Transcript Document

AHA/ASA Scientific Statement
Guidelines for the Management of Aneurysmal Subarachnoid
Hemorrhage (SAH)
A Statement for Healthcare Professionals from a Special Writing
Group of the Stroke Council, American Heart Association
Joshua B. Bederson, MD, Chair; E. Sander Connolly, Jr., MD, FAHA
Vice-Chair; H. Hunt Batjer, MD; Ralph G. Dacey, MD, FAHA;
Jacques E. Dion, MD, FRCPC; Michael N. Diringer, MD, FAHA,
FCCM; John E. Duldner, Jr., MD, MS; Robert E. Harbaugh, MD,
FACS, FAHA; Aman B. Patel, MD; Robert H.
Rosenwasser, MD, FACS, FAHA
7/7/2015© 2009, American Heart Association. All rights reserved.
Stroke Council Professional
Education Committee
• This slide presentation was
developed by members of the
Stroke Council Professional
Education committee.
– Opeolu Adeoye MD
– Dawn Kleindorfer MD
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Citation Information
• Key words included in the paper:
aneurysm; angiography; cerebrovascular disorders;
hemorrhage; stroke; surgery; vasospasm
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion
JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB,
Rosenwasser RH. Guidelines for the management of
aneurysmal subarachnoid hemorrhage: a statement for
healthcare professionals from a special writing group of
the Stroke Council, American Heart Association. Stroke
2009: published online before print January 22, 2009,
10.1161/STROKEAHA.108.191395.
7/7/2015© 2009, American Heart Association. All rights reserved.
This slide set was adapted from the
Guidelines for the Management of
Aneurysmal Subarachnoid Hemorrhage
paper
This guideline reflects a consensus of expert opinion
following thorough literature review that consisted of a
look at clinical trials and other evidence related to the
management of subarachnoid hemorrhage.
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Applying classification of recommendations
and levels of evidence
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Outline
• Introduction
• Epidemiology
• Acute Evaluation and Medical
Management
• Surgical and Endovascular Management
• Management of Common In-Hospital
SAH Complications
• Summary and Conclusions
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Introduction
• SAH is a common and devastating
condition
• SAH affects up to 30,000 persons
annually in the United States (US)
• Mortality rates are as high as 45% with
significant morbidity among survivors
• These recommendations summarize the
best available evidence for treatment of
patients with aneurysmal SAH
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Stroke
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Aneurysm
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Epidemiology
• SAH incidence varies greatly between
countries, from 2 cases/ 100,000 in
China to 22.5/100,000 in Finland
• Many cases of SAH are misdiagnosed
• Thus, the annual incidence of
aneurysmal SAH in the US may exceed
30,000
• Incidence increases with age, occurring
most commonly between 40 and 60
years of age (mean age > 50 years)
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Epidemiology
• SAH is ~1.6 times higher in women than
men
• Risk factors for SAH include
hypertension, smoking, female gender
and heavy alcohol use
• Cocaine-related SAH occurs in younger
patients
• Familial intracranial aneurysm (FIA)
syndrome occurs when two firstthrough third-degree relatives have
intracranial aneurysms
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CT Scan non-contrast showing blood
in basal cisterns (SAH) – so called
“Star-Sign”
CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery
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CT Scan of a 65 yo woman, Hunt and
Hess of 4 Subarachnoid Hemorrhage
Arrow:
Hyperintense
signal.
Blood in the
subarachnoid
space
CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery
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Angiogram - Giant ICA Aneurysm
Angio image courtsey: University of Texas Health Science Center at San Antonio - Department of Neurosurgery
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Prevention of SAH
• No randomized controlled trials have
examined whether treatment of medical
risk factors reduces SAH occurrence
• Hypertension is a common risk factor
for hemorrhagic stroke
• Indirect evidence suggests that smoking
cessation reduces risk for SAH
• Screening for asymptomatic intracranial
aneurysms in the general population is
not supported by the available literature
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Recommendations for Prevention
of SAH
• Class I Recommendations
– The relationship between
hypertension and aneurysmal SAH is
uncertain. However, treatment of high
blood pressure with antihypertensive
medication is recommended to
prevent ischemic stroke and
intracerebral hemorrhage, cardiac,
renal, and other end-organ injury
(LOE A)
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Recommendations for Prevention
of SAH
• Class II Recommendations
– Cessation of smoking is reasonable to
reduce the risk of SAH, although evidence
for this association is indirect (LOE B).
– Screening of certain high-risk populations
for unruptured aneurysms is of uncertain
value (LOE B); advances in noninvasive
imaging may be used for screening, but
catheter angiography remains the “gold
standard” when it is clinically imperative to
know if an aneurysm exists.
