Subarachnoid hemorrhage medical therapy

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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, deep vein thrombosis is prevented with compression stockings and/or intermittent pneumatic compression

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 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.

Medical Condition	Management
First 24h of admission	Intensive care unit admission (constant hemodynamic and neurologic monitoring) Endotracheal intubation in patient with: GCS ≤8 Elevated ICP Poor oxygenation or hypoventilation Hemodynamic instability Deep venous thrombosis (DVT) prophylaxis (pneumatic compression stocking) Intravenous fluid administration Euvolemia Normal electrolyte balance (avoid hyponatremia) Antithrombotic discontinuation
Increased intracranial pressure (ICP)	Place a ventriculostomy Direct measurement of intracranial pressure (ICP) Drainage of CSF Osmotic therapy and diuresis Avoid hyperventilation hyperventilation can result in exacerbate vasospasm
Blood pressure control	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)
Antiepileptic drug therapy	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
Antiepileptic drug therapy	The routine long-term use of anticonvulsants is not recommended unless in the following conditions: Prior seizure Intracerebral hematoma Intractable hypertension Infarction Aneurysm at the middle cerebral artery
Vasospasm	Monitoring Preforming Transcranial Doppler Perfusion imaging with CT or magnetic resonance in order to identify brain ischemia Management Nimodipine 60 mg PO q4h administered to all patients with aneurysmal SAH Avoid hypovolemia statin therapy Antiplatelet therapy (reduce delayed cerebral ischemia) Cerebral angioplasty

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.

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:

• Alteplase

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

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)"