SUBARACHNOID HEMORRHAGE
Management of subarachnoid hemorrhage
Created 01/04/2021, last revision 28/06/2022
Standard management of SAH is focused on:
- blood pressure control and normovolemia
- prevention and therapy of vasospasms
- eliminating the aneurysm from the circulation
- prevention and management of complications (intra- and extracerebral)
General therapy and patient monitoring
General therapy and patient monitoring- the initial management of patients with SAH is directed at patient stabilization
- assess the level of consciousness (LOC), airway, breathing, and circulation (ABCs)
- endotracheal intubation should be performed for patients presenting with coma, depressed level of consciousness, inability to protect their airway, or increased intracranial pressure (ICP)
- patients with signs of increased ICP or herniation should be hyperventilated (target pCO2 of 30-35 mm Hg)
- there are some specifics of conservative treatment of SAH; otherwise, the principles of general stroke therapy and intracranial hypertension management apply
Laboratory studies and other methods
- serum chemistry panel – a baseline for detection of future complications
- check natremia repeatedly
- CBC – evaluation of potential infection or hematologic abnormality
- prothrombin time (PT) and activated partial thromboplastin time (aPTT) – exclusion of coagulopathy
- blood typing/screening – get ready for potential transfusions
- cardiac enzymes, cardiac troponin
- to exclude possible myocardial ischemia
- predictor for the occurrence of pulmonary and cardiac complications
- a correlation was found between troponin levels and neurologic complications and outcome
- arterial blood gas (ABG) – necessary for pulmonary compromised patients
- a baseline chest radiograph
- ECG + ECG monitoring, transthoracic echocardiogram
- differentiate myocardial ischemia from frequent benign changes
- patients with SAH can have myocardial ischemia due to the increased level of circulating catecholamines or to autonomic stimulation from the brain
- nonspecific ST and T wave changes
- decreased PR intervals
- increased QRS intervals
- increased QT intervals
- presence of U waves
- dysrhythmias (premature ventricular contractions (PVCs), supraventricular tachycardia (SVT), and bradyarrhythmias)
Rebleeding prevention – timing
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Rebleeding prevention – methods
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Craniotomy and aneurysm clipping |
- indications:
- aneurysms in the MCA territory
- aneurysms with a wide neck
- patients indicated for concurrent ICH evacuation
- endovascular treatment is not available or has failed
- aneurysms in the MCA territory
- the advantage of clipping is immediate and permanent removal of the aneurysm from the circulation
- some aneurysms are not resolvable because of their shape/location
Endovascular procedures |
- the sac is most often filled with detachable platinum coils that lead to local thrombosis
- it takes some time before the aneurysm is entirely removed from the circulation, partial filling of the sac is more frequent, and repeated embolization is sometimes necessary (perform control CTA/DSA after the procedure)
- rebleeding rate is slightly higher than with clipping
- this method is preferred for aneurysms with a narrow neck (ideally < 5mm) in the posterior circulation and patients with more severe neurological deficits, cerebral edema, or older age with comorbidities
- using flow diverters, stents, or balloon-assisted coiling extends the indications for endovascular management to aneurysms with wider necks
Deconstructive procedures |
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Other surgical procedures
Multidisciplinary approach: neurosurgeon, interventional radiologist, anesthesiologist, neurologist
- external ventricular drainage (obstructive hydrocephalus) + ICP monitoring
- lumbar liquor drainage (hyporesorptive hydrocephalus) for 5-7 days, evacuate 100-200ml of CSF in 24h
- trepanation and insertion of micro-sensor for ICP (ventricular, parenchymal) and/or tissue monitoring
- ICH evacuation (in combination with clipping)
- decompressive craniectomy
Therapy results
- the effectiveness of aneurysm treatment is measured by rebleeding rate and clinical outcome
- ISAT (The International Subarachnoid Aneurysm Trial) was a prospective randomized trial comparing endovascular treatment with surgical clipping
- only patients suitable for both treatments were enrolled in the study, in centers performing both treatments (n=2143)
- the primary endpoint was the prevention of disability (mRS 3-5), and death from SAH within one year after treatment
- endovascular coiling was more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continued for at least 7 years
- dependency or death : 23% (endovascular) vs. 30.6% (clipping), benefit continues > 7 years
- risk of rebleeding was relatively low, more common after endovascular coiling than after neurosurgical clipping – 1.6% (coiling) vs. 0.7% (clipping)
- in both groups, rebleeding occurred most frequently during the first 30 days after aneurysm treatment, and rebleeding was associated with up to 50% mortality in both groups
- CARAT (Cerebral Aneurysm Rerupture After Treatment)
- the rebleeding rate was higher in the embolized patients (3.4% vs. 1.3%)
- rebleeding in coiled patients was mostly seen in angiographically incompletely filled aneurysms
- factors leading to incomplete aneurysm occlusion are:
- larger aneurysms (> 10 mm)
- wide neck (> 4 mm)
Follow-up
- long-term follow-up (especially in patients with incomplete occlusion) – ↑ risk of recurrence or new aneurysm formation