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Natural History and Outcome of an
Aneurysmal SAH
• 30-day mortality rate after SAH ranges from 3350%
• Severity of initial hemorrhage, age, sex, time to
treatment, and medical comorbidities impact
SAH outcome
• Aneurysm size, location in the posterior
circulation, and morphology may also impact
outcome
• Endovascular services at a given institution, the
volume of SAH patients treated, and the facility
where the patient is first evaluated may also
impact outcome
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Natural History of an Aneurysmal
SAH: Recommendations
• Class I Recommendations
– The severity of the initial bleed should
be determined rapidly as it is the most
useful indicator of outcome following
aneurysmal SAH and grading scales
which heavily rely on this factor are
helpful in planning future care with
family and other physicians (LOE B)
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Natural History of an Aneurysmal
SAH: Recommendations
• Class I Recommendations
– Case review and prospective cohorts have shown that
for untreated, ruptured aneurysms, there is at least a
3% to 4% risk of re-bleeding in the first 24 hours and
possibly significantly higher, with a high percentage
occurring immediately (within 2 to 12 hours) after the
initial ictus, a 1% to 2% per day risk in the first month,
and a long-term risk of 3% per year after 3 months.
Urgent evaluation and treatment of patients with
suspected SAH is therefore recommended (LOE B)
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Natural History of an Aneurysmal
SAH: Recommendations
• Class II Recommendations
– In triaging patients for aneurysm repair,
factors that can be useful in determining
the risk of re-bleeding include severity of
the initial bleed, interval to admission,
blood pressure, gender, aneurysm
characteristics, hydrocephalus, early
angiography, and the presence of a
ventricular drain (LOE B)
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Acute Evaluation - Diagnosis
• “The worst headache of my life” is
described by ~80% of patients
• “Sentinel” headache is described by ~20%
• Nausea/vomiting, stiff neck, loss of
consciousness, or focal neurological
deficits may occur
• Misdiagnosis of SAH occurred in as many
as 64% of cases prior to 1985
• Recent data suggest an SAH
misdiagnosis rate of approximately 12%
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Acute Evaluation - Diagnosis
• Importance of recognition of a warning
or sentinel leak cannot be
overemphasized
• A high index of suspicion is warranted in
the ED
• The diagnostic sensitivity of CT
scanning is not 100%, thus diagnostic
lumbar puncture should be performed if
the initial CT scan is negative
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Diagnosis of SAH -Recommendations
• Class I Recommendations
– SAH is a medical emergency that is
frequently misdiagnosed. A high level
of suspicion for SAH should exist in
patients with acute onset of severe
headache (LOE B)
– CT scanning for suspected SAH is
strongly recommended, and lumbar
puncture for analysis of cerebrospinal
fluid is strongly recommended when
the CT scan is negative (LOE B)
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Diagnosis of SAH –Recommendations
• Class I Recommendations
– Selective cerebral angiography to document
the presence and anatomic features of
aneurysms is strongly recommended in
patients with documented SAH (LOE B)
• Class II Recommendations
– MRA or CTA can serve as useful alternative
diagnostic tools when conventional
angiography cannot be performed in a
timely fashion (LOE B)
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Acute Evaluation –
Emergency Evaluation
• Emergency medical services (EMS) is first
medical contact in about 2/3 of SAH
patients
• EMS personnel should receive continuing
education regarding signs and symptoms
and the importance of rapid neurological
assessment in cases of possible SAH
• On-scene delays should be avoided
• Rapid transport and advanced notification
of the ED should occur
7/7/2015© 2009, American Heart Association. All rights reserved.
Acute Evaluation –
Emergency Evaluation
• Airway, breathing, and circulation should
be rapidly assessed and managed
• Emergency care providers should
evaluate SAH patients with an accepted
neurologic assessment scale and record it
in the ED
– Hunt and Hess, Fisher Scale, Glasgow Coma Scale,
World Federation of Neurological Surgeons Scale.
• Expedient transfer to an appropriate
referral center should be considered if
necessary
7/7/2015© 2009, American Heart Association. All rights reserved.
Emergency Evaluation
Recommendations
• Class II Recommendations
– The degree of neurological
impairment using an accepted SAH
grading system can be useful for
prognosis and triage (LOE B)
– A standardized ED management
protocol for the evaluation of patients
with headaches and other symptoms
of potential SAH does not currently
exist and needs development (LOE C)
7/7/2015© 2009, American Heart Association. All rights reserved.
