Aneurysmal subarachnoid hemorrhage treatment

Early treatment varies between treatment on day 0, within 24 h, 48 h, or 72 h after the SAH ictus 1)

Also, ultra-early treatment has been defined as treatment within 48 h 2).

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 3).

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 4).

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 5).

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 6).

Sedation in the acute phase of the disease and prolonged sedation to reduce cerebral metabolism over days are frequently used as therapeutic approaches to manage secondary brain damage and have become an integral part of neurocritical care in the treatment of SAH 7)

There are no conclusive recommendations in intracranial pressure monitoring for aneurysmal subarachnoid hemorrhage. New protocols establishing the indications for ICP monitoring in aSAH are needed. Given the high heterogeneity of the studies included, they cannot provide clinical recommendations regarding this issue 8).

Baggiani et al. report 69% of ICP monitored patients (inter-center variability from 6.4 to 82.1%), and out of them, 54.9% had external ventricular catheters; in poor grades (WFNS IV–V), the percentage is 73%. Intracranial hypertension is recorded in 54.7% of cases; in patients with DVE, the incidence of ICP > 20 mmHg is lower (46 vs. 75%).

ICP monitoring appears to be associated with lower rates of unfavorable outcomes 9).

Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial 10)

Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma Oncol Lett, 11 (5) (2016), pp. 3173-3178 View article CrossRefView in ScopusGoogle Scholar 5 J.R. Linzey, C. Williamson, V. Rajajee, K. Sheehan, B.G. Thompson, A.S. Pandey Twenty-four–hour emergency intervention versus early intervention in aneurysmal subarachnoid hemorrhage J Neurosurg, 128 (5) (2018), pp. 1297-1303 View article CrossRefView in ScopusGoogle Scholar 6 Y.-C. Luo, C.-S. Shen, J.-L. Mao, C.-Y. Liang, Q. Zhang, Z.-J. He Ultra-early versus delayed coil treatment for ruptured poor-grade aneurysm Neuroradiology, 57 (2) (2015), pp. 205-210 View PDF Your institution provides access to this article. CrossRefView in ScopusGoogle Scholar 7 J. Park, H. Woo, D.-H. Kang, et al. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes J Neurosurg, 122 (2) (2015), pp. 383-391 View in ScopusGoogle Scholar 8 T.J. Phillips, R.J. Dowling, B. Yan, J.D. Laidlaw, P.J. Mitchell Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome? Stroke, 42 (7) (2011), pp. 1936-1945 View in ScopusGoogle Scholar 9 A. Sonig, H. Shallwani, S.K. Natarajan, et al. Better outcomes and reduced hospitalization cost are associated with ultra-early treatment of ruptured intracranial aneurysms: a US nationwide data sample study Neurosurgery, 82 (4) (2018), pp. 497-505
Y. Egashira, S. Yoshimura, Y. Enomoto, M. Ishiguro, T. Asano, T. Iwama Ultra-early endovascular embolization of ruptured cerebral aneurysm and the increased risk of hematoma growth unrelated to aneurysmal rebleeding J Neurosurg, 118 (5) (2013), pp. 1003-1008 View in ScopusGoogle Scholar 11 J.-W. Pan, R.-Y. Zhan, L. Wen, Y. Tong, S. Wan, Y.-Y. Zhou Ultra-early surgery for poor-grade intracranial aneurysmal subarachnoid hemorrhage: a preliminary study Yonsei Med J, 50 (4) (2009), p. 521
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Florez WA, García-Ballestas E, Deora H, Agrawal A, Martinez-Perez R, Galwankar S, Keni R, Menon GR, Joaquim A, Moscote-Salazar LR. Intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev. 2020 Feb 1. doi: 10.1007/s10143-020-01248-9. [Epub ahead of print] Review. PubMed PMID: 32008128.
Baggiani M, Graziano F, Rebora P, Robba C, Guglielmi A, Galimberti S, Giussani C, Suarez JI, Helbok R, Citerio G. Intracranial Pressure Monitoring Practice, Treatment, and Effect on Outcome in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care. 2022 Dec 5. doi: 10.1007/s12028-022-01651-8. Epub ahead of print. PMID: 36471182.
Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. J Vasc Dis. 2023 Jun;2(2):197-211. doi: 10.3390/jvd2020014. Epub 2023 Apr 1. PMID: 37082756; PMCID: PMC10111247.
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