Managing Subarachnoid Hemorrhage in the Neurocritical Care Unit

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Key points

  • The management of patients with aneurysmal subarachnoid hemorrhage is challenging and requires a multidisciplinary team approach, and is best done at high-volume centers.

  • There is a paucity of randomized, blinded, placebo-controlled, prospective trials to aid in the management of aneurysmal subarachnoid hemorrhage.

  • The critical care management of aneurysmal subarachnoid hemorrhage varies between patients with microsurgical clipping and those with endovascular occlusion, and the critical care

Care setting

The care of patients with aSAH requires a multidisciplinary approach. Team members include neurosurgeons, neurointensivists, neurologists, neuroradiologists, and interventional neuroradiologists. Patients also require specialized critical care nursing with specialized training in neurosciences. We believe that these patients are best served in dedicated NCCUs that treat a high volume of such patients. This scenario is also supported in the literature, which shows that outcomes are improved at

Hydrocephalus

Hydrocephalus is a known complication of aSAH, first described experimentally in 1928 by Bagley.6 The incidence of acute hydrocephalus varies widely, and many studies report a range from 15% to 53%.7, 8, 9, 10, 11, 12, 13 The incidence of patients with SAH who go on to require permanent shunting also varies widely in the literature. Shunt rates from 2.3% to 36% have been reported.7, 8, 9, 10, 11, 12, 13, 14, 15, 16 This large variation is likely multifactorial, including varying indications for

Cardiac

Troponin elevation following subarachnoid hemorrhage is a well-known phenomenon. Elevation in troponin I was found to be associated with an increased risk of left ventricular dysfunction, pulmonary edema, DCI, and death or poor functional outcomes in a cohort of 253 patients at the time of discharge.77 Cardiac dysfunction following aSAH (also known as stunned myocardium, and the more recently proposed neurogenic stress cardiomyopathy) presents a challenge to the management of these patients.78

Pulmonary

Pulmonary complications have been reported in 22% of patients with aSAH, with pneumonia and congestive heart failure being the most common.83 In their study of 305 patients, Friedman and colleagues83 found that the incidence of symptomatic vasospasm was higher in patients with pulmonary complications. This finding is important, as it may relate to the fact that optimal treatment of vasospasm/DCI can be limited by the presence of pulmonary complications. Mechanisms by which pulmonary function is

Fluid Balance

An understanding of the fluid balance of patients with aSAH is important,87 as is sodium balance, which is closely linked to fluid physiology. Standard calculations of fluid-balance measurements do not accurately predict actual circulating blood volumes as measured by pulse dye densitometry.88 Given these findings, in a prospective controlled study Hoff and colleagues89 used pulse dye densitometry to measure blood volumes daily in 102 patients in the first 10 days following SAH. In the

Fever

Fever following subarachnoid hemorrhage is common. Predictors include poor Hunt-Hess grade and the presence of intraventricular hemorrhage.101 Of importance, refractory fever following SAH is associated with increased mortality and worse outcomes.101, 102 Despite this, the role of fever reduction in improving outcomes is not well known. The side effects of treating fever either by pharmacologic means (ie, potential antiplatelet effects of nonsteroidal anti-inflammatories) or by cooling devices

Glucose Control

Persistently elevated glucose (>200 mg/dL for 2 or more consecutive days), has been shown to result in patients being 7 times more likely of having a poor outcome at 10 months after treatment for aSAH than those patients who did not have persistently elevated glucose.105 Furthermore, elevated glucose levels at admission are also associated with an increased risk of poor outcome.106 Prolonged elevated glucose (ie, over a week) is also associated with worse outcomes.107 However, treatment of

Anemia

The ideal hemoglobin goal in patients with aSAH is not certain. Early animal data suggested that a hematocrit near 30% was optimal for protecting the brain in a canine model of ischemia.110 Subsequently, several human studies have shown that anemia and lower hemoglobin values are associated with worse outcomes in patients with aSAH, and that higher hemoglobin is associated with improved outcomes.111, 112, 113, 114 A recent prospective, randomized trial randomized 44 patients to a hemoglobin

NCCU management of endovascular versus surgically treated patients

It should be noted that patients treated endovascularly rather than with surgical clipping of aneurysms following aSAH present unique challenges, which vary with treatment modality. Some aneurysms are best treated with endovascular therapy (ie, mid-basilar aneurysms), whereas others are best treated with microsurgical clipping (ie, MCA aneurysms). However, the decision of whether to treat a particular aneurysm with microsurgical clipping versus endovascular occlusion is complex and beyond the

Summary

aSAH can be a devastating disease. Those patients who survive the initial hemorrhage are best cared for in specialized NCCUs with personnel well trained in the management of this disease. Despite the progress made over the last decades, there still remains a paucity of high-quality evidence with which to guide the management of these patients. This article aims to provide those caring for these patients with a brief review of some of the literature combined with our own experiences. Table 1

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  • Cited by (6)

    • Baroreflex sensitivity and heart rate variability are predictors of mortality in patients with aneurysmal subarachnoid haemorrhage

      2018, Journal of the Neurological Sciences
      Citation Excerpt :

      Our results show that disturbances in HRV indices and BRS are related to higher mortality after aSAH. However, it must be emphasized that patient mortality and morbidity after aSAH depend on multiple factors, such as the general condition of the patient before onset, severity of the initial bleeding, and post–aSAH complications (hydrocephalus, vasospasm, DCI, infections) [46,47]. Therefore, BRS and HRV indices assessment in aSAH patients should be interpreted along with other clinical prognostic factors.

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    Disclosures: None.

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