Acute Evaluation – Preventing
Re-bleeding
• Up to 14% of SAH patients may
experience re-bleeding within 2 hours of
the initial hemorrhage
• Re-bleeding was more common in those
with a systolic blood pressure
>160mm Hg
• Anti-fibrinolytic therapy may reduce rebleeding but has not been shown to
improve outcomes
7/7/2015© 2009, American Heart Association. All rights reserved.
Preventing Re-bleeding Recommendations
• Class I Recommendations
– Blood pressure should be monitored and
controlled to balance the risk of strokes,
hypertension-related re-bleeding, and
maintenance of cerebral perfusion pressure
(LOE B)
• Class II Recommendations
– Bed rest alone is not enough to prevent rebleeding after SAH. It may be considered as
a component of a broader treatment strategy
along with more definitive measures (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Preventing Re-bleeding Recommendations
• Class II Recommendations
– Recent evidence suggests that early
treatment with antifibrinolytic agents,
when combined with a program of
early aneurysm treatment followed by
discontinuation of the antifibrinolytic
and prophylaxis against hypovolemia
and vasospasm (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Preventing Re-bleeding –
Class II Recommendations
• Antifibrinolytic therapy to prevent
rebleeding may be considered in
certain clinical situations, e.g.,
patients with a low risk of
vasospasm and/or a beneficial
effect of delaying surgery (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• Occluding aneurysms using
endovascular coils was described in
1991
• Improved outcomes have been linked to
hospitals that provide endovascular
services
• Use of endovascular versus surgical
techniques varies greatly across centers
• Coil embolization is associated with a
2.4% risk of aneurysmal perforation and
an 8.5% risk of ischemic complications
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• A study of 431 patients undergoing
coiling of a ruptured aneurysm found an
early re-bleeding rate of 1.4%, with 100%
mortality
• The ISAT Trial reported a 1-year rehemorrhage rate of ~2.9% in aneurysms
treated with endovascular therapy
• Aneurysm size is an important predictor
of hemorrhage risk
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• The Cooperative Study evaluated 979
patients who underwent intracranial
surgery only
• Nine of 453 patients (2%) rebled after
surgery
• Nearly half (n=4) of these hemorrhages
occurred in patients with multiple
aneurysms
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• In the International Subarachnoid
Aneurysm Trial (ISAT) post-treatment
SAH occurred at an annualized rate of
0.9% with surgical clipping, compared to
2.9% with endovascular treatment
• The rate of incomplete obliteration and
recurrence appears significantly lower
with surgical clipping than with
endovascular treatment
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• Increased time to treatment is
associated with increased rates of
preoperative re-bleeding
–
–
–
–
–
0 to 3 days, 5.7%
4 to 6 days, 9.4%
7 to 10 days, 12.7%
11 to 14 days, 13.9%
15 to 32 days, 21.5%
• Postoperative re-bleeding did not differ
among time intervals (1.6% overall)
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• Estimating the consequences of
complications attributable to an
operation may be possible from data
regarding surgery for unruptured
aneurysms
• In-hospital mortality rates vary from
1.8% to 3.0% in large multicenter studies
• Adverse outcomes in survivors vary
from 8.9% to 22.4%
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• The only large prospective, randomized
trial to date comparing surgery and
endovascular techniques is ISAT
• At one year, there was no significant
difference in mortality rates (8.1% vs.
10.1% endovascular vs. surgical)
• Disability rates were greater in surgical
versus endovascular patients (21.6% vs.
15.6%)
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management of SAH
• Combined morbidity and mortality was
significantly greater in surgically treated
patients than in those treated with
endovascular techniques (30.9% vs. 23.5%;
absolute risk reduction 7.4%, P = 0.0001)
• During the short follow-up period in ISAT the
re-bleeding rate for coiling was 2.9% versus
0.9% for surgery
• There have been no randomized comparisons
of coiling versus clipping for unruptured
aneurysms
7/7/2015© 2009, American Heart Association. All rights reserved.
Clipping
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Left image arrow -Angio with Large aneurysm
Right image arrow – Angio showing aneurysm post clipping
Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management -Recommendations
• Class I Recommendations
– Surgical clipping or endovascular coiling is
strongly recommended to reduce the rate of
rebleeding after aneurysmal SAH (LOE B)
– Wrapped or coated aneurysms as well as
incompletely clipped or coiled aneurysms
have an increased risk of re-hemorrhage
compared to those completely occluded and
therefore require long-term follow-up
angiography. Complete obliteration of the
aneurysm is recommended whenever
possible (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management -Recommendations
• Class I Recommendations
– For patients with ruptured aneurysms judged by an
experienced team of cerebrovascular surgeons and
endovascular practitioners to be technically
amenable to both endovascular coiling and
neurosurgical clipping, endovascular coiling can be
beneficial (LOE B)
• Class II Recommendations
– Individual characteristics of the patient and the
aneurysm must be considered in deciding the best
means of repair, and management of patients in
centers offering both techniques is probably
recommended (LOE B)
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Coiling
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Coil system embolization: immediate
result
Angio showing large ICA
aneurysm
Same aneurysm - Post GDC Coiling
Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery
7/7/2015© 2009, American Heart Association. All rights reserved.
