SUBARACHNOID HEMORRHAGE
Management of subarachnoid hemorrhage
Created 01/04/2021, last revision 25/04/2023
Standard management of SAH focuses on:
- blood pressure control and normovolemia
- prevention and treatment of vasospasms
- elimination of the aneurysm from the circulation
- prevention and management of complications (intra- and extracerebral)
General therapy and patient monitoring
- the initial management of patients with SAH is directed toward the stabilization of the patient
- assess the level of consciousness (LOC), airway, breathing, and circulation (ABCs)
- endotracheal intubation should be performed in patients presenting with coma, decreased level of consciousness, inability to protect the 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 in the conservative treatment of SAH; otherwise, the principles of general stroke therapy and management of intracranial hypertension apply
Laboratory studies and other methods
- serum chemistry panel – a baseline for detecting future complications
- repeatedly check natremia
- CBC – evaluation of potential infection or hematologic abnormalities
- prothrombin time (PT) and activated partial thromboplastin time (aPTT) – rule out coagulopathy
- blood typing/screening – prepare for potential transfusions
- cardiac enzymes, cardiac troponin
- to exclude possible myocardial ischemia
- predictor of pulmonary and cardiac complications
- a correlation was found between troponin levels and neurological complications and outcome
- arterial blood gas (ABG) – required in pulmonary compromised patients
- a baseline chest X-ray
- ECG + ECG monitoring, transthoracic echocardiogram
- differentiate myocardial ischemia from common benign changes
- patients with SAH can have myocardial ischemia due to the increased level of circulating catecholamines or autonomic stimulation from the brain
- nonspecific ST and T wave changes
- decreased PR intervals
- prolonged QRS intervals
- prolonged QT intervals
- presence of U waves
- arrhythmias – 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 |
- the advantage of clipping is immediate and permanent removal of the aneurysm from the circulation
- some aneurysms are not treatable because of their shape/location
Endovascular procedures |
- in acute SAH, coiling alone should be performed (the use of stents and diverters requires antiplatelets)
- the sac is usually filled with detachable platinum coils that cause local thrombosis
- it takes some time for the aneurysm to be completely removed from the circulation, partial filling of the sac is more frequent, and repeated embolization is sometimes necessary (perform a control vascular imaging 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 in patients with more severe neurological deficits, cerebral edema, or older age with comorbidities
- the use of flow diverters, stents, or balloon-assisted coiling extends the indications for endovascular management to aneurysms with wider necks (mostly in elective procedures)
Deconstructive procedures |
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Other surgical procedures
Multidisciplinary approach: neurosurgeon, interventional radiologist, anesthesiologist, neurologist
- external ventricular drainage (obstructive hydrocephalus) + ICP monitoring
- lumbar CSF drainage (hyporesorptive hydrocephalus) for 5-7 days, evacuation of 100-200mL of CSF/24h
- trepanation and insertion of micro-sensor for ICP (ventricular, parenchymal) and/or tissue monitoring
- ICH evacuation (combined with clipping)
- decompressive craniectomy
Therapy results
- 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 eligible for both treatments were enrolled at 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), the 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
