Subarachnoid hemorrhage medical therapy: Difference between revisions

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__NOTOC__
__NOTOC__
{{Subarachnoid hemorrhage}}
{{Subarachnoid hemorrhage}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}
{{CMG}}; '''Associate Editor(s)-In-Chief:''' {{CZ}}; {{SaraM}}
==Overview==
The first priority is stabilization of the patient. In those with a depressed level of consciousness, [[intubation]] and [[mechanical ventilation]] may be required. [[Blood pressure]], [[pulse]], [[respiratory rate]] and [[Glasgow coma scale|Glasgow Coma Scale]] are monitored frequently. Once the diagnosis is confirmed, admission to an [[intensive care unit|intensive care unit (ICU)]] may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission. Nutrition is an early priority, with oral or [[Nasogastric intubation|nasogastric tube]] feeding being preferable over parenteral routes. [[Analgesia]] (pain control) is generally restricted to non-sedating agents, as sedation would interfere with the monitoring of the level of consciousness. There is emphasis on the prevention of complications; for instance, [[vasospasm]], [[cerebral ischemia]], [[pulmonary embolism]] and [[deep vein thrombosis]]. <ref name="pmid21773873">{{cite journal |vauthors=Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G |title=Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference |journal=Neurocrit Care |volume=15 |issue=2 |pages=211–40 |year=2011 |pmid=21773873 |doi=10.1007/s12028-011-9605-9 |url=}}</ref><ref name="pmid21178613">{{cite journal |vauthors=Wartenberg KE |title=Critical care of poor-grade subarachnoid hemorrhage |journal=Curr Opin Crit Care |volume=17 |issue=2 |pages=85–93 |year=2011 |pmid=21178613 |doi=10.1097/MCC.0b013e328342f83d |url=}}</ref>
 
==Medical Therapy==
==Medical Therapy==
The first priority is stabilization of the patient. In those with a depressed level of consciousness, [[intubation]] and [[mechanical ventilation]] may be required. Blood pressure, pulse, respiratory rate and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an [[intensive care unit]] (ICU) may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission. Nutrition is an early priority, with oral or [[Nasogastric intubation|nasogastric tube]] feeding being preferable over parenteral routes. [[Analgesia]] (pain control) is generally restricted to non-sedating agents, as sedation would interfere with the monitoring of the level of consciousness. There is emphasis on the prevention of complications; for instance, [[deep vein thrombosis]] is prevented with [[compression stockings]] and/or intermittent pneumatic compression.
The first priority is stabilization of the patient. In those with a depressed level of consciousness, [[intubation]] and [[mechanical ventilation]] may be required. [[Blood pressure]], [[pulse]], [[respiratory rate]] and [[Glasgow coma scale|Glasgow Coma Scale]] are monitored frequently. Once the diagnosis is confirmed, admission to an [[intensive care unit|intensive care unit (ICU)]] may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission.<ref name="pmid21773873">{{cite journal |vauthors=Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G |title=Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference |journal=Neurocrit Care |volume=15 |issue=2 |pages=211–40 |year=2011 |pmid=21773873 |doi=10.1007/s12028-011-9605-9 |url=}}</ref><ref name="pmid21178613">{{cite journal |vauthors=Wartenberg KE |title=Critical care of poor-grade subarachnoid hemorrhage |journal=Curr Opin Crit Care |volume=17 |issue=2 |pages=85–93 |year=2011 |pmid=21178613 |doi=10.1097/MCC.0b013e328342f83d |url=}}</ref>
 
The mainstay of management for subarachnoid hemorrhage includes:<ref name="pmid21773873">{{cite journal |vauthors=Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G |title=Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference |journal=Neurocrit Care |volume=15 |issue=2 |pages=211–40 |year=2011 |pmid=21773873 |doi=10.1007/s12028-011-9605-9 |url=}}</ref><ref name="pmid21178613">{{cite journal |vauthors=Wartenberg KE |title=Critical care of poor-grade subarachnoid hemorrhage |journal=Curr Opin Crit Care |volume=17 |issue=2 |pages=85–93 |year=2011 |pmid=21178613 |doi=10.1097/MCC.0b013e328342f83d |url=}}</ref>
* Early aneurysm repair
* Neuromodality and multimodality monitoring
* Management of medical complications
* Prevention and appropriate management of delayed cerebral ischemia 
** Control of [[intracranial hypertension]]
** Optimization of [[cerebral perfusion pressure]]
** Optimizing cardiac hemodynamics
** Correction of [[electrolyte abnormalities]]
 
