What is the management of ischemic stroke with subarachnoid hemorrhage (SAH) and cerebellar hemorrhage after discharge?

From the Guidelines

Management of ischemic stroke with subarachnoid hemorrhage (SAH) and cerebellar hemorrhage after discharge is focused on preventing delayed cerebral ischemia, managing blood pressure, and providing rehabilitation.

Key Considerations

• Early initiation of enteral nimodipine is beneficial in preventing delayed cerebral ischemia and improving functional outcomes after SAH 1.
• Elevating blood pressure and maintaining euvolemia in patients with symptomatic delayed cerebral ischemia can be beneficial in reducing the progression and severity of delayed cerebral ischemia 1.
• A multidisciplinary team approach to identify discharge needs and design rehabilitation treatment is recommended, as physical, cognitive, behavioral, and quality of life deficits are common and can persist after SAH 1.

Blood Pressure Management

• The optimal approach to blood pressure management in SAH is still uncertain, but consensus has formed that initiating blood pressure lowering early after the onset of intracerebral hemorrhage can be beneficial 1.
• However, blood pressure lowering in SAH may increase the risk of delayed cerebral ischemia, and therefore, the decision to lower blood pressure should be made on a case-by-case basis 1.

Rehabilitation and Follow-up

• Patients with SAH should undergo vascular imaging of the brain to investigate the cause of the hemorrhage, and high-quality CTA may be initially preferable to catheter angiography 1.
• The severity of SAH patients should be determined using a validated scale, such as the World Federation of Neurological Surgeons (WFNS), GCS, Hunt and Hess scale (H&H), NIHSS, and the Fisher Scale 1.
• Interventions for patients with SAH, such as nimodipine, should be started immediately, and patients with aneurysmal SAH should have the aneurysm secured urgently by endovascular coiling or microsurgical clipping 1.

Anticoagulation

• The decision to restart anticoagulation after a cerebral hemorrhage should be made on a case-by-case basis, taking into account the type of cerebral hemorrhage, patient age, risk factors for recurrent hemorrhage, and the indication for anticoagulation 1.
• In patients with a high risk of recurrent hemorrhage, anticoagulation may be contraindicated, while in patients with a high risk of ischemic stroke, anticoagulation may be necessary 1.

From the Research

Management of Ischemic Stroke with Subarachnoid Hemorrhage (SAH) and Cerebellar Hemorrhage after Discharge

• The management of patients with SAH includes adherence to published guidelines, such as those outlined by the American Heart Association/American Stroke Association and the Neurocritical Care Society 2, 3.
• Key recommendations for SAH management include:
  • Admission to high-volume centers under the management of a multidisciplinary team
  • Expeditious identification and treatment of the bleeding source
  • Management of patients in a neurocritical care unit with enteral nimodipine, blood pressure control, euvolemia, and close monitoring for neurologic and medical complications
  • Treatment of symptomatic cerebral vasospasm/delayed cerebral ischemia with induced hypertension and endovascular therapies
• Predictors of SAH in acute ischemic stroke patients treated endovascularly include hypertension, distal middle cerebral artery occlusion, use of rescue angioplasty after thrombectomy, and procedure-related vessel perforation 4.
• The diagnosis and management of SAH in the emergency department require a high index of suspicion and a judicious approach to evaluating the chief complaint of patients with spontaneous subarachnoid hemorrhage 5.
• Stroke subtypes, including acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, have varying treatment modalities and outcome predictive models 6.

Post-Discharge Care

• There is limited information available on the specific management of ischemic stroke with SAH and cerebellar hemorrhage after discharge.
• However, it is likely that post-discharge care would involve ongoing monitoring and management of neurologic and medical complications, as well as rehabilitation and follow-up with a multidisciplinary team 2, 3.

Complications and Outcomes

• SAH is a neurologic emergency with substantial morbidity and mortality, and management of patients with SAH requires early recognition and prevention of secondary brain injury 2, 3.
• Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities 3.
• The outcome of patients with SAH can be improved with adherence to published guidelines and early interventions to reduce morbidity and mortality 2, 3, 6.