Coagulopathy is a rare etiology of SAH: it is more commonly associated with intracerebral hemorrhage and subdural hematoma than with subarachnoid hemorrhage (see Intracerebral Hemorrhage and Subdural Hematoma)
Epidemiology: saccular aneurysms account for most cases of SAH
Clinical: aneurysms may be occult in some cases (due to interpretive errors on studies, small aneurysm size, or obscuration of the aneurysm related to vasospasm, hematoma, or thrombosis within the aneurysm)
Sensitivity: detects 92% of SAH if performed within 24 hrs of onset of bleed
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Acute diagnostic workup should include noncontrast head CT, which, if nondiagnostic, should be followed by lumbar puncture (Class I; Level of Evidence B)
Useful for Aeurysmal Detection and Presurgical Planning
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
CTA may be considered in the workup of aSAH. If an aneurysm is detected by CTA, this study may help guide the decision for type of aneurysm repair, but if CTA is inconclusive, DSA is still recommended (except possibly in the instance of classic perimesencephalic aSAH) (Class IIb; Level of Evidence C)
Brain MRI with proton density and FLAIR sequences may be as sensitive as head CT for the acute detection of SAH
Brain MRI FLAIR and T2 sequences have high sensitivity in patients with a subacute SAH presentations (>4 days from the bleed)
Brain MR Angiogram: useful for aneurysmal detection and presurgical planning
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Magnetic resonance imaging (fluid-attenuated inversion recovery, proton density, diffusion-weighted imaging, and gradient echo sequences) may be reasonable for the diagnosis of aSAH in patients with a nondiagnostic CT scan, although a negative result does not obviate the need for cerebrospinal fluid analysis (Class IIb; Level of Evidence C)
Clearing of Blood in Later Tubes: unreliable means of distinguishing a traumatic lumbar puncture from SAH, since SAH can also manifest a clearing of blood in later tubes
This observation is really only useful if the initial tube has lots of blood and the last tube has no blood
Xanthochromia (Pink or Yellow Tint Due to Hemoglobin Degradation Products): RBC’s present (and not due to traumatic lumbar puncture)
Presence of xanthochromia indicates that blood has been in the cerebrospinal fluid for ≥2 hrs
Most sensitive 6 hrs after onset of bleed
Other potential cause of xanthochromia: increased cerebrospinal fluid protein (≥150 mg/dL), systemic hyperbilirubinemia (serum bilirubin >10-15 mg/dL), and traumatic lumbar puncture with >100k RBC/μL
Xanthochromia can last for 2 or more weeks
Cerebral Angiogram/Digital Subtraction Angiography (DSA) (see Cerebral Angiogram)
Technique: usually done via femoral arterial approach
Findings
Identification and Characterization of Aneurysm
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
DSA with 3-dimensional rotational angiography is indicated for detection of aneurysm in patients with aSAH (except when the aneurysm was previously diagnosed by a noninvasive angiogram) and for planning treatment (to determine whether an aneurysm is amenable to coiling or to expedite microsurgery) (Class I; Level of Evidence B)
May Be Useful to Define Seizure Activity in Some Cases
Clinical Manifestations
General Comments
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Aneurysmal SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for Aneurysmal SAH should exist in patients with acute onset of severe headache (Class I; Level of Evidence B)
The initial clinical severity of Aneurysmal SAH should be determined rapidly by use of simple validated scales (eg, Hunt and Hess, World Federation of Neurological Surgeons), because it is the most useful indicator of outcome after Aneurysmal SAH (Class I; Level of Evidence B)
World Federation of Neurological Surgeons Subarachnoid Hemorrhage Grading Scale
Grade 1
GCS: 15
Motor Deficit: Absent
Grade 2
GCS: 13-14
Motor Deficit: Absent
Grade 3
GCS: 13-14
Motor Deficit: Present
Grade 4
GCS: 7-12
Motor Deficit: Absent or Present
Grade 5
GCS: 3-6
Motor Deficit: Absent or Present
Hunt and Hess Subarachnoid Hemorrhage Grading Scale
Grade 1: asymptomatic or mild headache and slight nuchal rigidity
Grade 2: severe headache, stiff neck, no neurologic deficit except cranial nerve palsy
Grade 3: drowsy or confused, mild focal neurologic deficit
Grade 4: stuporous, moderate or severe hemiparesis
