Subarachnoid hemorrhage secondary prevention

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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
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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.[1][2][3]

Secondary prevention

Effective measures for the secondary prevention of subarachnoid hemorrhage include:[1][2][3]

Life style modification

Life style modification measures which may help reduce the risk of subarachnoid hemorrhage recurrence and complications may include:[2][3]

  • 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[4][5][6]

Prevent the complications

Rebleeding

Other Complications

2012 AHA/ASA Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage[1]

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)"

References

  1. 1.0 1.1 1.2 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839
  2. 2.0 2.1 2.2
  3. 3.0 3.1 3.2 2014 AHA/ASA Guidelines for the Primary Prevention of Stroke http://stroke.ahajournals.org/content/early/2014/10/28/STR.00000000000000467 Accessed on November 17, 2016
  4. Matsuda M, Watanabe K, Saito A, Matsumura K, Ichikawa M. Circum- stances, activities, and events precipitating aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis. 2007;16:25–29.
  5. Naidech AM, Janjua N, Kreiter KT, Ostapkovich ND, Fitzsimmons BF, Parra A, Commichau C, Connolly ES, Mayer SA. Predictors and impact of aneurysm rebleeding after subarachnoid hemorrhage. Arch Neurol. 2005;62:410 – 416.
  6. Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological man- agement. Stroke. 2001;32:1176–1180.
  7. Starke RM, Kim GH, Fernandez A, Komotar RJ, Hickman ZL, Otten ML, Ducruet AF, Kellner CP, Hahn DK, Chwajol M, Mayer SA, Connolly ES Jr. Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008;39: 2617–2621.
  8. Hoh BL, Aghi M, Pryor JC, Ogilvy CS. Heparin-induced thrombocy- topenia type II in subarachnoid hemorrhage patients: incidence and complications. Neurosurgery. 2005;57:243–248.
  9. Ray WZ, Strom RG, Blackburn SL, Ashley WW, Sicard GA, Rich KM. Incidence of deep venous thrombosis after subarachnoid hemorrhage. J Neurosurg. 2009;110:1010 –1014.
  10. Rahman M, Friedman WA. Hyponatremia in neurosurgical patients: clinical guidelines development. Neurosurgery. 2009;65:925–935.
  11. Bruno A, Levine SR, Frankel MR, Brott TG, Lin Y, Tilley BC, Lyden PD, Broderick JP, Kwiatkowski TG, Fineberg SE; NINDS rt-PA Stroke Study Group. Admission glucose level and clinical outcomes in the NINDS rt-PA Stroke Trial. Neurology. 2002;59:669–674.
  12. Naidech AM, Drescher J, Ault ML, Shaibani A, Batjer HH, Alberts MJ. Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage. Neurosurgery. 2006;59:775–779.
  13. Naidech AM, Jovanovic B, Wartenberg KE, Parra A, Ostapkovich N, Connolly ES, Mayer SA, Commichau C. Higher hemoglobin is asso- ciated with improved outcome after subarachnoid hemorrhage. Crit Care Med. 2007;35:2383–2389.

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