Subarachnoid hemorrhage medical therapy

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Subarachnoid Hemorrhage Microchapters

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Overview

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Pathophysiology

Causes

Differentiating Subarachnoid Hemorrhage from other Diseases

Epidemiology and Demographics

Risk Factors

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Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

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Medical Therapy

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

Risk Factors/Prevention
Natural History/Outcome
Clinical Manifestations/Diagnosis
Medical Measures to Prevent Rebleeding
Surgical and Endovascular Methods
Hospital Characteristics/Systems of Care
Anesthetic Management
Cerebral Vasospasm and DCI
Hydrocephalus
Seizures Associated With aSAH
Medical Complications

Cost-Effectiveness of 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, 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. PMID 21773873. doi:10.1007/s12028-011-9605-9. 
  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. PMID 21178613. doi:10.1097/MCC.0b013e328342f83d. 
  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. PMID 16040918. doi:10.1148/radiol.2362031662. 
  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. PMID 8609551. doi:10.3171/jns.1996.84.3.0405. 
  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. PMID 19423854. doi:10.1161/STROKEAHA.108.538116. 
  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. PMID 22556195. doi:10.1161/STR.0b013e3182587839. 
  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. PMID 17943892. doi:10.1002/14651858.CD006184.pub2. 
  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. PMID 17636626. doi:10.1002/14651858.CD000277.pub3. 

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