What are the guidelines for managing aneurysmal subarachnoid hemorrhage (aSAH)?

From the Guidelines

Aneurysmal subarachnoid hemorrhage (aSAH) management guidelines are clear: early initiation of treatment, including securing the ruptured aneurysm and preventing delayed cerebral ischemia, is crucial for improving patient outcomes.

Key Recommendations

• Early initiation of enteral nimodipine is beneficial in preventing delayed cerebral ischemia and improving functional outcomes after aSAH 1.
• Securing the ruptured aneurysm by either clipping or coiling is essential to prevent rebleeding, and the choice of treatment modality should be based on patient-specific characteristics, including age, clinical grade, size, and location of the aneurysm 1.
• Coiling is preferred over clipping for posterior circulation aneurysms and for patients with good-grade aSAH from ruptured aneurysms of the anterior circulation equally suitable for both primary coiling and clipping 1.
• Emergency clot evacuation should be performed in salvageable patients with large intraparenchymal hematoma and decreased level of consciousness 1.
• Cerebrovascular imaging after treatment and subsequent imaging monitoring are important in treatment planning for remnants, recurrence, or regrowth of the treated aneurysm and to identify changes in other known aneurysms 1.
• A multidisciplinary team approach is recommended to identify discharge needs and design rehabilitation treatment, as physical, cognitive, behavioral, and quality of life deficits are common and can persist after aSAH 1.

Medical Management

• Blood pressure control is recommended to avoid severe hypotension, hypertension, and blood pressure variability in patients with unsecured aneurysm 1.
• Antifibrinolytic therapy is not recommended for routine use in preventing rebleeding 1.
• Statins and intravenous magnesium are not recommended for routine use in improving outcomes 1.

Nursing Interventions

• Evidence-based protocols and order sets should be used, and frequent neurological assessment, vital sign monitoring, and validated dysphagia screening protocols should be implemented 1.

From the Research

Guidelines for Managing Aneurysmal Subarachnoid Hemorrhage (aSAH)

• Admission of patients to high-volume centers (defined as more than 35 SAH admissions per year) under the management of a multidisciplinary, specialized team 2
• Expeditious identification and treatment of the bleeding source with evaluation by a multidisciplinary team consisting of cerebrovascular neurosurgeons, neuroendovascular specialists, and neurointensivists 2
• Management of patients in a neurocritical care unit with enteral nimodipine, blood pressure control, euvolemia, and close monitoring for neurologic and medical complications 2
• Treatment of symptomatic cerebral vasospasm/delayed cerebral ischemia with induced hypertension and endovascular therapies 2

Evolution of Guidelines

• Guidelines have evolved from a consensus-based approach to an evidence-based approach over time 3
• The use of nimodipine for the treatment of SAH is the only recommendation that remained consistent across guidelines over time 3
• A shift in the definitive treatment for aneurysms from open surgical clipping to endovascular coiling was noted 3

Current Guidelines

• Early and rapid open communication between the clinical specialties caring for the aSAH patient is vital for rapid data collection, decision-making, and definitive treatment 4
• Numerous medical emergencies, such as elevated intracranial pressure and cerebral vasospasm, must be effectively managed to ensure the best possible neurological outcome 4

International Consensus

• The Neurocritical Care Society, American Stroke Association (AHA), and European Stroke Organization have established guidelines for the management of aSAH 5
• The Korean Society of Interventional Neuroradiology (KSIN) has published clinical practice guidelines for the management of ruptured and unruptured aneurysms 5

Updates and Advances

• Advances in the comprehension of pathophysiology and improvements in critical care have been reflected in the reduction of mortality in SAH 6
• Despite the number of publications, the only treatments shown to be effective in adequate, well-controlled clinical trials are nimodipine and repair of the ruptured aneurysm 6