- •
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
Managing Subarachnoid Hemorrhage in the Neurocritical Care Unit
Section snippets
Key points
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
References (122)
- et al.
Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review
Lancet Neurol
(2009) - et al.
International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion
Lancet
(2005) - et al.
Triple-H therapy in the management of aneurysmal subarachnoid haemorrhage
Lancet Neurol
(2003) - et al.
Endovascular treatment of cerebral vasospasm: transluminal balloon angioplasty, intra-arterial papaverine, and intra-arterial nicardipine
Neurosurg Clin N Am
(2005) - et al.
Vasospasm after subarachnoid hemorrhage in haptoglobin 2-2 mice can be prevented with a glutathione peroxidase mimetic
J Clin Neurosci
(2010) - et al.
Inflammation and cerebral vasospasm after subarachnoid hemorrhage
Neurosurg Clin N Am
(2010) - et al.
Role of inflammation (leukocyte-endothelial cell interactions) in vasospasm after subarachnoid hemorrhage
World Neurosurg
(2010) - et al.
Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2)
Lancet Neurol
(2011) Cerebral salt wasting syndrome
Crit Care Clin
(2001)- et al.
Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference
Neurocrit Care
(2011)
Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association
Stroke
Mortality rates after subarachnoid hemorrhage: variations according to hospital case volume in 18 states
J Neurosurg
Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management
Stroke
Blood in the cerebrospinal fluid resultant functional and organic alterations in the central nervous system A. Experimental data
Arch Surg
Factors related to hydrocephalus after aneurysmal subarachnoid hemorrhage
Neurosurgery
Microsurgical fenestration of the lamina terminalis reduces the incidence of shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage
Neurosurgery
The impact of microsurgical fenestration of the lamina terminalis on shunt-dependent hydrocephalus and vasospasm after aneurysmal subarachnoid hemorrhage
Neurosurgery
Acute hydrocephalus after aneurysmal subarachnoid hemorrhage
J Neurosurg
Risk of shunt-dependent hydrocephalus after occlusion of ruptured intracranial aneurysms by surgical clipping or endovascular coiling: a single-institution series and meta-analysis
Neurosurgery
Shunt-dependent hydrocephalus after rupture of intracranial aneurysms: a prospective study of the influence of treatment modality
J Neurosurg
Predictors of long-term shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage. Clinical article
J Neurosurg
Shunt-dependent hydrocephalus after aneurysmal subarachnoid hemorrhage: incidence, predictors, and revision rates. Clinical article
J Neurosurg
Efficacy of lamina terminalis fenestration in reducing shunt-dependent hydrocephalus following aneurysmal subarachnoid hemorrhage: a systematic review. Clinical article
J Neurosurg
Ventriculoperitoneal shunting after aneurysmal subarachnoid hemorrhage: analysis of the indications, complications, and outcome with a focus on patients with borderline ventriculomegaly
Neurosurgery
Comparison of rapid and gradual weaning from external ventricular drainage in patients with aneurysmal subarachnoid hemorrhage: a prospective randomized trial
J Neurosurg
Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage
Stroke
Preoperative ventriculostomy and rebleeding after aneurysmal subarachnoid hemorrhage
J Neurosurg
Marked reduction of cerebral vasospasm with lumbar drainage of cerebrospinal fluid after subarachnoid hemorrhage
J Neurosurg
Seizures and epilepsy following aneurysmal subarachnoid hemorrhage: incidence and risk factors
J Korean Neurosurg Soc
Hypertension as a risk factor for epilepsy after aneurysmal subarachnoid hemorrhage and surgery
Neurosurgery
Predictors and clinical impact of epilepsy after subarachnoid hemorrhage
Neurology
Epilepsy after subarachnoid hemorrhage: the frequency of seizures after clip occlusion or coil embolization of a ruptured cerebral aneurysm: results from the International Subarachnoid Aneurysm Trial
J Neurosurg
Seizures and anticonvulsants after aneurysmal subarachnoid hemorrhage
Neurocrit Care
Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage
Stroke
Three-day phenytoin prophylaxis is adequate after subarachnoid hemorrhage
Neurosurgery
Outcome in patients with subarachnoid hemorrhage treated with antiepileptic drugs
J Neurosurg
Rebleeding after aneurysmal subarachnoid hemorrhage
Neurocrit Care
The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: surgical results
J Neurosurg
The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1: overall management results
J Neurosurg
Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage
Arch Neurol
Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage
Neurology
Predictors of rehemorrhage after treatment of ruptured intracranial aneurysms: the Cerebral Aneurysm Rerupture After Treatment (CARAT) study
Stroke
Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage
Cochrane Database Syst Rev
Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study
J Neurosurg
Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage
Stroke
The relationship between delayed infarcts and angiographic vasospasm after aneurysmal subarachnoid hemorrhage
Neurosurgery
Cerebral lesions due to intracranial aneurysms
Brain
Arteriographic demonstration of spasm of the intracranial arteries, with special reference to saccular arterial aneurysms
J Neurosurg
Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group
Stroke
Clinical response to hypertensive hypervolemic therapy and outcome after subarachnoid hemorrhage
Neurosurgery
Cited by (6)
Stellate ganglion block as rescue therapy in refractory vasospasm after subarachnoid hemorrhage
2019, Medicina IntensivaBaroreflex sensitivity and heart rate variability are predictors of mortality in patients with aneurysmal subarachnoid haemorrhage
2018, Journal of the Neurological SciencesCitation 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.
Aneurysm Surgery
2018, Neurocritical Care Management of the Neurosurgical PatientMachine learning prediction of the adverse outcome for nontraumatic subarachnoid hemorrhage patients
2020, Annals of Clinical and Translational NeurologyParameter Optimization for Selected Correlation Analysis of Intracranial Pathophysiology
2015, Computational and Mathematical Methods in Medicine
Disclosures: None.