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THERAPEUTIC AND EMOTIONAL RECOVERY AFTER
A SUB-ARACHNOID HEMORRHAGE: PATIENT AND
CAREGIVER PERSPECTIVES AND STRATEGIES.*
Roanne G. Brice, Ph.D., CCC-SLP
University of Central Florida, USA
[email protected]
Alejandro E. Brice, Ph.D., CCC-SLP
University of South Florida, USA
[email protected]
* The authors report no declaration of interest. The authors have no
financial interest, direct or indirect, in the subject matter or materials discussed
in the manuscript.
• This presentation focuses on what patients, caregivers, and family
members may experience when a neurological trauma occurs.
• It is the personal account and perspectives when a patient
suffered a vertebral artery aneurysm and sub-arachnoid
hemorrhage (SAH).
• The vertebral artery supplies blood to the unpaired basilar
artery (near the circle of Willis) and major areas of the brain
(Bear, Connors, & Paradiso, 2007).
• The rupture of the fusiform (i.e., spindle shaped) aneurysm on
the vertebral artery caused a subarachnoid hemorrhage (SAH)
wherein blood was dispersed throughout the cerebrospinal fluid
that surrounds the brain and spinal cord.
VERTEBRAL ARTERY
 BACKGROUND and INITIAL TRAUMA
•
Patient was a healthy 52 year-old male at the time of the
SAH who presented no health or neurological issues that are
typically associated with a vertebral artery lesion [e.g., motor
or sensory symptoms, dysarthria, imbalance, dizziness, tinnitus,
paresthesia (tickling or prickling of the skin), homonymous
hemianopsia (partial blindness), diplopia (double vision),
cranial nerve palsies, or dysphagia) (Harrigan & Deveikis,
2009).
•
However, he exhibited only one symptom associated with a
subarachnoid hemorrhage, i.e., continued fluctuating levels of
nausea (Josephson, 2010). The nausea was thought to be
related to gall bladder dysfunction. While in the hospital
awaiting the gall bladder surgery, the patient was discovered
on the floor in his hospital room, barely breathing and in
tachycardia.
•
Patient was rushed to the intensive care unit (ICU) and stabilized.
A CT of the head indicated that he had a suffered a subarachnoid
hemorrhage bleeding into the cerebrospinal fluid (CSF). Two MRI
studies were required do diagnose the exact location of the SAH
due to neurological vasospasms.
• The vertebral artery had a fusiform aneurysm that was
approximately 8 millimeters (mm) in length with significant
narrowing of the artery directly below the aneurysm.
• The artery ruptured causing blood to enter into the subarachnoid
space. Due to the rupture occurring in CSF rather than the brain,
The patient did not present with significant deficits in cognitive
functioning, speech, language, or motor abilities [as reported by the
neurosurgeon, primary care physician, and spouse (a certified and
state licensed SLP)].
FIGURE 1. MRI OF RIGHT VERTEBRAL ARTERY
SUB-ARACHNOID HEMORRHAGE
 RECOVERY
 Day 2 post trauma
• The fusiform dissecting aneurysm was repaired by a
Neuroradiologist. Two stents (i.e., 20 and 22 mm in length),
one inside of the other, were inserted in the vertebral
artery via an incision in the upper leg/groin area.
• The dual stents provided additional reinforcement and
support to the artery and aneurysm. In addition to the
aneurysm, a 10 mm length of the artery below the rupture
was extremely narrow, possibly due to a birth defect. To
repair the aneurysm, a coil was inserted into the bulged and
ruptured area of the artery.
DAY 2 POST TRAUMA CONT.
• The patient was also on IV antibiotics prescribed for the
inflammation of the meninges and to avoid potential
infections. Due to the severe pain and nausea, the patient
was medicated the majority of the time for the first two
weeks in ICU.
• The patient’s sodium and potassium levels in the blood
were extremely low for two weeks and initially required
monitoring every six hours. The decreased sodium is a
physiological response to the neurological trauma and blood
in the cerebrospinal fluid (Dooling & Winkelman, 2004;
Josephson, 2010).
 Day 11 post trauma
• The patient was continually monitored for vasospasms
which can cause a stroke after a SAH. On day 11, the
patient became agitated and was hallucinating, and hearing
voices. It was unsure if the cause was vasospasms or ICU
psychosis.
