ISSUE 24 ARCHIVE - DIVING AFTER SUBARACHNOID HAEMORRHAGE

A subarachnoid haemorrhage (SAH) is an uncommon type of stroke caused by bleeding on the surface of the brain.

More often than not as a result of a ruptured aneurysm. An aneurysm is a weakness in the wall of an artery that results in a balloon-like swelling that becomes weaker and weaker and eventually ruptures causing blood to spill out onto the surface of the brain. Symptoms include sudden, severe headache, usually with loss or impairment of consciousness. It's an extremely serious condition and usually fatal.

Those fortunate enough to survive, less than twenty percent who suffer a serious bleed, are usually left with some form of disability. Loss of movement, speech difficulties, memory issues and chronic fatigue are all common outcomes. Recovery is generally measured in years and lifelong residual issues are to be expected. We spoke to James Neal about his experience with SAH and his recovery so far.

About James

James is a PADI IDC Staff & Elite Instructor and SDI/TDI Instructor with Cheltenham Sub Aqua Club. He is also a BSAC & SAA Instructor. He has completed in excess of 1,000 dives of which over half have been post subarachnoid haemorrhage. He is a hypoxic trimix diver with a passion for instructing and diving wrecks & flooded mines. He's a self- confessed 'wreck head.'

Suffering a Subarachnoid Haemorrhage

James had an undiagnosed aneurysm, believed to be hereditary, that ruptured and caused a grade 4 bleed to the brain. Bleeds to the brain are measured from 1 – 5, with grade 5 being fatal.

He was found at home, on the living room floor, by his wife in the early hours of 23rd December 2013. It is believed that he had been unconscious for about 10 hours. Miraculously she had decided to come home a day early from a weekend away, had she not done so then the outcome would not have been anything like the same.

She called emergency services and James was rushed to Gloucester Royal hospital where he was given an immediate CT scan. Upon diagnosis of a bleed to the brain he was then transferred to Frenchay hospital in Bristol where he underwent emergency surgery at 3 am to relieve the pressure that was building up within the skull and threatening his life.

Condition Treatment

Initially this involves an emergency procedure to relieve the pressure within the skull. A large section of his head was shaved and an incision made in order to gain access to the skull. A hole was then drilled through his skull and 'ventricular drains' were inserted into the ventricles of the brain to drain off the blood and any excessive fluid caused by 'hydrocephalous'; a dangerous complication, that causes a further build up of excessive cerebrospinal fluid in the skull as a result of the blood irritating the surface of the brain. If this build up of blood and fluid isn't drained the result is death due to the pressure exerted on the brain.

Further surgery is then required to 'coil' the ruptured aneurysm. Endovascular coiling is a fairly recent technique, it has only been in use since 1991, and is a procedure that involves inserting platinum coils approximately the width of a hair into the ruptured artery. These coils are threaded up through the artery, usually from the groin, up through the abdomen, chest and neck and into the brain until they reach the site of the aneurysm where they are then 'coiled' up inside the ruptured aneurysm and induce clotting to take place to prevent further bleeding. The aneurysm is essentially blocked off and this is known as 'occlusion'.

In addition to the hydrocephalous James also developed further complications in the form of 'Vasospasm'. This is another life-threatening complication that results from a bleed on the brain. Vasospasms are a sudden constriction of the artery that can cut off blood flow and cause a stroke. This is treated by artificially increasing a patient's blood pressure in order to prevent the vasospasm. In James's case medication had to be administered every 3 hours, day and night, for a month.

Recovery Time

Recovery from SAH is measured in years and is very much specific to the individual as no two haemorrhages are the same. The early stages of recovery, during the first year, are very marked and noticeable with huge improvements being noticed almost daily. It is after this that things tend to slow down and take much longer for even the smallest of improvements. Fatigue and short- term memory issues tend to require a variety of coping strategies and present some of the biggest issues, particularly in James's case where the bleed caused damage to the frontal lobe.

James has, for all intents and purposes, made a remarkable recovery. To look at, the casual observer wouldn't be aware that anything had even happened to him. However, the issues he now faces are masked by the marvels of keyhole surgery as he has no visible scar tissue across his head, yet he does still have long- lasting problems with fatigue and short-term memory amongst other things.

Diving after a SAH

It's important to understand that the vascular system is largely unaffected by the pressure of depths generally associated with scuba diving. There is some need for the heart to beat a little harder to pump blood to the extremities, hands and feet, but that's about all. Pressure does, of course, affect the air spaces of the body; lungs, throat, ears, sinuses etc. It is the air in these spaces that is compressed and affected.

