Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

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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]

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

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 cerebrovas- cular 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)"

Natural History and Outcome of aSAH: Recommendations

Class I

"1.The initial clinical severity of aSAH should be determined rapidly by use of simple validated scales (eg, Hunt and Hess, World Federation of Neurological Surgeons), because it is the most useful indicator of outcome after aSAH (Level of Evidence: B)"

"2. The risk of early aneurysm rebleeding is high, and rebleeding is associated with very poor outcomes. Therefore, urgent evaluation and treatment of pa- tients with suspected aSAH is recommended (Level of Evidence: B)"

Class IIa

"1. After discharge, it is reasonable to refer patients with aSAH for a comprehensive evaluation, including cognitive, behavioral, and psychosocial assessments (Level of Evidence: B)"

Clinical Manifestations and Diagnosis of aSAH: Recommendations

Class I

"1. aSAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for aSAH should exist in patients with acute onset of severe headache (Level of Evidence: B)"

"2. Acute diagnostic workup should include noncontrast head CT, which, if nondiagnostic, should be followed by lumbar puncture (Level of Evidence: B)"

"3. DSA with 3-dimensional rotational angiography is indicated for detection of aneurysm in patients with aSAH (except when the aneurysm was previously diagnosed by a noninvasive angiogram) and for planning treatment (to determine whether an aneurysm is amenable to coiling or to expedite microsurgery) (Level of Evidence: B)"

Class IIa

"1. CTA may be considered in the workup of aSAH. If an aneurysm is detected by CTA, this study may help guide the decision for type of aneurysm repair, but if CTA is inconclusive, DSA is still recommended (except possibly in the instance of classic perimesen- cephalic aSAH) (Level of Evidence: C)"

"2. Magneticresonanceimaging (fluid-attenuatedinversion recovery, proton density, diffusion-weighted imaging, and gradient echo sequences) may be reasonable for the diagnosis of aSAH in patients with a nondiagnostic CT scan , although a negative result does not obviate the need for cerebrospinal fluid analysis (Level of Evidence: C)"

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)"

Surgical and Endovascular Methods of Treatment of Ruptured Cerebral Aneurysms: Recommendations

Class I

"1. Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Level of Evidence: B)"

"2. Complete obliteration of the aneurysm is recom- mended whenever possible (Level of Evidence: B)"

"3. Determination of aneurysm treatment, as judged by both experienced cerebrovascular surgeons and endovascular specialists, should be a multidisciplinary decision based on characteristics of the patient and the aneurysm (Level of Evidence: C)"

"4. For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Level of Evidence: B)"

"5. In the absence of a compelling contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and strong consideration should be given to retreatment, either by repeat coiling or microsurgical clipping, if there is a clinically significant (eg, growing) remnant (Level of Evidence: B)"

Class III (Harm)

"1. Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and should only be considered when less risky options have been excluded (Level of Evidence: C)"

Class IIb

"1. Microsurgical clipping may receive increased con- sideration in patients presenting with large (>50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling may receive increased consideration in the elderly (􏰃70 years of age), in those presenting with poor-grade (World Federation of Neurological Surgeons classi- fication IV/V) aSAH, and in those with aneurysms of the basilar apex (Level of Evidence: C)"

Hospital Characteristics and Systems of Care: Recommendations

Class I

"1. Low-volume hospitals (eg, <10 aSAH cases per year) should consider early transfer of patients with aSAH to high-volume centers (eg, >35 aSAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurointensive care services (Level of Evidence: B)"

Class IIa

"1. Annual monitoring of complicationratesforsurgical and interventional procedures is reasonable (Level of Evidence: C)"

"2. A hospital credentialing process to ensure that proper training standards have been met by individual physicians treating brain aneurysms is reasonable (Level of Evidence: C)"

Anesthetic Management During Surgical and Endovascular Treatment: Recommendations

Class III (Harm)

"1. Induced hypothermia during aneurysm surgery is not routinely recommended but may be a reasonable option in selected cases (Level of Evidence: B)"

Class IIa

"1. Minimization of the degree and duration of intraoperative hypotension during aneurysm surgery is probably indicated (Level of Evidence: B)"

"2. There are insufficient data on pharmacological strategies and induced hypertension during temporary vessel occlusion to make specific recommendations, but there are instances when their use may be considered reasonable (Level of Evidence: C)"

Class IIb

"1. Prevention of intraoperative hyperglycemia during aneurysm surgery is probably indicated (Level of Evidence: B)"

"2. The use of general anesthesia during endovascular treatment of ruptured cerebral aneurysms can be beneficial in selected patients (Level of Evidence: C)"

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 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 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 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 toatarget 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)"