{| style="border: 0px; font-size: 90%; margin: 3px;" align=center
|+
! style="background: #4479BA; width: 250px;" | {{fontcolor|#FFF|Medical Condition}}
! style="background: #4479BA; width: 400px;" | {{fontcolor|#FFF|Management}}
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''First 24h of admission<ref name=aSAH>Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839 </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*Intensive care unit admission (constant hemodynamic and neurologic monitoring)
*Endotracheal intubation in patient with:
**[[Glasgow coma scale|GCS ≤]]8
**[[Elevated ICP]]
**Poor oxygenation or [[hypoventilation]]
**[[Hemodynamic instability]]
*[[Deep venous thrombosis|Deep venous thrombosis (DVT)]] prophylaxis ([[Compression stockings|pneumatic compression stocking]])
*Intravenous fluid administration
**Monitoring volume status (combination of [[central venous pressure]], [[pulmonary wedge pressure]], and [[fluid balance]]
**Euvolemia
**Normal electrolyte balance (avoid [[hyponatremia]])
 
*[[Antithrombotic]] discontinuation
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''[[intracranial pressure|Increased intracranial pressure (ICP)]]
| style="padding: 5px 5px; background: #F5F5F5;" |
*Place a [[ventriculostomy]]
**Direct measurement of [[intracranial pressure|intracranial pressure (ICP]])
**Drainage of [[CSF]]
*[[Osmotic diuresis|Osmotic therapy]] and [[diuresis]]
*Avoid [[hyperventilation]] (results in exacerbate [[vasospasm]])
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Blood pressure control<ref name=aSAH>Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839 </ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*No clear targeted blood pressure is defined
*Decrease in [[systolic blood pressure]] to <160mm Hg 
*Preferred regimen
**[[Labetalol]]
**[[Nicardipine]]
**[[Enalapril]]
*Decrease in [[systolic blood pressure]] to <160mm Hg
*[[Nitroprusside]] or [[nitroglycerin]] should be avoided (possible increase [[Intracranial pressure|intracranial pressure)]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Antiepileptic drug therapy<ref name=aSAH>Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839 </ref><ref name="pmid16424735">{{cite journal |vauthors=Naval NS, Stevens RD, Mirski MA, Bhardwaj A |title=Controversies in the management of aneurysmal subarachnoid hemorrhage |journal=Crit. Care Med. |volume=34 |issue=2 |pages=511–24 |year=2006 |pmid=16424735 |doi= |url=}}</ref>
| style="padding: 5px 5px; background: #F5F5F5;" |
*May be considered in the immediate posthemorrhagic period
*The routine long-term use of anticonvulsants is not recommend unless in the following conditions:
**Prior [[seizure]]
**[[Intracerebral hematoma]]
**Intractable hypertension
**[[Infarction]]
**[[Aneurysm]] at the [[middle cerebral artery]]
|-
| style="padding: 5px 5px; background: #DCDCDC;" | '''Vasospasm<ref name=aSAH>Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839 </ref>'''
| style="padding: 5px 5px; background: #F5F5F5;" |
*Monitoring<ref name="pmid16040918">{{cite journal |vauthors=Krejza J, Kochanowicz J, Mariak Z, Lewko J, Melhem ER |title=Middle cerebral artery spasm after subarachnoid hemorrhage: detection with transcranial color-coded duplex US |journal=Radiology |volume=236 |issue=2 |pages=621–9 |year=2005 |pmid=16040918 |doi=10.1148/radiol.2362031662 |url=}}</ref>
**Preforming [[Transcranial Doppler]]<ref name="pmid15136667">{{cite journal |vauthors=Sloan MA, Alexandrov AV, Tegeler CH, Spencer MP, Caplan LR, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Babikian VL, Lefkowitz D, Goldman RS, Armon C, Hsu CY, Goodin DS |title=Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology |journal=Neurology |volume=62 |issue=9 |pages=1468–81 |year=2004 |pmid=15136667 |doi= |url=}}</ref>
**Perfusion imaging with [[CT]] or [[magnetic resonance]] in order to identify brain ischemia
*Management (prevention and treatment)