Elevated Serum BNP is Associated with Increased Mortality in SAH (Neurology, 2009) [MEDLINE]
Physiology
BNP Likely Originates from Injured Cardiac Muscle, as BNP Levels are Associated with Myocardial Necrosis, Pulmonary Edema and Both Systolic/Diastolic Left Ventricular Dysfunction (Stroke, 2005) [MEDLINE]
Physiology: abnormal cerebral blood flow to the hippocampus/brain stem/basal ganglia (suggesting activation of these areas) -> excessive catecholamine release, resulting in sympathetic stimulation of the myocardium
Echocardiographic Wall Motion Abnormalities (see Echocardiogram)
Epidemiology
Echocardiographic Wall Motion Abnormalities Occur in 25% of SAH Cases
Echocardiographic Wall Motion Abnormalities are Associated with Worse Mortality in SAH (Neurology, 2009) [MEDLINE]
Physiology
Myocardial Injury Commonly Occurs in SAH
Mechanism: sympathetic stimulation and catecholamine discharge
Increased ICP is Common in SAH: occurs in approximately 54% of cases (J Neurosurg, 2004) [MEDLINE]
Mechanisms
Hemorrhage Volume
Acute Hydrocephalus
Reactive Hyperemia After SAH/Ischemia
Distal Cerebral Arteriolar Vasodilation
Diagnosis
External Ventricular Drain (EVD) (see External Ventricular Drain): generally indicated for patients with evidence of hydrocephalus (on head CT) or World Federation of Neurological Surgeons Subarachnoid Hemorrhage Grade ≥3
Although Meningismus May Occur in Association with the Onset of Headache, It Typically Does Not Develop Until Several (4-6) Hours After the Initial Bleed: due to breakdown of blood products in the cerebrospinal fluid
“Sentinel Headache”: 30-50% of patients report a history of a sudden/severe headache which precedes a major SAH by a period of 6-20 days
Abrupt Onset
Commonly Presents as the “Worse Headache of My Life”
Headache is Lateralized to Side of Aneurysm in 30% of Cases
Headache May Be Associated with Brief Loss of Consciousness/Meningismus/Nausea and Vomiting
Vasospasm and Delayed Cerebral Ischemia (DCI)
Definitions
General Comments: since the current definitions of these entities are inconsistent, clinical trials instead should use radiographic evidence of cerebral infarction and functional outcome as the primary outcome measures
Vasospasm: post-SAH arterial narrowing, as demonstrated by radiographic images or ultrasound -> narrowing may produce cerebral ischemia or infarction
The Term “Vasospasm” Defines a Finding on Diagnostic Studies (and the Patient May, Therefore, Be Asymptomatic)
Vasospasm Generally Occurs After 72 hrs (Peak: 7-8 Days)
Selective Serotonin Reuptake Inhibitor Use (SSRI) (see xxxx)
Statin Use (see xxxx): risk may be related rebound related to statin discontinuation at the time of admission (since some data suggests that statins might be protective against the development of vasospasm)
Delayed Cerebral Ischemia (DCI): any neurological deterioration (hemiparesis, aphasia, altered consciousness), presumably related to ischemia, which persists for >1 hr and cannot be explained by other physiological abnormalities (on standard radiographic, electrophysiologic, or laboratories)
The Term “Delayed Cerebral Ischemia” Defines a Clinical Finding
Mechanisms Resulting in Delayed Cerebral Ischemia
Vasospasm: presumably the most common mechanism
Hypovolemia
Cerebral Artery Occlusion (Either Temporary or Permanent) During Aneurysm Surgery
Embolism Unrelated to SAH
Thromboembolism Related to Turbulent/Stagnant Aneurysmal Blood Flow or Aneurysmal Clipping
Delayed Cerebral Ischemia May Be Asymptomatic: or at least difficult to detect in patients in poor neurologic condition or on sedation
However, Delayed Cerebral Ischemia May Result in Cerebral Infarction
Risk Factors for Pulmonary Complications After Subarachnoid Hemorrhage
Poor-Grade Subarachnoid Hemorrhage
Physiology: due to sympathetic hyperactivity or cardiac failure
Clinical
Prognosis
In General, Pulmonary Complications in SAH are Associated with Higher Degree of Symptomatic Vasospasm (Neurosurgery, 2003) [MEDLINE]
In General, Pulmonary Complications in SAH are Associated with Higher Mortality Rate (Neurosurgery, 2003) [MEDLINE]: however, at least some of the increased mortality risk is related to older age and worse clinical grade at admission
Acute Lung Injury in SAH is Associated with Increased ICU Length of Stay (Crit Care Med, 2006) [MEDLINE]
Renal Manifestations Hyponatremia (see Hyponatremia)
Epidemiology
Hyponatremia is the Most Common Electrolyte Imbalance in Aneurysmal SAH: occurs in 30-50% of cases
