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

  • 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
Treatment Regimen
  • admission to the intensive care unit (ICU)
  • strict bed rest with the head of the bed kept elevated at 30°  (optimal venous drainage ⇒ ↓ ICP)
  • prevention of constipation (especially in an untreated aneurysm)
    • LACTULOSE
Monitoring
  • repeated neurological examination, including check-ups of the level of consciousness (LOC)
  • monitoring of hemodynamics and respiratory parameters or extended neuromonitoring
  • monitor and treat hyponatremia → see here
  • monitoring of cardiac complications see here
  • TCD/TCCD monitoring of vasospasms (see below)
  • detect and manage other SAH complications
Blood pressure
  • immediately start non-invasive continuous BP monitoring; with severe SAH or fluctuating blood pressure, prefer invasive monitoring
  • BP control is complex for SAH because there are rationales for both BP lowering (↓ rebleeding risk ) and elevation (↓ risk of DID)
  • with an untreated source of bleeding, maintain SBP ≤ 130-140 mm Hg
    • postoperatively around 150-175 mm Hg (⇒ ↑ CPP)
  • in the presence of cerebral vasospasms in a patient with a secured aneurysm, the target SBP target is approx. 180-220 mmHg (to improve perfusion in the affected area)
  • excessive and rapid correction of BP can be damaging (↓CPP ⇒ risk of ischemia due to vasospasms)
  • avoid nitrates if possible (may elevate ICP)

 

Analgesics, anxiolytics
  • analgesics, often opioids, are needed to contain severe headaches
  • corticosteroids can be used successfully in the treatment of aseptic meningitis (e.g., Solumedrol 250-500mg /d + 500 ml FR for several days)
  • consider anxiolytics
  • a short-acting benzodiazepine (midazolam) and opioids should be administered prior to invasive procedures
Prevention of trombembolism
  • intermittent pneumatic compression (IPC)
  • LMWH only after securing the bleeding aneurysm

→ see here

Hemostypics
  • hemostyptics reduce the incidence of bleeding but increase the risk of ischemia
  • should only be administered in cases of proven hypocoagulable states
DICYNONE amp i.v á 6-8h
Fever
  • fever is expected in the first days after SAH (neurogenic dysregulation, presence of blood in the liquor spaces)
  • infectious complications are common in the later phase
    • monitor CRP and procalcitonin
  • treatment aims to maintain normothermia
Epileptic seizures
  • seizures increase intracranial hypertension and the risk of rebleeding
  • prophylactic administration can be considered for a few days in the acute stage, at least until an aneurysm is secured

→ acute symptomatic seizures

Anemia
  • Hb < 90 g/l (for VSP < 100g/l) is a predictor of a poor outcome
  • transfusion also worsens the prognosis
  • ⇒  individual assessment required

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)

Prevention and treatment of vasospasms

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
  • 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
Aneurysm clipping
Aneurysm clipping, artifact from the clip on CT scan
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  Stent and balloon assissted coiling
Aneurysm coiling
Aneurysm coiling
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
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