lifting a heavy load alone at home and experienced a classic "thunderclap headache" (TH) severe nausea, sweating, and almost instant neck stiffness (meningism / meningeal irritation). I thought immediately "[expletive], I've had a SAH". After about 5", when the nausea had subsided and I could swallow I took two paracetamol and went online to see what proportion of TH turn out to be SAH (~10%). I WhatsApped my keyholding neighbours to ask them to ring me in 15" and if I did not sound right to take me to the emergency department (ED) and tell them that I had had a TH and that SAH needed to be excluded. I spoke to my daughter, a Medical Registrar (senior trainee) in Internal Medicine 85 miles away to tell her what had happened and to try to convince myself and her that I did not have to go to ED! At 4 hours I had not improved so walked to ED and was triaged for urgent assessment. At 8 hours, ED being frantically busy, I was seen by a medic and a non-contrast cranial CT was requested. At 12 hours I had the CT which was initially reported as normal. At 18 hours I had a lumbar puncture. It was a "****** tap" meaning that blood from the procedure contaminated the cerebrospinal fluid (CSF) which had been taken. However, it also showed xanthochromia (presence of breakdown products of blood, confirming that there had been a recent bleed into the subarachnoid space - i.e. a SAH). At 22 hours I had a venous contrast cranial CT to look at the blood vessels in the brain; no aneurysms or other vascular anomalies were identified. At 30 hours I was transferred to the regional neurosurgery unit and admitted to the intensive care unit (ICU) as there were no beds on the neurosurgery high dependency ward, started on Nimodipine (a cerebral artery vasodilator conventionally given for 3/52 in aneurysmal SAH), continued on regular 6 hourly paracetamol, supplemented by Oramorph (a liquid preparation of morphine) titrated against the pain. The plan was for a digital subtraction angiogram (DSA) later that day. For a DSA a slender catheter is introduced into the femoral artery in the groin and threaded up the aorta, past the heart to the large vessels supplying the neck and head to inject dye and provide very detailed images of the vessels supplying the brain. At 42 hours I was discussed at the daily early morning multi-disciplinary meeting (MDM) between the surgeons and radiologists at which they review the images and clinical condition of patients admitted over the previous 24hrs, discuss each case and reach consensus as to the best management plan. At the MDM my first CT was re-interpreted as showing a Grade I SAH with the characteristic distribution of a PMNASAH, so the DSA was cancelled (much to my relief!) and a second venous contrast CT requested. At 46hrs the repeat venous contrast CT confirmed the absence of a vascular abnormality, so a definitive diagnosis of PMNASAH was made. At 70hrs I was discharged home from ICU, Nimodipine was discontinued (trials have not shown benefit in our subgroup of SAH). Days 5 to 9: Headache largely controlled by regular paracetamol with 30 - 60mg codeine, taking regular (over the counter) Dulcoease stool softener to help prevent anticipated codeine-induced constipation. The headache which was continuous, frontal and behind the eyes, became accompanied by a savage pulsatile exacerbation on getting up too quickly. This lasted 5 to 10 heartbeats as the blood pressure and flow adjusts (as it always does, but we don't notice) to pressure changes because venous blood pools in our lower body and arterial blood has to be pumped higher. The neck/thoracic stiffness eased and was replaced by very severe pulsatile pain in the lumbar and sacral region of the lower back and pelvis, radiating into the buttocks and down the backs of both thighs, the pulsations simultaneous with, and lasting as long as those in my head. I theorised that this was because the irritant blood from the bleed had migrated down the meninges from the head and neck to the lower part of the spine; though this is not well-described in the literature, it seems to be fairly common in posts in this forum and some of you have been told that this is the explanation so that fits my hypothesis. Days 9 to 11: Headache waning, but still requires regular paracetamol and codeine, pulsatile element of headache disappeared but became worse in the lower spinal region / buttocks, backs of thighs, on standing or on flexing hips and extending knees. Presumably that is from stretching of the sciatic nerve on each side, causing traction on the meninges around the lower cord / cauda equina, again something we don't notice normally but manifests now because the meninges down there are irritated and therefore hypersensitive. Day 12: Sacral pain eases, pain is still triggered by movement, bending over or crossing legs when sitting but is now confined to lower buttocks and backs of thighs. I walked 7km without issue, albeit with a slightly odd, bent knee gait, presumably to minimise stretching of the sciatic nerves. Observations: Rarity of the condition: SAH is rare and PMNASAH rarer. At home I have my wife's 2010 5th edition of the major UK reference book on internal medicine, the Oxford Textbook of Medicine (3 volumes with 5518 pages). It