Aneurysmal Subarachnoid Hemorrhage Guidelines
https://www.ahajournals.org/doi/full/10.1161/str.0b013e3182587839
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3. PubMed PMID: 22556195 1).
Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage
The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to the short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on a consensus conference held in 2011.
Treggiari et al. provide updated recommendations based on an appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology.
The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full-text review of selected reports. Data were abstracted in duplicate from notices meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for the assessment of RCTs and the “Risk of Bias In Nonrandomized Studies - of Interventions” tool for the assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations.
The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation.
These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered 2).
Hospital Characteristics and Systems of Care
According to current Aneurysmal Subarachnoid Hemorrhage Guidelines (aSAH) patients are mostly managed in intensive care units (ICU) regardless of baseline severity.
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 neuro-intensive care services (Class I; Level of Evidence B). (Revised recommendation from previous guidelines)
Annual monitoring of complication rates for surgical and interventional procedures is reasonable (Class IIa; Level of Evidence C). (New recommendation)
A hospital credentialing process to ensure that proper training standards have been met by individual physicians treating brain aneurysms is reasonable (Class IIa; Level of Evidence C). (New recommendation) 3).
The adjusted odds of definitive repair were significantly higher in urban teaching hospitals than in urban nonteaching hospitals (odds ratio, 1.62) or rural hospitals (odds ratio, 3.08).7 In another study from 1993 to 2003, teaching status and larger hospital size were associated with higher charges and longer stay but also with better outcomes (P<0.05) and lower mortality rates (P<0.05), especially in patients who underwent aneurysm clipping (P<0.01). Endovascular treatment, which was more often used in the elderly, was also associated with significantly higher mortality rates in smaller hospitals (P<0.001) and steadily increasing morbidity rates (45%). Large academic centers were associated with better results, particularly for surgical clip placement 4).
Llull et al. from a Comprehensive Stroke Center in Barcelona assessed the prognostic and economic implications of initial admission of low-grade aSAH patients into a Stroke Unit (SU) compared to initial ICU admission.
They reviewed prospectively registered data from consecutive aSAH patients with a WFNS grade lower than 3 admitted at a Comprehensive Stroke Center between April-2013 and September-2018. Clinical and radiological baseline traits, in-hospital complications, length of hospital stay (LOS) and poor outcome at 90 days (modified Rankin Scale >2) were compared between the ICU and SU groups in the whole population and in a propensity score matched cohort.
From 131 patients, 74 (56%) were initially admitted in the ICU and 57 (44%) in the SU. In-hospital complication rates were similar in the ICU and SU groups and included rebleeding (10% vs 7%, p=0.757), angiographic vasospasm (61% vs 60%, p=0.893), delayed cerebral ischemia (12% vs 12%, p=0.984), pneumonia (6% vs 4%, p=0.697) and death (10% vs 5%, p=0.512). LOS did not differ across both groups [median (IQR) 22 (16-30) vs 19 (14-26) days, p=0.160]. In adjusted multivariate models, the location of initial admission was not associated with long-term poor outcome either in the whole population (OR=1.16, 95%CI=0.32-4.19, p=0.825) or in the matched cohort (OR=0.98, 95%CI=0.24-4.06, p=0.974).
A dedicated SU cared by a multidisciplinary team might be an optimal alternative to ICU to initially admit patients with low-risk aSAH 5).
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. doi: 10.1161/STROKEAHA.108.191395. Epub 2009 Jan 22. Review. Erratum in: Stroke. 2009 Jul;40(7):e518. PubMed PMID: 19164800. 6).