**[[Nimodipine]] 60 mg PO q4h administered to all patients with aneurysmal SAH<ref name="pmid9566366">{{cite journal |vauthors=Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J |title=Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage: a systematic review |journal=Neurology |volume=50 |issue=4 |pages=876–83 |year=1998 |pmid=9566366 |doi= |url=}}</ref><ref name="pmid8609551">{{cite journal |vauthors=Barker FG, Ogilvy CS |title=Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis |journal=J. Neurosurg. |volume=84 |issue=3 |pages=405–14 |year=1996 |pmid=8609551 |doi=10.3171/jns.1996.84.3.0405 |url=}}</ref>
** Avoid [[hypovolemia]]<ref name="pmid19423854">{{cite journal |vauthors=Hoff R, Rinkel G, Verweij B, Algra A, Kalkman C |title=Blood volume measurement to guide fluid therapy after aneurysmal subarachnoid hemorrhage: a prospective controlled study |journal=Stroke |volume=40 |issue=7 |pages=2575–7 |year=2009 |pmid=19423854 |doi=10.1161/STROKEAHA.108.538116 |url=}}</ref>
** [[Statin therapy]]<ref name="pmid22556195">{{cite journal |vauthors=Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P |title=Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association |journal=Stroke |volume=43 |issue=6 |pages=1711–37 |year=2012 |pmid=22556195 |doi=10.1161/STR.0b013e3182587839 |url=}}</ref>
** Antiplatelet therapy (reduce delayed cerebral ischemia)<ref name="pmid17943892">{{cite journal |vauthors=Dorhout Mees SM, van den Bergh WM, Algra A, Rinkel GJ |title=Antiplatelet therapy for aneurysmal subarachnoid haemorrhage |journal=Cochrane Database Syst Rev |volume= |issue=4 |pages=CD006184 |year=2007 |pmid=17943892 |doi=10.1002/14651858.CD006184.pub2 |url=}}</ref>
**[[angioplasty|Cerebral angioplasty]]
|}
===Prevention of Vasospasm===
===Prevention of Vasospasm===
[[Vasospasm]] is a serious complication of SAH.  It may be seen in 50% of SAH patients studied with angiography, and is symptomatic roughly 30% of the time.  This condition can be verified by [[transcranial doppler]] or [[cerebral angiography]], and can cause ischemic brain injury that can cause permanent brain damage, and if severe can be fatal.  [[Nimodipine]], an oral [[calcium channel blocker]], has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm.<ref name="pmid6338383">{{cite journal |author=Allen GS, Ahn HS, Preziosi TJ, ''et al'' |title=Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage |journal=N. Engl. J. Med. |volume=308 |issue=11 |pages=619-24 |year=1983 |pmid=6338383 |doi=}}</ref><ref name="pmid17636626">{{cite journal |author=Dorhout Mees S, Rinkel G, Feigin V, ''et al'' |title=Calcium antagonists for aneurysmal subarachnoid haemorrhage |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD000277 |year=2007 |pmid=17636626 |doi=10.1002/14651858.CD000277.pub3}}</ref>
[[Vasospasm]] is a serious complication of SAH.  It may be seen in 50% of SAH patients studied with angiography, and is symptomatic roughly 30% of the time.  This condition can be verified by [[transcranial doppler]] or [[cerebral angiography]], and can cause ischemic brain injury that can cause permanent brain damage, and if severe can be fatal.  [[Nimodipine]], an oral [[calcium channel blocker]], has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm.<ref name="pmid6338383">{{cite journal |author=Allen GS, Ahn HS, Preziosi TJ, ''et al'' |title=Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage |journal=N. Engl. J. Med. |volume=308 |issue=11 |pages=619-24 |year=1983 |pmid=6338383 |doi=}}</ref><ref name="pmid17636626">{{cite journal |author=Dorhout Mees S, Rinkel G, Feigin V, ''et al'' |title=Calcium antagonists for aneurysmal subarachnoid haemorrhage |journal=Cochrane database of systematic reviews (Online) |volume= |issue=3 |pages=CD000277 |year=2007 |pmid=17636626 |doi=10.1002/14651858.CD000277.pub3}}</ref>
===Follow-Up===
A patient who recovers without immediate intervention may receive follow-up [[angiography]] to identify [[aneurysm]]s which may be amenable to either surgical clipping or endovascular coiling to prevent recurrent episodes of SAH.
===Contraindicated medications===
{{MedCondContrAbs
|MedCond = Subarachnoid hemorrhage|Alteplase}}
==2012 AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage<ref name=aSAH>Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839 </ref>==