Hyponatremia Increases the Risk of Cerebral Ischemia in SAH, Even if Fluid Restriction is Not Applied (Ann Neurol, 1990) [MEDLINE]
Both Cerebral Salt Wasting and SIADH May Exist in the Same Patient: with excessive urine output and simultaneous excessive free water retention (Anesth Analg, 2009) [MEDLINE]
The Clinical Entity of Cerebral Salt Wasting Was First Described in 1950 (While SIADH Was First Described in 1959)
Diagnosis of Cerebral Salt Wasting Generally Requires the Presence of Hypovolemia, While the Diagnosis of SIADH Requires the Presence of Euvolemia or Modest Hypervolemia
Physiology: due to a non-infectious, systemic inflammatory reaction
Prognosis
Fever is Associated with Increased Incidence of Cerebral Infarction
Fever is Associated with Worse Outcome
Prevention Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Treatment of high blood pressure with antihypertensive medication is recommended to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ injury (Class I; Level of Evidence A)
Hypertension should be treated, and such treatment may reduce the risk of Aneurysmal SAH (Class I; Level of Evidence B)
Tobacco use and alcohol misuse should be avoided to reduce the risk of Aneurysmal Subarachnoid Hemorrhage (Class I; Level of Evidence B)
In addition to the size and location of the aneurysm and the patient’s age and health status, it might be reasonable to consider morphological and hemodynamic characteristics of the aneurysm when discussing the risk of aneurysm rupture (Class IIb; Level of Evidence B)
Consumption of a diet rich in vegetables may lower the risk of Aneurysmal SAH (Class IIb; Level of Evidence B)
It may be reasonable to offer noninvasive screening to patients with familial (at least 1 first-degree relative) Aneurysmal SAH and/or a history of Aneurysmal SAH to evaluate for de novo aneurysms or late regrowth of a treated aneurysm, but the risks and benefits of this screening require further study (Class IIb; Level of Evidence B)
After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment (Class I; Level of Evidence B)
Treatment General Hospital Care of Subarachnoid Hemorrhage Clinical Data
Management of Subarachnoid Hemorrhage in High-Volume Centers
Only 15% of Subarachnoid Hemorrhage Patients are Transferred From the Lowest Volume Centers and Only 4.5% are Sent to the Highest Volume Centers [MEDLINE]
Mortality is 10-20% Higher at Low Volume Centers [MEDLINE]
SAH Should Be Therefore Treated at High-Volume Centers [MEDLINE]: due to need for neurointensive care unit, neurointensivists, vascular neurosurgeons and interventional neuroradiologists
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Low-volume hospitals (eg, <10 aSAH cases per year) should consider early transfer of patients with aSAH to high-volume centers (eg, >35 aSAH cases per year) with experienced cerebrovascular sur- geons, endovascular specialists, and multidisciplinary neuro-intensive care services (Class I; Level of Evidence B)
The risk of early aneurysm rebleeding is high, and rebleeding is associated with very poor outcomes. Therefore, urgent evaluation and treatment of patients with suspected Aneurysmal SAH is recommended (Class I; Level of Evidence B)
Annual monitoring of complication rates for surgical and interventional procedures is reasonable (Class IIa; Level of Evidence C)
A hospital credentialing process to ensure that proper training standards have been met by indi- vidual physicians treating brain aneurysms is reasonable (Class IIa; Level of Evidence C)
Anemia Management (see Anemia) Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Minimize Blood Loss
Maintain Hemoglobin >8-10 g/dL: higher targets may be required for patient with delayed cerebral ischemia, but data are lacking
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
The Use of Packed Red Blood Cell Transfusion to Treat Anemia Might Be Reasonable in Patients with Aneurysmal SAH Who are at Risk of Cerebral Ischemia (Class IIb Recommendation, Level of Evidence B)
The Optimal Hemoglobin Goal is Undetermined (Class IIb Recommendation, Level of Evidence B)
Aneurysmal Repair Markedly Decreases the Risk of Aneurysmal Rebleeding: clip ligation is slightly more efficacious than coil embolization in preventing rebleeding [MEDLINE]
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Early Aneurysm Repair is Recommended to Prevent Rebleeding
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Management Decisions