•
Intensive care unit (ICU) psychosis is experienced by 1 out
of 3 patients in the ICU for extended periods of time. Due
to sleep deprivation, constant stimulation of lights, noises,
checking vital signs (i.e., blood pressure, temperature, pulse,
respiratory rate, pain scale, and cognitive orientation), stress
on the body, medications, salt wasting (i.e., hyponatremia)
often bring about ICU psychosis.
Differential Diagnosis:
• To determine if the behaviors were ICU psychosis or due
to vasospasms, the neurosurgeon conducted an angiogram.
The angiogram indicated moderate vasospasms which
continued to occur; however, after sedated sleep the
behaviors and symptoms disappeared. Thus, the symptoms
appeared to be related to ICU psychosis.
 Day 14-18 post trauma.
• The patient was moved to a neuro-ICU (progressive unit), a
step down from the more critical care ICU.
• Sixteen days after the SAH, the patient started physical
therapy by walking in the hallway a few feet and was able to
go to the restroom with assistance.
• While in the hospital, the neurosurgeon had completed a
follow-up angiogram to examine his cerebral arteries and
the stents and coil about 10 days after they were
inserted. The repaired artery was healing and the aneurysm
had slightly reduced in size.
 Day 22 post trauma
• The patient was released from the hospital.
•
He experienced some minor anomias (or word finding
difficulties, particularly of famous individuals or low incidence
names). He did not have any difficulties with names of family,
friends, or colleagues.
• Word retrieval abilities were estimated to be at 95% two
months post-trauma. As with spontaneous recovery of
individuals with aphasia (Brookshire, 2007); it is estimated that
his full mental abilities would return within six months posttrauma (as indicated by the neurosurgeon on a two month
follow-up visit).
 PATIENT PERSPECTIVE
• Transitions after a significant health issue can be stressful.
Leaving the hospital induced fear and anxiety. My
thought…what if the aneurysm ruptured again?
• While, in the hospital the patient was continuously asked
orientation questions such as my name, birth-date, and location.
“I was able to perform this task within days of my trauma. Over
time I began to recognize my decreased ability to remember and
recall (short term memory).” Therefore, simple tasks may hide
higher order and executive function cognitive disabilities.
• Working memory, particularly word retrieval, and immediate
memory have been the cognitive and language features that have
been most impacted from the trauma. Focusing his attention
has also been an issue.
 CAREGIVER / SPOUSE PERSPECTIVE
•
A call in the middle of the night…Your husband “has taken a turn
for the worse” and the doctors had “brought him back”… “come
to the hospital immediately!”
•
Immediate shock of learning the details and severity of my
husband’s SAH, I realized the importance of my role of being his
patient advocate, medical researcher, and emotional support
during this crisis.
•
Research all aspects of the medical condition to become
knowledgeable so that you can assist in making appropriate
medical decisions. Research-based, rather than emotionally-based
decisions, are crucial decisions for maximum recovery.
 Speech-language pathologists should target the following goals for
the patient and family to facilitate an increased quality of life
(Hidecker, Jones, Imig, & Villarruel, 2009):
 Reduce the family burden issues;
 (2) Reduce the patient dependence levels;
 (3) Improve the patient’s ability to cope to everyday and new
situations;
 (4) Address cognitive-language impairments (e.g., concentration,
memory);
 (5) Address mood disturbances; emotional issues (e.g., anger,
irritability);
 (6) Address fatigue, tiredness issues (directly or indirectly);
 (7) Address the patient’s passivity issues (note that in AB’s
situation this resulted from a feeling of being overwhelmed).
 Suggestions from personal experience:
 Research all aspects of the medical condition to become knowledgeable
so that you can assist in making appropriate medical decisions. Researchbased, rather than emotionally-based decisions, are crucial decisions for
maximum recovery.
 Designate 1-2 individuals who are close to the patient to continually stay
at the hospital, preferably in the patient’s room. Physicians and nurses
continually rotate, therefore, having a constant person monitor progress
or decline in condition is essential.
 Research all medications prescribed and monitor the patient’s symptoms.
Being aware of medication side effects and the patient’s symptoms can
provide important ongoing information to medical personnel for
appropriate medication decisions.
 Use technology to support the caregiver/patient’s needs. Computers,
tablets, cell phones, etc. are essential to managing medical, family, and
work related communication during the crisis and recovery stages.
Designate someone to assist.
 Build a family and friends’ support system and accept assistance.
 Remind families to work with their employers to seek advice
regarding medical benefits that could be available to them in a time
of medical crisis.
