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Neuro monitoring practice at Virginia Hospital Center saves lives after subarachnoid hemorrhage

Only about 1 percent of the population experiences a subarachnoid hemorrhage, but two nurses - and sisters - at Virginia Hospital Center see so much of it that they forget it doesn't strike everyone.

The facility's 28-bed neuroscience unit in Arlington, VA, treats a broad spectrum of patients with conditions ranging from trigeminal neuralgia to Parkinson's disease to brain cancer.

Melanie Manthripragada, BSN, RN, CCRN and her sister Monica "Moe" Heinrich, BSN, RN, exclusively minister to patients who've experienced a subarachnoid hemorrhage.

Traditionally, surgical clipping of the neck of the aneurysm has been the standard of care. For the past 20 years or so, new hope has been available for patients who have undergone a subarachnoid hemorrhage.

Endovascular detachable coil treatment (coiling), which involves inserting a detachable platinum coil device into the blood vessel via a small incision (usually in the groin) and passed up to the brain under X-ray guidance, is increasingly popular.

Only about half the patients are good candidates for coiling, the nurses said. Doctors calculate the aneurysm geography, as the decision depends on the location of the neck of the aneurysm.

Coiling is the less-invasive option, but it is favored only when the patient has a poor clinical grade, is medically unstable, and has an aneurysm location suggesting a surgical risk, a smaller neck aneurysm in the posterior fossa, early vasospasm or multiple aneurysms in different arterial territories.


Guiding Through Aneurysm

Nurses' role is critical in monitoring even seemingly recovered patients to prevent fatal complications.

Although the doctor makes the final call about coiling versus surgery, the coiling treatment is so detailed it requires extreme precision from the entire clinical team.

"It's such a delicate procedure," explained Heinrich. "The patient has to be so still they don't even want them breathing. So the patient is intubated. It reminds me of a grab-and-go game because the coil can slip around or past the aneurysm."

In some cases, there's too much blood in the way for the doctor to even find the aneurysm and there's no choice but to continue monitoring it. Never does the nurses' role as the liaison between the clinical team and the family become so critical.

"It's a very scary to have blood in your head and not know why," said Manthripragada. "This is common and probably happens 10 percent of the time, but families are understandably scared when they hear all we can do is schedule another scan in a month."

Intuitive Monitoring

Though their role as navigators is an important part of the job description, Heinrich and Manthripragada are responsible for making very technical clinical judgments.

After the coiling or surgery, the breakdown of the patient's blood can irritate arterial walls and cause vasospasm. The nurses said it's not entirely uncommon for a patient to be watching TV and suddenly find they can't move one side of their body or speak, which typically appears 4-10 days after subarachnoid hemorrhage. This can lead to tissue ischemia and even death. It's up to the nurses to do everything they can to prevent a vasospasm.

"We have a pretty important role," said Manthripragada. "We have to wake them every hour and ask them their name and if they know where they are. From that, we determine if there's a change in their neurostatus or if they're just sleep-deprived."

Even though they tell patients at the beginning of their ICU stay about the purpose of the monitoring, the repeated interruption of the sleep cycle takes a toll. Heinrich always warns her patients they'll hate her by the time they're discharged, but she has to check pupils, determine if speech is slurred, etc.

"We've had many families get frustrated and tell us we're causing a mental status change by not allowing them to sleep," she said. "The families have been through a lot and it's hard for them to understand a mental status change if the patient was just up and moving around 30 minutes ago."

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AVOIDING VASOSPASM: Moe Heinrich, BSN, RN, conducts one of the hourly neurostatus assessments that are so crucial for patients with subarachnoid hemorrhage. This is just part of the intensive nursing care these patients require following surgery or a coiling procedure.

Because there's such a fine line between speech that's slurred because of fatigue or a true change in neurostatus, nurses rely upon the rapport they may have built with the patients and err on the side of caution.

"It's possible to re-bleed or develop hydrocephalus. When people get drowsy, you think of this," said Manthripragada. "When you get to know the patient, you develop an intuition and know when there's more going on besides being sleepy."

Complicating matters, there can be other explanations for a change in the patient's level of alertness.

Maintaining a consistently high blood pressure of 170-180 is part of the "Triple H" or hypervolemia, hemodilution and hypertension therapy.

Blood pressure is purposely kept high with medication so profusion travels to the brain. Blood is diluted for less viscosity and transcranial dopplers measure for cerebral flow velocity every day.

In this job, nurses can't be afraid to call the neurosurgeon if something seems off. Even though it's common to order another scan that turns out to be negative, it's better than playing the odds with a patient's life, the sisters said.

"These are tough patients," acknowledged Manthripragada. "As you can imagine, they're also at high risk for blood clots in their legs. You have to cluster your care and get everything done in the 5 minutes they're awake. There's no skipping the neurocheck. You really have to use your brain."

Uncertain Outcome

Regardless of the nurses' diligence during rounding, it's medically impossible to predict a patient's prognosis after subarachnoid hemorrhage.

According to Heinrich and Manthripragada, few families are comforted by the doctor's observation that one-third of patients will make a full recovery, one-third will regain partial functioning and one-third will be completely disabled.

Both have seen some inspiring cases. Manthripragada said one of her favorite parts of the job was asking a neurosurgeon about a prior patient's progress and learning that 6 months in a rehab facility helped the patient regain movement in one leg. Another patient left the unit barely able to move and returned triumphantly a year later moving both extremities.

Statistically speaking, all patient stories aren't that inspiring. Yet, the two nurses manage to find perspective in working with even the most desperate patients.

"A lot of people don't make it," conceded Heinrich. "You know deep down that a lot of these people will have very bad outcomes and never function again. I at least try to help them in other ways. Something as simple as shampooing their hair makes them at least feel better. Sometimes, there's nothing you can do but show them the respect they deserve."

Robin Hocevar is senior regional editor at ADVANCE.


This presentation was excellent and most informative. My brother-in-law experienced such an event in December and is now recovering slowly in rehab. His course of treatment and recovery process was clearly presented in the video and article. Since this area of medicine is way out of my field, I appreciated the efforts these two young nurses put forth to educated the families and their collegues. Both are precise educators and compassionate nurses in every sense.

Carole Bergin,  RN,  IFOHApril 19, 2012
Fairfax, VA


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