Surgical and Endovascular
Management Recommendations
• Class II Recommendations
– Although previous studies showed that
overall outcome was not different for early
versus delayed surgery after SAH, early
treatment reduces the risk of rebleeding
after SAH, and newer methods may increase
the effectiveness of early aneurysm
treatment. Early aneurysm treatment is
reasonable and is probably indicated in the
majority of cases (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Hospital/Systems of Care
• Treatment volume is an important
determinant of outcome for intracranial
aneurysms – higher volume equals
lower mortality
• This effect may be more important for
patients with unruptured aneurysms
than for those with ruptured aneurysms
• It is uncertain whether the benefits of
receiving care at a high-volume center
would outweigh the costs and risks of
transfer
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Hospital/Systems of Care -Recommendations
• Class II Recommendations
– Early referral to high-volume centers
that have both experienced
cerebrovascular surgeons and
endovascular specialists is
reasonable (LOE B)
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Management of Common InHospital SAH Complications
• Common issues related to inhospital management of SAH
include:
– Anesthetic Management
– Cerebral Vasospasm
– Hydrocephalus
– Seizures
– Hyponatremia
7/7/2015© 2009, American Heart Association. All rights reserved.
Anesthetic Management During
Surgical and Endovascular
Treatments
• Goals of intraoperative anesthetic
management during aneurysm treatment
include:
– limiting the risk of intraprocedural
aneurysm rupture
– protecting the brain against ischemic
injury
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Anesthetic Management -Recommendations
• Class II Recommendations
– Minimizing the degree and duration of
intraoperative hypotension during aneurysm
surgery is probably indicated (LOE B)
– There are insufficient data on
pharmacological strategies and induced
hypertension during temporary vessel
occlusion to make specific
recommendations, but there may be
instances where their use can be considered
reasonable (LOE C)
7/7/2015© 2009, American Heart Association. All rights reserved.
Anesthetic Management -Recommendations
• Class III Recommendations
– Induced hypothermia during
aneurysm surgery may be a
reasonable option in some cases but
is not routinely recommended (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Cerebral
Vasospasm after SAH
• Following aneurysmal SAH, angiographic
vasospasm is seen in 30% to 70% of patients
• Typical onset is 3 to 5 days after the
hemorrhage, maximal narrowing at 5 to 14 days,
and a gradual resolution over 2 to 4 weeks
• 15% to 20% of patients with delayed neurologic
deficits suffer stroke or die from vasospasm
despite maximal therapy
• The index of suspicion needs to be higher in
poor grade patients even with subtle changes
in neurological exam
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Cerebral
Vasospasm after SAH
• The literature is inconclusive regarding
the sensitivity and specificity of TCD
monitoring
• However, severe spasm can be
identified with fairly high reliability using
TCD monitoring
• Other modalities such as diffusion
perfusion, MRI, and xenon-CT cerebral
perfusion studies may be
complementary in guiding management
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Cerebral
Vasospasm after SAH
• Hypertensive hypervolemic
hemodilution (HHH) therapy has become
a mainstay in the management of
cerebral vasospasm
• Only one randomized study has been
performed to assess its efficacy
• Two small single-center prospective
randomized studies strongly suggest
that avoiding hypovolemia is advisable,
but there is no evidence for prophylactic
hyperdynamic therapy
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Cerebral
Vasospasm after SAH
• Calcium-channel blockers, particularly
nimodipine, have been approved for use
for treatment of vasospasm
• However, the reduction in morbidity and
improvement in functional outcome may
have been due more to cerebral
protection than actual effect on the
cerebral vasculature
• Intravenous nicardipine interestingly
showed a 30% reduction in spasm but
no improvement in outcome
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Cerebral
Vasospasm after SAH
• Balloon angioplasty has been shown to
be effective in reversing cerebral
vasospasm in large proximal conducting
vessels but has not been shown to
improve ultimate outcome
• Angioplasty is not effective or safe in
distal perforating branches beyond
second-order segments
• Angioplasty is effective in reducing
angiographic spasm, promoting an
increase in CBF, and reducing deficits
7/7/2015© 2009, American Heart Association. All rights reserved.