===Management of Cerebral Vasospasm and DCI After aSAH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Oral [[nimodipine]] should be administered to all patients with aSAH† ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Maintenance of euvolemia and normal circulating blood volume is recommended to prevent [[DCI]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Induction of hypertension is recommended for patients with [[DCI]] unless blood pressure is elevated at baseline or cardiac status precludes it  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prophylactic [[hypervolemia]] or [[balloon angioplasty]] before the development of angiographic spasm is not recommended  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Transcranial Doppler]] is reasonable to monitor for the development of [[arterial vasospasm]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Perfusion imaging]] with [[CT]] or magnetic resonance can be useful to identify regions of potential [[brain ischemia]]  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Cerebral angioplasty]] and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to [[hypertensive therapy]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
===Management of Seizures Associated With aSAH: Recommendations===
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' The routine long-term use of anticonvulsants is not recommended ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIb]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' The routine long-term use of anticonvulsants may be considered for patients with known risk factors for delayed seizure disorder, such as prior seizure, intracerebral [[hematoma]], [[intractable hypertension]], i[[nfarction]], or aneurysm at the [[middle cerebral artery]]  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
===Management of Hydrocephalus Associated With aSAH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario)  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' aSAH-associated chronic symptomatic hydrocepha- lus should be treated with permanent cerebrospinal fluid diversion ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: C]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Weaning EVD over >24 hours does not appear to be effective in reducing the need for ventricular shunting ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''2.''' Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and therefore should not be routinely performed. ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
===Management of Cerebral Vasospasm and DCI After aSAH: Recommendations===
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LightGreen"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class I]]
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''1.''' Oral [[nimodipine]] should be administered to all patients with aSAH† ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''2.''' Maintenance of euvolemia and normal circulating blood volume is recommended to prevent [[DCI]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
| bgcolor="LightGreen"|<nowiki>"</nowiki>'''3.''' Induction of hypertension is recommended for patients with [[DCI]] unless blood pressure is elevated at baseline or cardiac status precludes it  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.
{|class="wikitable"
|-
|colspan="1" style="text-align:center; background:LightCoral"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (Harm)
|-
|bgcolor="LightCoral"|<nowiki>"</nowiki>'''1.''' Prophylactic [[hypervolemia]] or [[balloon angioplasty]] before the development of angiographic spasm is not recommended  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
{|class="wikitable"
|-
| colspan="1" style="text-align:center; background:LemonChiffon"|[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class IIa]]
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''1.''' [[Transcranial Doppler]] is reasonable to monitor for the development of [[arterial vasospasm]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''2.''' [[Perfusion imaging]] with [[CT]] or magnetic resonance can be useful to identify regions of potential [[brain ischemia]]  ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|-
|bgcolor="LemonChiffon"|<nowiki>"</nowiki>'''3.''' [[Cerebral angioplasty]] and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to [[hypertensive therapy]] ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''<nowiki>"</nowiki>
|}
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}
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{{WS}}
{{WS}}