Determination of aneurysm treatment, as judged by both experienced cerebrovascular surgeons and endovascular specialists, should be a multidisciplinary decision based on characteristics of the patient and the aneurysm (Class I; Level of Evidence C)
Timing of Intervention
Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after Aneurysmal Subarachnoid Hemorrhage (Class I; Level of Evidence B)
Technique
Complete obliteration of the aneurysm is recommended whenever possible (Class I; Level of Evidence B)
For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of Evidence B)
In the absence of a compelling contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and strong consideration should be given to retreatment, either by repeat coiling or microsurgical clipping, if there is a clinically significant (eg, growing) remnant (Class I; Level of Evidence B)
Microsurgical clipping may receive increased consideration in patients presenting with large (>50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling may receive increased consideration in the elderly ( 70 years of age), in those presenting with poor-grade (World Federation of Neurological Surgeons classi- fication IV/V) aSAH, and in those with aneurysms of the basilar apex (Class IIb; Level of Evidence C)
Aneurysmal Stenting
Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and should only be considered when less risky options have been excluded (Class III; Level of Evidence C)
Anesthesia Management During Surgical/Endovascular Management
Minimization of the degree and duration of intraoperative hypotension during aneurysm surgery is probably indicated (Class IIa; Level of Evidence B)
There are insufficient data on pharmacological strategies and induced hypertension during temporary ves- sel occlusion to make specific recommendations, but there are instances when their use may be considered reasonable (Class IIb; Level of Evidence C)
Induced hypothermia during aneurysm surgery is not routinely recommended but may be a reasonable option in selected cases (Class III; Level of Evidence B)
Prevention of intraoperative hyperglycemia during aneurysm surgery is probably indicated (Class IIa; Level of Evidence B)
The use of general anesthesia during endovascular treatment of ruptured cerebral aneurysms can be beneficial in selected patients (Class IIa; Level of Evidence C)
Anticonvulsant Use in Patients with Seizures Occurring After Presentation: standard management
Continuous EEG Monitoring (see Electroencephalogram): may be considered in patients with poor-grade Subarachnoid Hemorrhage who fail to improve or have neurological deterioration of unclear etiology
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period (Class IIb; Level of Evidence B)
The routine long-term use of anticonvulsants is not recommended (Class III; Level of Evidence B) but may be considered for patients with known risk factors for delayed seizure disorder, such as prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm at the middle cerebral artery (Class IIb; Level of Evidence B)
Anti-Fibrinolytic Therapy Significantly Decreases the Risk of Rebleeding , But Does Not Impact Outcome: likely due to higher incidence of cerebral ischemia with anit-fibrinolytic thearpy
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Early Short Course of Anti-Fibrinolytics May Be Considered Prior to Aneurysmal Repair: begin at diagnosis and continue until aneurysmal reapir (or 72 hrs, whichever is shorter)
Avoid Delayed Start of Anti-Fibrinolytics (>48 hrs After Bleed) or Prolonged Anti-Fibrinolytics (>3 Days): since the risk of rebleeding during this later period is less
Avoid Anti-Fibrinolytics in Patients with Risk Factors for Thromboembolic Complications
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
For patients with an unavoidable delay in obliteration of aneurysm, a significant risk of rebleeding, and no compelling medical contraindications, short-term (<72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk of early aneurysm rebleeding (Class IIa Recommendation, Level of Evidence B)
Antiplatelet Therapy Rationale
Antiplatelet Therapy Decreases the Risk of Delayed Cerebral Ischemia
Meta-Analysis of Deep Venous Thrombosis Prophylaxis in Mixed Neurosurgical Population (Chest, 2008) [MEDLINE]
SCD’s, Unfractionated Heparin, and Low Molecular Weight Heparin were Similarly Effective in Preventing DVT
There Was a Trend Toward Higher Rates of Intracerebral Hemorrhage and Non-Cerebral Minor Hemorrhage with Low Molecular Weight Heparin, as Compared to SCD’s and Unfractionated Heparin
