Subarachnoid hemorrhage secondary prevention

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

Overview

Effective measures for the secondary prevention of subarachnoid hemorrhage include life style modification, treatment of modifiable risk factors such as blood pressure control and avoidance, and enforcing the measures to prevent the complications.

Secondary prevention

Effective measures for the secondary prevention of subarachnoid hemorrhage include:

Life style modification

Life style modification measures which may help reduce the risk of subarachnoid hemorrhage recurrence and complications may include:

• Eating healthy balanced diet
• Smoking cessation
• Decreased alcohal intake
• Patient education (involvement in BP monitoring to improve adherence to therapy

Blood pressure control

Receive early treatment targeted to an SBP level <160 mmHg to improve the chances of achieving better functional recovery

Prevent the complications

Rebleeding

• Short-term (<72 hours) therapy with tranexamic acid or aminocaproic acid to reduce the risk of early aneurysm rebleeding

Complications

• Early identification targeted treatment and screening paradigms may prevent complications such as Heparin-induced thrombocytopenia and deep venous thrombosis are
• Use of fludrocortisone acetate and hypertonic saline solution is reasonable for preventing and correcting hyponatremia
• Careful glucose management with strict avoidance of hypoglycemia
• Use of packed red blood cell transfusion to treat anemia in order to reduced the risk of cerebral ischemia

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

Management of Medical Complications Associated With aSAH: Recommendations

Class I

"1. Heparin-induced thrombocytopenia and deep venous thrombosis are relatively frequent complications after aSAH. Early identification and targeted treatment are recommended, but further research is needed to identify the ideal screening paradigms (Level of Evidence: B)"

Class III (Harm)

"1. Administration of large volumes of hypotonic fluids and intravascular volume contraction is not recommended after aSAH (Level of Evidence: B)"

Class IIa

"1. Monitoring volume status in certain patients with recent aSAH by some combination of central venous pressure, pulmonary wedge pressure, and fluid balance is reasonable, as is treatment of volume contraction with crystalloid or colloid fluids (Level of Evidence: B)"

"2. Aggressive control of fever to a target of normothermia by use of standard or advanced temperature modulating systems is reasonable in the acute phase of aSAH (Level of Evidence: B)"

"3. The use of fludrocortisone acetate and hypertonic saline solution is reasonable for preventing and correcting hyponatremia (Level of Evidence: B)"

Class IIb

"1. Careful glucose management with strict avoidance of hypoglycemia may be considered as part of the general critical care management of patients with aSAH (Level of Evidence: B)"

"2. The use of packed red blood cell transfusion to treat anemia might be reasonable in patients with aSAH who are at risk of cerebral ischemia. The optimal hemoglobin goal is still to be determined (Level of Evidence: B)"

Medical Measures to Prevent Rebleeding After aSAH: Recommendations

Class I

"1. Between the time of aSAH symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure ( (Level of Evidence: B)"

Class IIa

"1. The magnitude of blood pressure control to reduce the risk of rebleeding has not been established, but a decrease in systolic blood pressure to <160 mm Hg is reasonable (Level of Evidence: C)"

"2. For patients with an unavoidable delay in obliteration of aneurysm, a significant risk of rebleeding, and no compelling medical contraindications, short-term (<72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk of early aneurysm rebleeding (Level of Evidence: B)"

Risk Factors for and Prevention of aSAH: Recommendations

Class I

"1. Treatment of high blood pressure with antihypertensive medication is recommended to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ injury (Level of Evidence: A)"

"2. Hypertension should be treated, and such treatment may reduce the risk of aSAH (Level of Evidence: B)"

"3. Tobacco use and alcohol misuse should be avoided to reduce the risk of aSAH (Level of Evidence: B)"

"4. After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment (Level of Evidence: B)"

Class IIb

"1. In addition to the size and location of the aneurysm and the patient’s age and health status, it might be reasonable to consider morphological and hemody- namic characteristics of the aneurysm when discuss- ing the risk of aneurysm rupture (Level of Evidence: B)"

"2. Consumption of a diet rich in vegetables may lower the risk of aSAH (Level of Evidence: B)"

"3. It may be reasonable to offer noninvasive screening to patients with familial (at least 1 first-degree relative) aSAH and/or a history of aSAH to evaluate for de novo aneurysms or late regrowth of a treated aneurysm, but the risks and benefits of this screening require further study (Level of Evidence: B)"