Top Things to Know: 2023 Aneurysmal Subarachnoid Hemorrhage Guideline
Published: May 22, 2023
- Improving timely and equitable access to health care system resources such as comprehensive stroke centers is important to improve overall patient outcomes. Management of aneurysmal subarachnoid hemorrhage (aSAH) in centers with dedicated neurocritical care units, experience with higher case volumes, physician expertise in aneurysm treatment, expert nursing care, and multidisciplinary teams is associated with lower mortality and increased likelihood of good functional outcomes. Timely transfer to centers with expertise in aSAH is recommended.
- Acute rebleeding after initial aSAH is associated with increased mortality and poor clinical outcomes. Prompt evaluation, identification of aneurysmal source, and treatment of the ruptured aneurysm are recommended, preferably within 24 hours. The goal of treatment should be complete obliteration whenever feasible to reduce the risk of rebleeding and retreatment.
- Balancing the goal of securing the ruptured aneurysm with risk of intervention is based on patient and aneurysm characteristics and should be determined by specialists with expertise in endovascular and surgical treatments. Use of established grading scales can assist in prognostication and shared decision-making with patients, families, and surrogates.
- Medical complications in multiple organ systems are associated with worse outcomes after aSAH. Standard intensive care unit bundles of care for mechanically ventilated patients and venous thromboembolism prophylaxis are recommended. Close hemodynamic monitoring and blood pressure management to minimize blood pressure variability are beneficial. Goal-directed treatment of intravascular volume status to maintain euvolemia and avoid excess morbidity associated with hypervolemia is also important in improving overall outcomes. Routine use of antifibrinolytic therapy did not improve functional outcomes.
- For new-onset seizures after aSAH, treatment with antiseizure medication for 7 days is recommended. Prophylactic antiseizure medication should not be routinely used but can be considered in highrisk patients (with ruptured middle cerebral artery aneurysm, intraparenchymal hemorrhage, highgrade aSAH, hydrocephalus, or cortical infarction). Phenytoin use is associated with excess morbidity and should be avoided. Monitoring with continuous electroencephalography can detect nonconvulsive seizures, especially in patients with depressed consciousness or fluctuating neurological examination.
- Delayed cerebral ischemia remains a significant complication and is associated with worse outcomes after aSAH. Monitoring of clinical deterioration requires trained nurses with expertise to rapidly detect neurological examination changes. Diagnostic modalities, including transcranial Doppler, computed tomography angiography, and computed tomography perfusion, when performed by trained expert interpreters, can be useful to detect cerebral vasospasm and predict DCI. Continuous electroencephalography and invasive monitoring may also be useful in patients with highgrade aSAH with limited neurological examination.
- Early initiation of enteral nimodipine is beneficial in preventing DCI and improving functional outcomes after aSAH. Routine use of statin therapy and intravenous magnesium is not recommended.
- Elevating blood pressure and maintaining euvolemia in patients with symptomatic DCI can be beneficial in reducing the progression and severity of DCI. However, prophylactic hemodynamic augmentation and hypervolemia should not be performed to minimize iatrogenic patient risks.
- Cerebrovascular imaging after treatment and subsequent imaging monitoring are important in treatment planning for remnants, recurrence, or regrowth of the treated aneurysm and to identify changes in other known aneurysms. Although the risk of rerupture is low, the use of imaging to guide treatment decisions that may reduce the risk of future aSAH among survivors is recommended, especially in patients with residual aneurysm. Imaging monitoring for the development of de novo aneurysms is also important in younger patients with multiple aneurysms or with ≥2 firstdegree relatives with aSAH.
- A multidisciplinary team approach to identify discharge needs and design rehabilitation treatment is recommended. Among aSAH survivors, physical, cognitive, behavioral, and quality of life deficits are common and can persist. Early identification with validated screening tools can identify deficits, especially in behavioral and cognitive domains. Interventions for mood disorders can improve long-term outcomes, and counseling on the higher risk for long-term cognitive dysfunction may be beneficial.
Citation
Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R; Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association [published online ahead of print May 22, 2023]. Stroke. doi: 10.1161/STR.0000000000000436