New Guidelines on the Management of Aneurysmal Subarachnoid Hemorrhage

New guidelines have been released on the management of aneurysmal subarachnoid hemorrhage (aSAH), detailing responses from the initial bleed to the devastating delayed effects of rupture.

Among the recommendations in the new guidelines are that these patients be treated at high-volume centers where endovascular interventions as well as neurosurgical services are available; for the initial evaluation of headache, computerized tomography (CT) scanning for suspected SAH is strongly recommended, followed by lumbar puncture if the CT is negative; early surgery is defined as reasonable and probably indicated in the majority of cases, since early treatment of the aneurysm reduces the risk for rebleeding after aSAH.

Medical measures to prevent rebleeding include blood-pressure (BP) monitoring and control and bed rest, although these should be part of a broader strategy with more definitive measures; short course of antifibrinolytics may be considered prior to definitive treatment. To reduce poor outcomes associated with vasospasm, the authors strongly recommend use of oral nimodipine; the value of other calcium antagonists, however, remains uncertain. Treatment usually begins with early management of the ruptured aneurysm, and in most cases maintaining normal circulating blood volume and avoiding hypovolemia is probably indicated. Another reasonable approach to symptomatic vasospasm, according to the guidelines, is volume expansion with induction of hypertension and hemodilution (the "triple-H” therapy). Other recommendations in the document focus on the management of hydrocephalus, hyponatremia, volume contractions, as well as seizures. The new guidelines, released by the American Heart Association (AHA, Dallas, TX, USA) and the American Stroke Association (Dallas, TX, USA), were published in the January 22, 2009, issue of Stroke.

"The majority of aneurysms do not rupture, and as much as 1% of the population dies of old age with a small, unruptured aneurysm. When they do rupture, the focus of treatment has to be on both prevention of rebleeding and management of the pathological adverse effects that the bleed has in the brain,” said the chair of the writing group for the new guidelines, Professor Joshua Bederson M.D., head of the department of neurosurgery at Mount Sinai Medical Center (New York, NY, USA).

"The current standard of practice calls for microsurgical clipping or endovascular coiling of the aneurysm neck whenever possible,” concluded the writing group. "Treatment morbidity is determined by numerous factors, including patient, aneurysm, and institutional factors. Favorable outcomes are more likely in institutions that treat high volumes of patients with SAH, in institutions that offer endovascular services, and in selected patients whose aneurysms are coiled rather than clipped.”

The guideline authors also caution that despite having generally among the most dramatic presentations in medicine, aSAH can present as a milder sentinel headache, and the hemorrhages should be considered in the differential diagnosis of all patients with new headache.

Related Links:
American Heart Association
American Stroke Association