[[Category:Neurotrauma]]
 
[[Category:Neurosurgery]]
[[Category:Intensive care medicine]]
[[Category:Neurology]]
[[Category:Neurology]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Disease]]
[[Category:Needs overview]]

Latest revision as of 16:44, 15 December 2016

Subarachnoid Hemorrhage Microchapters

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AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (2012)

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]; Sara Mehrsefat, M.D. [3]

Overview

The first priority is stabilization of the patient. In those with a depressed level of consciousness, intubation and mechanical ventilation may be required. Blood pressure, pulse, respiratory rate and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care unit (ICU) may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission. Nutrition is an early priority, with oral or nasogastric tube feeding being preferable over parenteral routes. Analgesia (pain control) is generally restricted to non-sedating agents, as sedation would interfere with the monitoring of the level of consciousness. There is emphasis on the prevention of complications; for instance, vasospasm, cerebral ischemia, pulmonary embolism and deep vein thrombosis. [1][2]

Medical Therapy

The first priority is stabilization of the patient. In those with a depressed level of consciousness, intubation and mechanical ventilation may be required. Blood pressure, pulse, respiratory rate and Glasgow Coma Scale are monitored frequently. Once the diagnosis is confirmed, admission to an intensive care unit (ICU) may be considered preferable, especially given that 15% have a further episode (rebleeding) in the first hours after admission.[1][2]

The mainstay of management for subarachnoid hemorrhage includes:[1][2]

Medical Condition Management
First 24h of admission[3]
Increased intracranial pressure (ICP)
Blood pressure control[3]
Antiepileptic drug therapy[3][4]
Vasospasm[3]

Prevention of Vasospasm

Vasospasm is a serious complication of SAH. It may be seen in 50% of SAH patients studied with angiography, and is symptomatic roughly 30% of the time. This condition can be verified by transcranial doppler or cerebral angiography, and can cause ischemic brain injury that can cause permanent brain damage, and if severe can be fatal. Nimodipine, an oral calcium channel blocker, has been shown to reduce the chance of a bad outcome, even if it does not significantly reduce the amount of angiographic vasospasm.[12][13]

Follow-Up

A patient who recovers without immediate intervention may receive follow-up angiography to identify aneurysms which may be amenable to either surgical clipping or endovascular coiling to prevent recurrent episodes of SAH.

Contraindicated medications

Subarachnoid hemorrhage is considered an absolute contraindication to the use of the following medications:

2012 AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage[3]

Management of Cerebral Vasospasm and DCI After aSAH: Recommendations

Class I
"1. Oral nimodipine should be administered to all patients with aSAH† (Level of Evidence: A)"
"2. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Level of Evidence: B)"
"3. Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (Level of Evidence: B)"

†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.

Class III (Harm)
"1. Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended (Level of Evidence: B)"
Class IIa
"1. Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Level of Evidence: B)"
"2. Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Level of Evidence: B)"
"3. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (Level of Evidence: B)"

Management of Seizures Associated With aSAH: Recommendations

Class III (Harm)
"1. The routine long-term use of anticonvulsants is not recommended (Level of Evidence: B)"
Class IIb
"1. The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period (Level of Evidence: B)"
"2. The routine long-term use of anticonvulsants may be considered for patients with known risk factors for delayed seizure disorder, such as prior seizure, intracerebral hematoma, intractable hypertension, infarction, or aneurysm at the middle cerebral artery (Level of Evidence: B)"

Management of Hydrocephalus Associated With aSAH: Recommendations

Class I
"1. aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (EVD or lumbar drainage, depending on the clinical scenario) (Level of Evidence: B)"
"2. aSAH-associated chronic symptomatic hydrocepha- lus should be treated with permanent cerebrospinal fluid diversion (Level of Evidence: C)"
Class III (Harm)
"1. Weaning EVD over >24 hours does not appear to be effective in reducing the need for ventricular shunting (Level of Evidence: B)"
"2. Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus and therefore should not be routinely performed. (Level of Evidence: B)"

Management of Cerebral Vasospasm and DCI After aSAH: Recommendations

Class I
"1. Oral nimodipine should be administered to all patients with aSAH† (Level of Evidence: A)"
"2. Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Level of Evidence: B)"
"3. Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it (Level of Evidence: B)"

†It should be noted that this agent has been shown to improve neuroogical outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.