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
DVT Prophylaxis with Sequential Compression Devices (SCD’s) Should Be Used in All Patients
Pharmacologic Prophylaxis Should Be Withheld in Patients with Unsecured Aneurysms Who are Expected to Undergo Surgery
Pharmacologic Prophylaxis with Unfractionated Heparin Can Be Started 24 hrs Post-Op
Unfractionated Heparin/Low Molecular Weight Heparin Prophylaxis Should Be Withheld 24 hrs Before/After Intracranial Procedures
Recommended Duration of DVT Prophylaxis is Unclear
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Deep Venous Thrombosis is a Relatively Frequent Complication After Aneurysmal SAH
Early Identification and Targeted Treatment are Recommended, But Further Research is Needed to Identify the Ideal Screening Paradigm (Class I Recommendation, Level of Evidence B)
Management of Heparin-Induced Thrombocytopenia (HIT) (see Heparin-Induced Thrombocytopenia) Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Heparin-Induced Thrombocytopenia is a Relatively Frequent Complication After Aneurysmal Subarachnoid Hemorrhage
Early Identification and Targeted Treatment are Recommended, But Further Research is Needed to Identify the Ideal Screening Paradigm (Class I Recommendation, Level of Evidence B)
Fever Management (see Fever) Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Surface Cooling: used in cases where anti-pyretics are ineffective
Intravascular Cooling: used in cases where anti-pyretics are ineffective
Monitoring/Treatment of Shivering
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Aggressive Control of Fever to a Target of Normothermia by the Use of Standard or Advanced Temperature Modulating Systems is Reasonable in the Acute Phase of Aneurysmal Subarachnoid Hemorrhage (Class IIa, Level of Evidence B)
Glucose Management Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Avoid Hypoglycemia (<80 mg/dL)
Avoid Hyperglycemia (>200 mg/dL)
If Cerebral Microdialysis is Being Used: serum glucose may be adjusted to avoid cerebral hypoglycemia
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Careful Glucose Management with Strict Avoidance of Hypoglycemia is Recommended in Aneurysmal Subarachnoid Hemorrhage (Class IIb, Level of Evidence B)
Blood Pressure Management Agents
Nicardipine (Cardene) (see Nicardipine): most commonly used agent
Considerations if Intracranial Pressure (ICP) Monitoring is Not Employed
Alert Patient (Without ICP Measurement): cerebral perfusion pressure is deemed to be adequate -> lowering blood pressure in this setting may decrease the risk of re-rerupture
Obtunded Patient (Without ICP Measurement): withhold antihypertensive therapy -> lowering blood pressure in this setting may be hazardous, since this may result in decreased cerebral perfusion pressure
Clinical Efifcacy
Prospective Randomized Trial Comparing Hypertensive/Hypervolemic/Hemodilution (Hyperdynamic) Therapy with Normovolemic Therapy (Neurosurgery, 2001) [MEDLINE]: n = 32
No Difference with Respect to Cerebral Vasospasm or Outcome at 1 Year
Hyperdynamic Group Had Higher Costs and Complication Rate
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
In Unsecured, Recently Ruptured Aneurysms: target MAP <110
Use Pre-Morbid Baseline Blood Pressure as a Guide to Refine the Blood Pressure Target
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Between the time of Aneurysmsl Subarachnoid Hemorrhage symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure (Class I; Level of Evidence B)
The magnitude of blood pressure control to reduce the risk of rebleeding has not been established, but a decrease in systolic blood pressure to <160 mm Hg is reasonable (Class IIa; Level of Evidence C)
Intravascular Volume Management
Techniques to Monitor Intravascular Volume Status
Central Venous Pressure (CVP) (see Hemodynamics): unreliable indicator of intravascular volume status [MEDLINE] [MEDLINE]
FloTrac Assessment of Cardiac Index in Post-Operative Subarachnoid Hemorrhage is Inferior to Thermodilution Cardiac Output (see FloTrac) [MEDLINE]
Echocardiographic Assessment of Inferior Vena Cava Distensibility May Be a Better Predictor of Fluid Responsiveness in Subarachnoid Hemorrhage (see Echocardiogram) [MEDLINE]
Clinical Efifcacy
Prospective Randomized Trial Comparing Hypertensive/Hypervolemic/Hemodilution (Hyperdynamic) Therapy with Normovolemic Therapy (Neurosurgery, 2001) [MEDLINE]: n = 32
No Difference with Respect to Cerebral Vasospasm or Outcome at 1 Year