So as far as an aneurysm is concerned, provided it's been successfully treated, then there's no reason why the patient shouldn't return to diving, provided that individual has otherwise made a good recovery to sufficient a degree to be able to otherwise dive safely. James was able to return to diving after an initial 10 month recovery period.

It's also important to appreciate that every case is unique and every case needs to be judged on its own merits and circumstances. James has been assessed by several doctors and specialists, including his neurosurgeon and all have agreed that it is safe for him to dive.

Diving Restrictions

From a fit to dive perspective, there are no restrictions. But the advice was to phase his return and to take it easy and build back up, much like for any extended absence from diving. Consequently James undertook a standard 'Fit To Dive' medical and spent a year diving for himself, gradually building back up both the duration of his dives and their depth, starting with one dive a day. After doing that he then came into the London Diving Chamber to be assessed for an HSE medical with a view to returning to instructing. He was assessed by Dr. Oliver Firth, the Medical Director, who had been given complete access to all of James's medical records and was aware of the entire history.

When asked about this James replied, "Dr. Oliver Firth has been extremely supportive and encouraging throughout. It's been a desperately tough journey at times and to have 'Dr. Oli' on side has helped tremendously, especially given the fact that I was initially told by one doctor that my diving days would probably be over!"

A year after that HSE examination James enquired at his next medical about moving into trimix and going beyond recreational limits. He was given the all clear to do so but opted to wait another two years before completing his trimix course. He said, "Initially I was just happy to be back in the water, then I was delighted to be back teaching and after that I went after my Elite Instructor status and my IDC Staff certification. It just wasn't really a priority but I'm thrilled at having now completed it."

Other Issues

James has what is effectively a hidden disability, an 'invisible illness' and whilst he isn't one to look for any form of sympathy he did comment that "The one thing that I did discover, whilst fighting for my life, was who my friends really were. But what shocked me the most was being discriminated against once I was starting to get back on my feet.

"In the very early days I couldn't defend myself or properly explain my condition, a couple of horrible people took great advantage of this and I found myself on the receiving end of a hate campaign. The old adage of kicking a bloke when he's down comes to mind. There were times when I felt I should wear a bandage around my head, simply for the benefit of some ignorant people. Shockingly, I still feel that way today and the same little group of people continues to discriminate!"

Ongoing Issues

A wry smile crossed James's face upon being asked what ongoing issues he experiences and he went on to explain that it's highly unlikely that people will really understand the issues faced by SAH survivors unless they themselves have either survived SAH / Stroke, are close to a survivor or work in the medical profession.

"It's difficult for people to understand what they can't see. The daily struggles I face, especially with fatigue management, which in itself can become physically draining. As do all the 'coping mechanisms' that I rely on.

"It can take me five times longer to do things, I find organising anything difficult and some things just get too complex. As the day goes on I start to get 'cranky' because the fatigue wears me down; I find this aspect the most difficult as people who don't know me or understand my condition think that I'm being difficult, rude or angry, when in fact that isn't the case at all, I simply need to rest.

"I particularly struggle with non-verbal communication. I don't pick up on the subtle signals that people put out. This tends to be difficult for the other person, I'm just simply unaware of it. I also say exactly what I think, something that not everyone appreciates!" He laughs.

It is also necessary for James to think about the logistics of doing certain things. Travelling to and from a dive weekend for example will require additional time and potentially cost. It may be necessary to incorporate several stops or to stay an additional night and travel back the following day. He will need to ensure that he is well rested in advance and, if necessary, sit out a dive if he's not feeling up to it.

Future Plans

We asked James what his future diving plans were and he said, "Presently I'm chasing my PADI Master Instructor certification. I'd love to achieve that, for no real purpose other than my ego. I honestly don't mind admitting that, it's not to show off or anything, simply for my own personal gratification, to know that I've done something that just a few short years ago seemed impossible.

"I'm also hoping to achieve my SDI Course Director qualification. Mark Powell has been hugely supportive over the years and I have come to admire and respect him hugely. He's given me the opportunity to do a sort of internship with him, working around the fatigue management, doing what I can, when I can. I've no idea if it'll ultimately work, it may not, but I'm determined to give it my all. I'd really like to achieve TDI Instructor Trainer, but that could prove to be a step too far and if not, it will likely take me several years!

"Mark recently said to me, 'You just keep doing what you're doing'. And whilst I don't actually have any idea what it is that I'm doing, it seems like good advice, so I'm going to keep doing it and hopefully figure it all out along the way!"