Class III (Harm)
"1. Prophylactic hypervolemia or balloon angioplasty before the development of angiographic spasm is not recommended (Level of Evidence: B)"
Class IIa
"1. Transcranial Doppler is reasonable to monitor for the development of arterial vasospasm (Level of Evidence: B)"
"2. Perfusion imaging with CT or magnetic resonance can be useful to identify regions of potential brain ischemia (Level of Evidence: B)"
"3. Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy (Level of Evidence: B)"

References

  1. ↑ 1.0 1.1 1.2 Diringer MN, Bleck TP, Claude Hemphill J, Menon D, Shutter L, Vespa P, Bruder N, Connolly ES, Citerio G, Gress D, Hänggi D, Hoh BL, Lanzino G, Le Roux P, Rabinstein A, Schmutzhard E, Stocchetti N, Suarez JI, Treggiari M, Tseng MY, Vergouwen MD, Wolf S, Zipfel G (2011). "Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference". Neurocrit Care. 15 (2): 211–40. doi:10.1007/s12028-011-9605-9. PMID 21773873.
  2. ↑ 2.0 2.1 2.2 Wartenberg KE (2011). "Critical care of poor-grade subarachnoid hemorrhage". Curr Opin Crit Care. 17 (2): 85–93. doi:10.1097/MCC.0b013e328342f83d. PMID 21178613.
  3. ↑ 3.0 3.1 3.2 3.3 3.4 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839
  4. ↑ Naval NS, Stevens RD, Mirski MA, Bhardwaj A (2006). "Controversies in the management of aneurysmal subarachnoid hemorrhage". Crit. Care Med. 34 (2): 511–24. PMID 16424735.
  5. ↑ Krejza J, Kochanowicz J, Mariak Z, Lewko J, Melhem ER (2005). "Middle cerebral artery spasm after subarachnoid hemorrhage: detection with transcranial color-coded duplex US". Radiology. 236 (2): 621–9. doi:10.1148/radiol.2362031662. PMID 16040918.
  6. ↑ Sloan MA, Alexandrov AV, Tegeler CH, Spencer MP, Caplan LR, Feldmann E, Wechsler LR, Newell DW, Gomez CR, Babikian VL, Lefkowitz D, Goldman RS, Armon C, Hsu CY, Goodin DS (2004). "Assessment: transcranial Doppler ultrasonography: report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology". Neurology. 62 (9): 1468–81. PMID 15136667.
  7. ↑ Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J (1998). "Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage: a systematic review". Neurology. 50 (4): 876–83. PMID 9566366.
  8. ↑ Barker FG, Ogilvy CS (1996). "Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis". J. Neurosurg. 84 (3): 405–14. doi:10.3171/jns.1996.84.3.0405. PMID 8609551.
  9. ↑ Hoff R, Rinkel G, Verweij B, Algra A, Kalkman C (2009). "Blood volume measurement to guide fluid therapy after aneurysmal subarachnoid hemorrhage: a prospective controlled study". Stroke. 40 (7): 2575–7. doi:10.1161/STROKEAHA.108.538116. PMID 19423854.
  10. ↑ Connolly ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P (2012). "Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association". Stroke. 43 (6): 1711–37. doi:10.1161/STR.0b013e3182587839. PMID 22556195.
  11. ↑ Dorhout Mees SM, van den Bergh WM, Algra A, Rinkel GJ (2007). "Antiplatelet therapy for aneurysmal subarachnoid haemorrhage". Cochrane Database Syst Rev (4): CD006184. doi:10.1002/14651858.CD006184.pub2. PMID 17943892.
  12. ↑ Allen GS, Ahn HS, Preziosi TJ; et al. (1983). "Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage". N. Engl. J. Med. 308 (11): 619–24. PMID 6338383.
  13. ↑ Dorhout Mees S, Rinkel G, Feigin V; et al. (2007). "Calcium antagonists for aneurysmal subarachnoid haemorrhage". Cochrane database of systematic reviews (Online) (3): CD000277. doi:10.1002/14651858.CD000277.pub3. PMID 17636626.

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