Hyperdynamic Group Had Higher Costs and Complication Rate
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Euvolemia is Recommended: this is especially true in the setting of neurogenic pulmonary edema/ARDS
Avoid Hypovolemia: due to risk of increased harm
Avoid Hypervolemia: due to risk of cerebral infarction
Normal Saline is the Preferred Agent to Maintain Euvolemia (see Normal Saline)
In Cases with Persistent Negative Fluid Balance Despite Standard Measures, Fludrocortisone or Hydrocortisone May Be Considered (see Fludrocortisone and Hydrocortisone)
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Administration of Large Volumes of Hypotonic Intravenous Fluid and Intravascular Volume Contraction are Not Recommended After Aneurysmal Subarachnoid Hemorrhage (Class III Recommendation, Level of Evidence B)
Monitoring Volume Status in Certain Patients with Recent Aneurysmal Subarachnoid Hemorrhage by Some Combination of Central Venous Pressure, Pulmonary Capillary Wedge Pressure (PCWP), and Fluid Balance is Reasonable (Class IIa Recommendation, Level of Evidence B)
Treatment of Volume Contraction with Intravenous Crystalloid/Colloid is Reasonable (Class IIa Recommendation, Level of Evidence B)
Hyponatremia Management (see Hyponatremia) Clinical Data
Retrospective Study of the Impact of Fluid Restriction in Subarachnoid Hemorrhage (Ann Neurol, 1985) [MEDLINE]
Fluid Restriction Increases the Risk of Cerebral Infarction in SAH
Data from Traumatic Brain Injury (TBI) Suggests that Hypertonic Saline Lowers Intracranial Pressure and May Improve Cerebral Perfusion (see Traumatic Brain Injury)
Limited Data in in Poor-Grade Subarachnoid Hemorrhage Suggests Clinical Benefit from 23.5% Hypertonic Saline (Stroke, 2010) [MEDLINE]
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Do Not Use Fluid Restriction to Treat Hyponatremia in Subarachnoid Hemorrhage (Strong Recommendation, Weak Quality Evidence)
Minimize Free Water Intake (Strong Recommendation, Very Low Quality Evidence)
Early Treatment with Hydrocortisone or Fludrocortisone May Be Used to Limit Natriuresis and Hyponatremia (Weak Recommendation, Moderate Quality Evidence) (see Hydrocortisone and Fludrocortisone)
Hypertonic Saline May Be Used to Correct Hyponatremia (Strong Recommendation, Very Low Quality Evidence) (see Hypertonic Saline)
While Vasopressin-Receptor Antagonists May Be Considered to Correct Hyponatremia, Extreme Caution Should Be Exercised to Avoid Hypovolemia (Strong Recommendation, Weak Quality Evidence) (see Conivaptan and Tolvaptan)
Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Administration of Large Volumes of Hypotonic Intravenous Fluid and Intravascular Volume Contraction are Not Recommended After Aneurysmal Subarachnoid Hemorrhage (Class III Recommendation, Level of Evidence B)
Use of Fludrocortisone Acetate and Hypertonic Saline Solution is Reasonable for Preventing and Correcting Hyponatremia After Aneurysmal Subarachnoid Hemorrhage (Class IIa Recommendation, Level of Evidence B)
Hypothalamic Dysfunction Management Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE]
Management of Adrenal Insufficiency with Standard Therapy
Fludrocortisone May Be Used to Inhibit Natriuresis and Hyponatremia: see Hyponatremia Management above
Consider Stress-Dose Corticosteroids for Patients with Vasospasm and Vasopressor-Unresponsive Hypotension
World Federation of Neurological Surgeons Subarachnoid Hemorrhage Grade ≥3
Rationale: allows for intracranial pressure monitoring and treatment by drainage of cerebrospinal fluid
Hydrocephalus Management (see Hydrocephalus) Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE]
Subarachnoid Hemorrhage-Associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario) (Class I; Level of Evidence B)
Aneurysmal Subarachnoid Hemorrhage-associated chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion (Class I; Level of Evidence C)
Weaning EVD over >24 hrs does not appear to be effective in reducing the need for ventricular shunting (Class III; Level of Evidence B)
Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and therefore should not be routinely performed (Class III Recommendation, Level of Evidence B)
Serum Magnesium Level Management Rationale
Magnesium Acts as a Non-Competitive Calcium Antagonist: may have vascular and potentially neuroprotective effects
Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE] Induction of Hypermagnesemia is Not Recommended Avoid Hypomagnesemia Respiratory Support Hyperventilation is Generally Avoided Since it May Precipitate or Exacerbate Vasospasm Other Measures Decompressive Craniectomy (see Decompressive Craniectomy) May Be Required in Some Cases with Severe Cerebral Edema Mannitol (see Mannitol): osmotic diuretic Statins (see HMG-CoA Reductase Inhibitors) Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE] Patients on Statins Prior to Presentation with Aneurysmal SAH Should Have Statin Continued in the Acute PhaseConsider Acute Statin Therapy in Statin-Naive Patients: may decrease the incidence of delayed cerebral ischemia after aneurysmal SAH Vasospasm and Delayed Cerebral Ischemia (DCI) Management Monitoring and General Management of Delayed Cerebral Ischemia Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE] Patients at Risk for Delayed Cerebral Ischemia Should Be Monitored in the ICUNimodipine (Nimotop) (see Nimodipine): cerebral vessel vasodilator Nimodipine Has Been Demonstrated to Improve Outcome, But Does Not Affect the Incidence or Either Angiographic or Symptomatic Vasospasm Dose: 60 mg PO q4hrs begun within 4 days on onset and continued x 21 days Transcranial Dopplers May Be Used to Monitor for Large Artery Vasospasm (see Transcranial Doppler Ultrasound) Imaging of Vascular Anatomy and/or Perfusion Can Be Used to Confirm a Diagnosis of DCI in Monitored Good-Grade Patients Who Exhibit a Change in Neurologic Exam or Trans-Cranial Doppler Studies (see Transcranial Doppler Ultrasound) Digital Subtraction Angiogram is the Gold Standard for Detection of Large Artery VasospasmHigh-Quality CT Angiogram Can Be Used For Vasospasm Screening: due to its high specificity, it may reduce the need for digital subtraction angiogram studies EEG/Cerebral Microdialysis/CT Perfusion May Be Used to Monitor for Delayed Cerebral Ischemia Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE] Oral nimodipine should be administered to all patients with aSAH (Class I; Level of Evidence A)Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Class I; Level of Evidence B)Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended (Class III; Level of Evidence B)Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Class IIa; Level of Evidence B)Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Class IIa; Level of Evidence B) Hemodynamic Management of Delayed Cerebral Ischemia Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE] Maintain EuvolemiaIntravenous Normal Saline Infusion May Be Used as a Measure to Increase Cerebral Blood Flow in Advance of Other InterventionsConsider Trial of Induced Hypertension: proceed in a stepwise manner with assessment of neurologic function If Nimodipine Induces Hypotension, Should Change to Lower Dose at a More Frequent Interval: if hypotension persists, may discontinue nimodipine Choice of Vasopressor Should Be Based on Other Clinical Parameters In Cases with Unsecured Aneurysm (Which Was Responsible for the Initial Subarachnoid Hemorrhage), Caution Should Be Exercised with Induced Hypertension Inotropic Support to Maintain Cardiac Output (Inotropes, Intra-Aortic Balloon Pump): may be considered in select cases Avoid Hemodilution: except in cases of polycythemia Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE] Maintenance of euvolemia and normal circulating blood volume is recommended to prevent Delayed Cerebral Ischemia (Class I; Level of Evidence B)Induction of hypertension is recommended for patients with Delayed Cerebral Ischemia unless blood pressure is elevated at baseline or cardiac status precludes it (Class I; Level of Evidence B) Endovascular Management of Delayed Cerebral Ischemia Recommendations (Neurocritical Care Society Guidelines, 2011) [MEDLINE] Balloon Angiplasty May Be ConsideredIntra-Arterial Nicardipine May Be Considered (see Nicardipine): may be used for vasospasm Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal Subarachnoid Hemorrhage Management Guidelines, 2012) (Stroke, 2012) [MEDLINE] Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (Class IIa; Level of Evidence B) Post-Admission Evaluation/Rehabilitation Recommendations for Aneurysmal Subarachnoid Hemorrhage (American Heart Association/American Stroke Association Aneurysmal SAH Management Guidelines, 2012) (Stroke, 2012) [MEDLINE] After discharge, it is reasonable to refer patients with Aneurysmal SAH for a comprehensive evaluation, including cognitive, behavioral, and psychosocial assessments (Class IIa; Level of Evidence B) Prognosis xxx Worse with age >50, aneurysm >10 mm, etc. References General Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage. N Engl J Med. 2000 Jan 6;342(1):29-36 [MEDLINE] Aneurysmal subarachnoid hemorrhage. N Engl J Med. 2006 Jan 26;354(4):387-96 [MEDLINE] Epidemiology Antiplatelet drugs and risk of subarachnoid hemorrhage: a population-based case-control study. J Thromb Haemost. 