Aneurysmal Subarachnoid Hemorrhage (aSAH)

Aneurysmal Subarachnoid Hemorrhage (aSAH)

What is the initial management of Aneurysmal Subarachnoid Hemorrhage (aSAH)?

  • Ensure adequacy of airway patency, breathing, and circulation.
  • Avoid administration of hypotonic fluid administration.
  • Provide analgesia with narcotics and antiemetics if necessary.
  • Control blood pressure.
  • Administer nimodipine for 21 days or until day of discharge.
  • Place an external ventricular drain if hydrocephalus develops.
  • Treat seizures (avoid phenytoin as literature suggests it worsens cognitive and functional outcome).
  • Secure the ruptured aneurysm early.

What is the blood pressure goal prior to securing the ruptured aneurysm? 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 has been recommended.

When should the aneurysm be treated? 

Either 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.

There is currently no clear absolute timeline, but treatment of the ruptured cerebral aneurysm should be undertaken within 24 to 48 hours of presentation.

What is the blood pressure goal after the ruptured aneurysm is secured? Liberal blood pressure goals should be set for patients with Aneurysmal Subarachnoid Hemorrhage after the aneurysm is secured.

Although blood pressure goals should be individualized to account for patient-specific characteristics, most centers apply the AHA guidelines for acute ischemic stroke and do not use antihypertensive medications unless the systolic blood pressure exceeds 220 mm Hg or the diastolic blood pressure exceeds 120 mm Hg.

What are the causes of poor outcome in Aneurysmal Subarachnoid Hemorrhage patients? 

At admission: Poor grade SAH, high blood pressure, older age, thicker subarachnoid clot, pre-existing medical conditions and posterior circulation aneurysm. 

Later: Delayed cerebral ischemia (DCI), stroke, fever, and use of phenytoin.

How to manage acute symptomatic hydrocephalus related to Aneurysmal Subarachnoid Hemorrhage? 

Acute symptomatic hydrocephalus related to Aneurysmal Subarachnoid Hemorrhage should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario).

What is the incidence of convulsive seizure at onset of SAH? 

Clinical seizures are uncommon after the initial aneurysm rupture (occurring in 1% to 7% of patients). When they do occur in patients with an unsecured aneurysm, they are often the manifestation of aneurysmal rerupture.

What is the incidence of nonconvulsive seizure at onset of Subarachnoid Hemorrhage? 

In comatose (poor-grade) Aneurysmal Subarachnoid Hemorrhage patients, nonconvulsive seizures may be detected on continuous EEG (cEEG) in 10% to 20% of cases.

What cardiopulmonary complications occur after Subarachnoid Hemorrhage? 

Cardiac: Elevated troponin, electrocardiogram (ECG) changes, regional or global wall motion abnormality, stunned myocardium, and Takatsubo cardiomyopathy.

Pulmonary: Pulmonary edema (either cardiac or neurogenic), acute lung injury, or adult respiratory distress syndrome (ARDS).

Mechanism for both complications: Most likely a catecholamine surge at Aneurysmal Subarachnoid Hemorrhage onset.

How should cardiopulmonary complications be managed? 

In cases of either pulmonary edema or lung injury, the goal of therapy should include avoiding excessive fluid intake and judicious use of diuretics targeting euvolemia. 

Standard management of heart failure is indicated with the exception that cerebral perfusion pressure should be maintained as appropriate for the neurologic condition.

How should the aSAH patient be assessed for vasospasm? 

Serial neurologic examination is the mainstay in the monitoring for cerebral vasospasm.

Serial measurements, rather than a single transcranial Doppler (TCD) ultrasound measurement, are indicated to assess for trends in the mean CBF velocities and to help predict vasospasm.

CTA, MRA, DSA, or CT perfusion may be considered in patients who do not have adequate temporal bone windows for TCD and in those high-risk patients with poor-grade Aneurysmal Subarachnoid Hemorrhage and too poor an exam to document the presence of cerebral vasospasm.

Should central venous pressure (CVP) be used to guide fluid management in aSAH? 

CVP appears to be an unreliable indicator of intravascular volume. Fluid management based solely on CVP measurements is not recommended.

What is the etiology of hyponatremia after Aneurysmal Subarachnoid Hemorrhage? 

Hyponatremia is common after Aneurysmal Subarachnoid Hemorrhage and has been associated with development of DCI and poor clinical outcome. It can be secondary to either cerebral salt wasting or inappropriate secretion of antidiuretic hormone.

How is hyponatremia treated in aSAH? 

Hyponatremia should not be treated with volume restriction, as hypovolemia is associated with poor outcome.

In patients with a persistently negative fluid balance, use of fludrocortisone or hydrocortisone may be considered.

These agents help correct the negative sodium balance and reduce the need for fluids.

The administration of 1.5% to 3% saline also has been recommended.

When should family members of patients with aSAH be screened for the presence of an aneurysm? 

It may be reasonable to offer noninvasive screening to patients with familial (at least one first-degree relative) aSAH and/or a history of aSAH to evaluate for de novo aneurysms or late regrowth of a treated aneurysm.

The risks and benefits of this screening require further study.


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