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aneurysmal_subarachnoid_hemorrhage_treatment

The idea of unruptured intracranial aneurysm screenings is interesting because, despite recent advances in surgical and endovascular treatment, the mortality related to aneurysmal subarachnoid hemorrhage reaches 30%.

In general, surgically managed patients include those with parenchymal hematoma and large aneurysm, while endovascular therapy is preferred in elderly, patients with significant co-morbidity, poor grades and basilar artery aneurysm 1).

Intravascular volume and electrolyte status should dictate type and quantity of fluids, with a goal to maintain euvolemia and normal electrolyte function.

In aneurysmal subarachnoid haemorrhage, endovascular or surgical exclusion of the aneurysm responsible for the bleeding is mandatory to prevent re-bleeding.

The recent guidelines on management of aneurysmal subarachnoid hemorrhage (aSAH) advise pharmacological thromboprophylaxis (PTP) after aneurysm obliteration.

The initiation of PTP within 24 hours may be safe after the treatment of a ruptured aneurysm or in angiogram-negative SAH patients with diffuse aneurysmal hemorrhage pattern. We suggest caution with concomitant use of PTP and dual antiplatelet agents, because it possibly increases the risk for intracerebral hemorrhage 2).

Current treatment guidelines to prevent delayed cerebral ischemia is limited to oral nimodipine, maintenance of euvolemia, induction of hypertension if ischemic signs occur and endovascular therapy for patients with continued ischemia after induced hypertension. Future investigations will involve agents targeting vasodilation, anticoagulation, inhibition of apoptosis pathways, free radical neutralization, suppression of cortical spreading depolarization and attenuation of inflammation 3).

Racial and socioeconomic factors are associated with delayed time to treatment in aSAH. Identification of factors underlying these delays and standardization of care may allow for more uniform treatment protocols and improved patient care 4).

Aneurysm occlusion can be performed in day time within 72 h after ictus, instead of on an emergency basis. However, due to the retrospective, non-randomized design of the study of Oudshoorn et al., the results cannot be considered as definitive evidence 5).

1)
Connolly ES, Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012;43:1711–37.
2)
de Oliveira Manoel AL, Turkel-Parrella D, Germans M, Kouzmina E, da Silva Almendra P, Marotta T, Spears J, Abrahamson S. Safety of early pharmacological thromboprophylaxis after subarachnoid hemorrhage. Can J Neurol Sci. 2014 Sep;41(5):554-61. doi: 10.1017/cjn.2014.16. PubMed PMID: 25373803.
3)
Serrone JC, Maekawa H, Tjahjadi M, Hernesniemi J. Aneurysmal subarachnoid hemorrhage: pathobiology, current treatment and future directions. Expert Rev Neurother. 2015 Feb 26:1-14. [Epub ahead of print] PubMed PMID: 25719927.
4)
Attenello FJ, Wang K, Wen T, Cen SY, Tenser MK, Amar AP, Sanossian N, Giannotta S, Mack WJ. Health Disparities in Time to Aneurysm Clipping/Coiling among Aneurysmal Subarachnoid Hemorrhage Patients: A National Study. World Neurosurg. 2014 Aug 28. pii: S1878-8750(14)00821-3. doi: 10.1016/j.wneu.2014.08.053. [Epub ahead of print] Review. PubMed PMID: 25175276.
5)
Oudshoorn SC, Rinkel GJ, Molyneux AJ, Kerr RS, Dorhout Mees SM, Backes D, Algra A, Vergouwen MD. Aneurysm Treatment <24 Versus 24-72 h After Subarachnoid Hemorrhage. Neurocrit Care. 2014 Mar 18. [Epub ahead of print] PubMed PMID:24639201.
aneurysmal_subarachnoid_hemorrhage_treatment.txt · Last modified: 2017/01/22 12:36 (external edit)