2010;8(7):1468 [MEDLINE] Diagnosis Complications of Swan-Ganz catheterization for hemodynamic monitoring in patients with subarachnoid hemorrhage. Neurosurgery. 1995;37: 872–5 [MEDLINE] Plasma B-type natriuretic peptide levels are associated with early cardiac dysfunction after subarachnoid hemorrhage. Stroke. 2005;36(7):1567. Epub 2005 Jun 9 [MEDLINE] Evaluation of the FloTrac uncalibrated continuous cardiac output system for perioperative hemodynamic monitoring after subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2009;21:218–25 [MEDLINE] Inferior vena cava distensibility as a predictor of fluid responsiveness in patients with subarachnoid hemorrhage. Neurocrit Care. 2010;13:3–9 [MEDLINE] Clinical Hyponatremia and cerebral infarction in patients with ruptured intracranial aneurysms: is fluid restriction harmful? Ann Neurol. 1985 Feb;17(2):137-40 [MEDLINE] Volume depletion and natriuresis in patients with a ruptured intracranial aneurysm. Ann Neurol. 1985;18:211–6 [MEDLINE] Hyponatremia is associated with cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. Ann Neurol. 1990;27:106–8 [MEDLINE] Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med. 1995; 23:1007–17 [MEDLINE] Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg. 1996;84:35–42 [MEDLINE] Hyponatraemia in a neurosurgical patient: syndrome of inappropriate antidiuretic hormone secretion versus cerebral salt wasting. Nephrol Dial Transplant. 2000;15:262–8 [MEDLINE] Hyponatremia in critically ill neurological patients. Neurologist. 2003;9:290–300 [MEDLINE] Pulmonary complications of aneurysmal subarachnoid hemorrhage. Neurosurgery. 2003;52:1025–31 [MEDLINE] Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg. 2004;101(3):408 [MEDLINE] Neurogenic pulmonary edema and other mechanisms of impaired oxygenation after aneurysmal subarachnoid hemorrhage. Neurocrit Care. 2004;1:157–70 [MEDLINE] Acute lung injury in patients with subarachnoid hemorrhage: incidence, risk factors, and outcome. Crit Care Med. 2006;34:196–202 [MEDLINE] Neurogenic pulmonary edema in patients with subarachnoid hemorrhage. J Neurosurg Anesthesiol. 2008;20: 188–92 [MEDLINE] Hyponatremia in neurological patients: cerebral salt wasting versus inappropriate antidiuretic hormone secretion. Intensive Care Med. 2008;34:125–31 [MEDLINE] Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-analysis. Neurology. 2009;72(7):635 [MEDLINE] Endocrine response after severe subarachnoid hemorrhage related to sodium and blood volume regulation. Anesth Analg. 2009;108:1922–8 [MEDLINE] Lower incidence of cerebral infarction correlates with improved functional outcome after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab. 2011;31:1545–53 [MEDLINE] Treatment Hyponatremia and cerebral infarction in patients with ruptured intracranial aneurysms: is fluid restriction harmful? Ann Neurol. 1985;17: 137–40 [MEDLINE] Hypervolemic therapy prevents volume contraction but not hyponatremia following subarachnoid hemorrhage. Ann Neurol. 1992;31:543–50 [MEDLINE] Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001 Sep;49(3):593-605; discussion 605-6 [MEDLINE] Outcomes after cerebral aneurysm clip occlusion in the United States: the need for evidence-based hospital referral. J Neurosurg. 2003;99:947–52 [MEDLINE] International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet. 2005;366:809–17 [MEDLINE] Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev, 2007 Oct 17;(4):CD006184 [MEDLINE] Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39:2617–21 [MEDLINE] Prevention of venous thromboembolism in neurosurgery: a metaanalysis. Chest. 2008;134:237–49 [MEDLINE] Hypertonic saline in patients with poor-grade subarachnoid hemorrhage improves cerebral blood flow, brain tissue oxygen, and pH. Stroke. 2010;41(1):122 [MEDLINE] Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3 [MEDLINE] Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care. 2011 Sep;15(2):211-40. doi: 10.1007/s12028-011-9605-9 [MEDLINE] Prognosis Association between subarachnoid hemorrhage outcomes and number of cases treated at California hospitals. Stroke. 2002; 33:1851–6 [MEDLINE]