Cerebral Vasospasm -Recommendations
• Class I Recommendations
– Oral nimodipine is strongly
recommended to reduce poor
outcome related to aneurysmal
subarachnoid hemorrhage (LOE A)
– The value of other calcium
antagonists, whether administered
orally or intravenously, remains
uncertain
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Cerebral Vasospasm -Recommendations
• Class II Recommendations
– Treatment of cerebral vasospasm begins
with early management of the ruptured
aneurysm, and in most cases maintaining
normal circulating blood volume and
avoiding hypovolemia is probably indicated
(LOE B)
– One reasonable approach to symptomatic
cerebral vasospasm is volume expansion,
induction of hypertension and hemodilution
[Triple-H therapy] (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Cerebral Vasospasm -Recommendations
• Class II Recommendations
– Alternatively, cerebral angioplasty
and/or selective intraarterial
vasodilator therapy may also be
reasonable, either following, together
with, or in the place of, Triple-H
therapy depending on the clinical
scenario (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Hydrocephalus
Associated With SAH
• Acute hydrocephalus (ventricular enlargement
within 72 hours) occurs in about 20% to 30% of
SAH patients
• The ventricular enlargement is often, but not
always, accompanied by intraventricular blood
• Acute hydrocephalus is more frequent in
patients with poor clinical grade, and higher
Fischer Scale scores
• Two single-center series suggested that routine
fenestration of the lamina terminalis reduces
the incidence of chronic hydrocephalus
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Hydrocephalus -Recommendations
• Class I Recommendation
– Temporary or permanent CSF diversion is
recommended in symptomatic patients with
chronic hydrocephalus following SAH
(LOE B)
• Class II Recommendation
– Ventriculostomy can be beneficial in patients
with ventriculomegaly and diminished level
of consciousness following acute SAH
(LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Seizures
Associated With SAH
• A large number of seizure-like episodes are
associated with aneurysmal rupture
• It is unclear, however, whether all these
episodes are truly epileptic
• Retrospective reviews report that early seizures
occur in 6% to 18% of SAH patients
• Non-convulsive seizures may occur in 19% of
stuporous or comatose SAH patients
• The relationship between seizures and outcome
is uncertain
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Seizures -Recommendations
• Class II Recommendations
– The administration of prophylactic
anticonvulsants may be considered in the
immediate posthemorrhagic period (LOE B)
• Class III Recommendations
– The routine long-term use of anticonvulsants
is not recommended (LOE B) but
– may be considered for patients with risk
factors such as prior seizure, parenchymal
hematoma, infarct, or MCA aneurysms
(Class II, LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Hyponatremia
and Volume Contraction
• Hyponatremia occurs in 10-30% of SAH
patients
• Hyponatremia has been associated with
excessive natriuresis and volume
contraction
• Volume contraction has been linked to
symptomatic vasospasm
• Administration of large amounts of
fluids (hypervolemic therapy)
ameliorates volume contraction
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Hyponatremia -Recommendations
• Class I Recommendations
– Administration of large volumes of
hypotonic fluids and intravascular volume
contraction should generally be avoided
following SAH (LOE B)
• Class II Recommendations
– Monitoring volume status in certain patients
with recent SAH using some combination of
central venous pressure, pulmonary artery
wedge pressure, fluid balance, and body
weight is reasonable as is treatment of
volume contraction with isotonic fluids
(LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Management of Hyponatremia -Recommendations
• Class II Recommendations
– The use of fludrocortisone acetate
and hypertonic saline is reasonable
for correcting hyponatremia (LOE B)
– In some instances, it may be
reasonable to reduce fluid
administration to maintain a
euvolemic state (LOE B)
7/7/2015© 2009, American Heart Association. All rights reserved.
Summary and Conclusions
• The current standard of practice calls for
microsurgical clipping or endovascular
coiling of the aneurysm neck whenever
possible
• Treatment morbidity is determined by
numerous factors, including patient,
aneurysm, and institutional factors
7/7/2015© 2009, American Heart Association. All rights reserved.
Summary and Conclusions
• Favorable outcomes are more likely in
institutions that treat high volumes of
patients with SAH, in institutions that
offer endovascular services, and in
selected patients whose aneurysms are
coiled rather than clipped
• Optimal treatment requires availability of
both experienced cerebrovascular
surgeons and endovascular surgeons
working in a collaborative effort to
evaluate each case of SAH
7/7/2015© 2009, American Heart Association. All rights reserved.