has only 2 pages on SAH with 4 sentences on PMNASAH. On average a GP will expect to see one SAH every 8 years, so there is only one PMNASAH in two GP working lifetimes, and therefore many will never encounter one. At an incidence of 0.5/100,000, there are only about 335 a year in the UK. Therefore, it is not surprising that, as many of you report, your doctors know little about the condition and do not have detailed knowledge of its sequelae, recovery etc. All doctors will be expected to recognise that a thunderclap headache (TH) requires urgent assessment to exclude SAH and it seems that most of you found that they did. New NICE guidelines on SAH. On the day of my bleed the National Institute for Health and Care Excellence (NICE) issued new guidance on the investigation and treatment of SAH, which my daughter found and read immediately after I told her I had had a TH, so that she could update her knowledge and delve deeper into the subject than her medical school teaching and clinical exposure had hereto given her. The guidance deals specifically with aneurysmal SAH (ASAH) so it has little to say about PMNASAH but one thing was of interest; section 1.1.11 "If a CT head scan done within 6 hours of symptom onset and reported and documented by a radiologist shows no evidence of a subarachnoid haemorrhage, do not routinely offer a lumbar puncture [LP], think about alternative diagnoses and seek advice from a specialist" and, section 1.1.12 "If a CT head scan done more than 6 hours after symptom onset shows no evidence of a subarachnoid haemorrhage, consider a lumbar puncture". Essentially, CT scan within 6 hours is so sensitive, picking up >99% that LP can be avoided if it is negative - that raises the question as to what happens if, as in my case, the initial report misses a SAH which is present on the scan, but continued symptoms would usually trigger review of the CT by a neuroradiologist and of course, my scan was after 6hrs so a LP was indicated anyway. The NICE guidance has lots of useful and interesting stuff about ASAH which may be useful to people suffering from that - the Mods may wish to flag it in the appropriate forum. https://www.nice.org.uk/guidance/NG228 There is much more very detailed information about the data and meta-reviews behind the guidance accessible though links within the document - for example, the subsection on diagnostic investigations runs to 174 pages! Driving and DVLA: We have to inform DVLA and stop driving until certain criteria are met. I was encouraged to see that they recognise PMNASAH as a separate category. When I filled out their form I accompanied it with a covering letter, quoting the criteria they state in the detailed guidance for medical professionals assessing fitness to drive, specifically that "Driving may resume on clinical confirmation of recovery, and, if no other cause has been identified, documented normal cerebrovascular imaging". I pointed out that the second criterion had already been fulfilled with two negative CT angiograms and that I expected the first to be fulfilled at my follow-up appointment in 6/52. I included a copy of my discharge summary so that they had the relevant information about my case so far. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1084397/assessing-fitness-to-drive-may-2022.pdf Of course, DVLA, like all departments, is suffering from delays due to years of austerity and the effects of Covid so I fear that my licence will not be reinstated promptly. Lower back and leg pain - this is covered in the later part of the "history" above. Number of us who are athletes. Reading the posts in the forum I was struck by how many of us were at the gym or running when we bled. I am a keen cyclist, specialising in hill/mountain ascents either out on the road or in the basement on a turbo trainer, with (of interest to you runners) an estimated VO2max which fluctuates between about 55 and 65ml of oxygen/kg.min (normal for a fit 20yr old!) depending how trained I am - sadly it must be declining now because I have not got back on the bike yet. Whether the high number of fitness enthusiasts in the PMNASAH cohort here is real or whether we are a group of health obsessives who are more likely to post our SAH experience is an interesting question 😉 As PMNASAH is thought to be due to bursting of a vein, or possibly of a venous anomaly rather than an arterial aneurysm and whether we are therefore more likely to be doing something which results in a rise in venous pressure (a Valsalva manoeuvre, as in my case when lifting a heavy load) rather than a spike in arterial pressure, as occurs at orgasm or when taking a line of cocaine is also interesting. However, PMNASAH is also associated with orgasm, perhaps because of arching the neck (stretching the brainstem) and possibly a Valsalva manoeuvre at the same time. Well, if you've persevered with this long account, congratulations. I hope there has been something of interest. While it has been an unpleasant experience, I am very lucky to have had this variant of SAH and I will update my post with a (briefer) account of progress in due course. Old Steptoe. 4 Quote Link to comment Share on other sites More sharing options...
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