 Use of a patient progress reporting website is essential to
continually update the patient’s status. The convenience of being able
to enter information real time into a web-based blog allows all family
and friends to monitor their loved ones progress. It also provides a
way to communicate well-wishes to the patient and immediate
family. An example is CaringBridge, a non-profit organization, located
at http://www.caringbridge.org.
 Above all, the caregiver(s) must be aware of their physical and
emotional needs and limits. Take particular care to maintain personal
nourishment and needed rest.
Family focused intervention for SLPs in working families of disabled
individuals should include (adapted from Ciccia & Threats, 2015):
 (a) family education on the disability and rehabilitation;
 (b) changing expectations and supporting successes rather than
failures;
 (c) fostering environments that promote daily participation
and interactions;
 (d) supporting and encouraging family members to advocate for
the individual with the disability.
 When SLPs implement these strategies, patients, families, and
caregivers can experience better home integration, less
caregiver stress, and greater patient social integration when the
caregiver receives sufficient support (Sady et al., 2010; Sander et al.,
2012; Schure , et al., 2006; Sit, Wong, Clinton, & Fong, 2004; Visser-Meily, van
Heugsten, Schepers, & Lindeman, 2005).
 The cognitive, language, memory, daily life rehabilitation
needs must be addressed. SLPs are well versed in targeting
perception, processing, memory, and attention needs.
Additional areas:
 word naming tasks
 word memory tasks,
 auditory attention,
 divided attention,
 working memory, and
 cognitive speed utilizing reading and writing tasks.
 The patient's emotional needs also must be considered.
Panic attacks, the inability to sleep, and emotional episodes
may occur. Other adjustments will be needed as the patient
adapts to a new way of functioning post-trauma (Forster et
al., 2014). For example, Forster et al., (2014) identified four
possible post-stroke patient outcomes:
(a) disruption, adjustment, and acceptance;
(b) cycles of disruption, adjustment, and acceptance;
(c) disruption without adjustment and acceptance;
(d) continuing on-going decline. The patient may need
continued therapy and/or counseling.
 Suggestions for caregivers is often an overlooked aspect of
speech and language therapy. Caregivers are instrumental in
the patient's recovery. Hence, it is vital to reduce family stress
after a cerebral trauma:
 reducing family burden,
 reducing patient dependence,
 enabling the patient to cope with everyday situations,
decreasing patient mood disturbances, decreasing patient
fatigue, and also decreasing patient passivity.
 In support of family members, SLPs must also encourage the
family to always advocate, but, most importantly to seek
support.
 Support in therapy sessions and/or support groups are
recommended. The role of families, being culture specific,
needs to be further examined and considered.
 In summary, speech-language pathologists should recognize
that caregiver and family support is vital to our client's
outcomes.
•
Research all medications prescribed and monitor the
patient’s symptoms. Being aware of medication side effects
and the patient’s symptoms can provide important ongoing
information to medical personnel for appropriate medication
decisions.
•
Use technology to support the caregiver/patient’s needs.
Computers, iPads, cell phones, etc. are essential to managing
medical, family, and work related communication during the
crisis and recovery stages. Designate someone to assist.
•
Build a family and friends support system and accept
assistance offered.
 SIX-MONTH FOLLOW-UP MAGNETIC
RESONANCE ANGIOGRAM (MRA)
• A six month follow-up magnetic resonance angiogram
indicated normal blood flow, healing, stabilization of the
aneurysm, and normal diameter of the right vertebral
artery. Monitoring using MRAs on six-month intervals
were conducted for the first two years and subsequently
every year after the 3rd year. See Figure 2.
FIGURE 2. SIX MONTH FOLLOW-UP MRA
DEFICITS
 Patient presented deficits similar to traumatic brain injury affecting memory
(declarative memory), attention, and focus issues.
 Declarative memory- , explicit memory, which allows for factual recall.
Declarative memory can be further subdivided into episodic and semantic
memory.
 Episodic memory is described as the recollection of autobiographical
information with a temporal and/or spatial context, whereas semantic
memory involves recall of factual information with no such association
(language, history, geography, etc.).
 Semantic memory- meanings, understandings, concepts; Medial temporal
lobes and hippocampus, left inferior prefrontal cortex (PFC) and the left
posterior temporal areas are other areas involved in semantic memory use.
 Issues mostly resolved 3 years post-trauma. Near full recovery 5 years later.
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QUESTIONS?