Recovery after subarachnoid haemorrhage: rehabilitation and long-term follow-up

The NHS describes subarachnoid haemorrhage as a rare type of stroke that causes bleeding on the brain, most often from a burst brain aneurysm. The main treatment is surgery to stop the bleeding, either neurosurgical clipping or endovascular coiling, together with medicines to control symptoms and lower the risk of further bleeding. NICE guideline NG228 describes specialist neurosurgical centres, monitoring for complications and a plan for follow-up.

Once the aneurysm is secured, attention turns to complications and recovery. These can include hydrocephalus, where fluid builds up around the brain, delayed reduction in the blood supply to the brain, seizures, and communication or physical disabilities. Most people stay in hospital for some time and many need further rehabilitation before returning home.

NICE tells clinicians to explain that common symptoms reported by people who have had a subarachnoid haemorrhage include headaches, fatigue and sleep disturbance, anxiety, low mood and increased irritability, problems with memory and cognitive function, and changes to smell, taste, hearing or vision. The NHS adds restlessness, heart, lung or liver problems in some people, and unusual head sensations such as trickling or itching feelings. A small number of people develop epilepsy.

These effects are not always visible, and relatives may only notice that the person tires easily, is less patient or forgets appointments. Recognising them as consequences of the bleed, rather than as personality faults or laziness, is an important first step.

NICE says to offer rehabilitation in line with its guidelines on stroke rehabilitation in adults and rehabilitation after critical illness. The NHS lists the possible elements: physiotherapy for movement, balance, breathing, swallowing or pain; speech and language therapy for communication problems; cognitive behavioural therapy for mood changes, depression and restlessness; and cognitive exercises for concentration and memory.

Therapy can be delivered in hospital, in a specialist neurorehabilitation unit, at home or through community neurorehabilitation teams. Occupational therapists support return to daily tasks, and psychologists support adjustment, which can be difficult when the event was sudden and outwardly recovery looks good.

Fatigue is one of the most persistent problems. Rehabilitation guidance recommends asking about it routinely, checking for treatable contributors such as mood, sleep, medicines, nutrition and endocrine function, and offering pacing, energy conservation, cognitive behavioural therapy and appropriate physical activity.

NICE says headaches after SAH are common and generally benign, should be assessed and managed in line with its headache guideline, and may be due to chronic hydrocephalus if additional features appear such as gait disturbance, incontinence, incoordination or cognitive impairment. Anyone with such features, or with a sudden severe headache, needs prompt medical assessment, and a sudden thunderclap headache is a 999 emergency.

NICE recommends an agreed written follow-up plan, rehabilitation, and consideration of follow-up neuroimaging based on the type of treatment, the presence of other aneurysms, the estimated risk of further bleeding and the person's preference. Other unruptured aneurysms are reviewed by a team that includes an interventional neuroradiologist and a neurosurgeon, who weigh coiling, clipping and monitoring.

Blood pressure should be managed in line with hypertension guidance, people who smoke are encouraged to stop, and antiplatelet or anticoagulant treatment should not be withheld solely because of the SAH once the ruptured aneurysm has been secured. NICE also explains that routine screening of relatives has not been shown to save lives and is usually limited to people with at least two affected first-degree relatives.

NICE says people should be given advice on returning to usual activities, including work, exercise, driving and sexual activity. The NHS notes that people may need to stop work for a short time or long term. A phased return, adjusted duties and attention to fatigue are common.

GOV.UK says that if a ruptured aneurysm caused the haemorrhage and was treated by endovascular surgery or craniotomy, you do not need to tell the DVLA and can drive again once your doctor says you have recovered, whereas a subarachnoid haemorrhage without aneurysm surgery must be reported. Bus, coach and lorry drivers must tell the DVLA of any subarachnoid haemorrhage.

The NHS suggests emotional support from people who have recovered from a subarachnoid haemorrhage or other types of stroke, in addition to the clinical team. Recovery can be slow and frustrating, and relatives often carry a substantial emotional load. Neurorehabilitation teams and charities such as Headway also support people with the effects of brain injury and haemorrhage.