Subarachnoid haemorrhage - a medical emergency

Subarachnoid haemorrhage (SAH) is a medical emergency. Fast admission to hospital for surgery is critical as any delay in surgical treatment can result in severe brain injury or death. Mortality and morbidity rates are high: 30% of people who suffer a SAH die within 24 hours; overall, around half of all cases of SAH result in death; and those who survive can experience long-term disability from brain damage. Getting It Right First Time’s (GIRFT) recent report into cranial neurosurgery highlighted surgery for SAH as one of the most time-critical procedures undertaken by cranial neurosurgeons. It is also one of the areas in which the GIRFT team found that critical delays in admission for surgery are putting patients’ lives at risk.

What is subarachnoid haemorrhage (SAH)?

A subarachnoid haemorrhage (SAH) is a type of stroke caused by bleeding into the subarachnoid space between the membranes on the surface of the brain. It is often, but not always, caused by a cerebral (brain) aneurysm – a bulge in a weakened area of a blood vessel – which ruptures and bleeds into the area surrounding the brain. SAH often occurs without warning but can sometimes follow activity which involves physical effort or straining.

Cerebral aneurysms are often symptomless until they rupture but can sometimes be detected before rupture if the patient starts experiencing symptoms, such as visual problems, pain on one side of the face or around the eye or persistent headaches, from pressure on the brain caused by the (unruptured) bulge in the blood vessel. If an aneurysm is detected before it ruptures, surgery is often recommended to prevent rupture leading to SAH.

Cerebral aneurysms are hard to predict or prevent but the following may increase an individual’s  risk: 

• smoking
• high blood pressure
• excessive alcohol consumption
• a family history of the condition
• other rare conditions including autosomal dominant polycystic kidney disease (ADPKD)

Less common causes of SAH include:

• abnormal development of blood vessels 
• brain tumour (either cancerous or benign) causing damage to the blood vessels
• brain infection, e.g. encephalitis
• rare conditions which narrow or block the brain’s arteries
• vasculitis – inflammation of the brain’s blood vessels, e.g. from infection

The symptoms of SAH:

• sudden, agonising headache – often described as a blinding pain unlike anything experienced before, as if hit on the head
• neck stiffness
• nausea and vomiting
• sensitivity to light (photophobia)
• blurred or double vision
• stroke-like symptoms – e.g. slurred speech or weakness on one side of the body
• loss of consciousness or convulsions (fits)

What is the treatment for SAH?

If someone is suspected to have suffered an SAH they need to be admitted to hospital as an emergency. On admission to hospital the diagnosis of SAH will be confirmed by a CT scan. If the CT scan is negative but the patient’s symptoms suggest they have had an SAH, a lumbar puncture might be carried out to check the cerebro-spinal fluid (CSF) for evidence of bleeding into the brain.

If SAH is diagnosed or suspected, the patient will be transferred to a hospital offering cranial neurosurgery. If the haemorrhage has been caused by a brain aneurysm, surgical repair and prevention of further bleeding may take place, either by clipping – a surgical procedure involving craniotomy in which the blood vessel is clipped to prevent further bleeding - or coiling, in which platinum coils are fed into the aneurysm via a catheter inserted into a blood vessel in the patient’s groin or leg. Both procedures take place under general anaesthetic.

Medication may also be given:

• To prevent secondary cerebral ischaemia – a complication of SAH in which brain damage occurs from reduced blood supply to the brain
• To prevent seizures
• To reduce sickness and vomiting

How common is SAH?

Around 6,000 people a year are admitted to hospitals in England with a subarachnoid haemorrhage. SAH is the cause of one in every 20 strokes in the UK. It can happen to people of all ages but is most common between the age of 45 and 70. Slightly more women suffer from SAH than men.

Deficiencies in medical treatment of SAH

Subarachnoid haemorrhage is a medical emergency. The recent GIRFT report into cranial neurosurgery described treatment of SAH as “one of the most time-critical procedures undertaken by cranial neurosurgeons, where bleeding from a ruptured cerebral aneurysm can cause rapid and extensive brain damage”. With SAH mortality rates of 30% within 24 hours and around half of all SAH cases leading to fatality, even a short delay in admission for surgery can be fatal. The longer the delay in treating SAH, the greater the risk of severe brain damage or death.

In 2013, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) recommended that the nationally-agreed standard of 48 hours from diagnosis for surgical treatment of all bleeding brain aneurysms should be met consistently and comprehensively by all health care professionals treating these patients. In doing so it recommended a move towards seven day service provision.

In June 2018, the cranial neurosurgery GIRFT team found that 10% of patients do not receive surgery for subarachnoid haemorrhage within the target of 48 hours from diagnosis. Issues raised in the report about delays in throughput and patient pathways across cranial neurosurgery nationwide, such as lack of available theatres and beds, were thought to contribute to the SAH treatment delays, with the day-of-the-week of the patient’s admission disproportionately affecting the timing of their treatment. Despite the NCEPOD’s recommendation for seven-day service provision, SAH patients receiving treatment within the 48 hour target fell to 74% for patients admitted on a Friday and 58% for those admitted on a Saturday, compared with 83% for other days of the week. 

At Boyes Turner we are highly experienced in acting for brain injured and severely disabled clients whose injury arose in whole or in part from negligent delays in their medical treatment. These cases are complex and are often contested. They require specialist handling to disentangle the extent and impact of the negligently caused injury from the patient’s outcome if correct medical treatment had been given. We work hard to secure early admissions of liability, interim payments, and ultimately the best settlements for our clients which will meet their needs for care, therapies, specialist equipment and adapted accommodation. 

Boyes Turner welcome the findings and recommendations of the GIRFT team’s report into cranial neurosurgery in the hope that genuine improvements in healthcare will reduce the number of patients unnecessarily harmed by delays in treatment for SAH. Meanwhile, we will continue to work to protect the interests of those who have already been harmed or bereaved as a result of negligent healthcare. 

If you have suffered disability or bereavement from delayed medical treatment please contact our specialist lawyers - email them at mednegclaims@boyesturner.com.