Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors’ experience, aimed at providing practical aid to those caring for patients with this disease.
Key points
- •
The management of patients with aneurysmal subarachnoid hemorrhage is challenging and requires a multidisciplinary team approach, and is best done at high-volume centers.
- •
There is a paucity of randomized, blinded, placebo-controlled, prospective trials to aid in the management of aneurysmal subarachnoid hemorrhage.
- •
The critical care management of aneurysmal subarachnoid hemorrhage varies between patients with microsurgical clipping and those with endovascular occlusion, and the critical care practitioner should be aware of these differences.
- •
Much of the morbidity from aneurysmal subarachnoid hemorrhage occurs in a delayed manner following the initial hemorrhage. It is the role of the neurocritical care unit to understand and manage these complications.
Introduction
Aneurysmal subarachnoid hemorrhage (aSAH) can be a devastating condition that leads to significant morbidity and mortality. Over the past several decades, there has been an overall decrease in the incidence of strokes in high-income countries, but without a concomitant decrease in the incidence of SAH. Unlike other causes of SAH (ie, trauma), aSAH represents a unique physiology, which sets up a cascade of events that leads to further pathologic processes involving multiple organ systems. If a patient survives the initial hemorrhage, it is these pathologic processes that are the source of the significant morbidity and mortality following aSAH. As such, a thorough understanding of these processes and their management are a necessity for any practitioner caring for patients with aSAH. Furthermore, given the complexity of the management of these patients, this care is best done in a dedicated neurocritical care unit (NCCU).
In 2011 and 2012, 2 sets of guidelines were published on the management of aSAH. These guidelines by the Neurocritical Care Society and the American Heart Association/American Stroke Association (AHA/ASA), and their supporting articles, provide comprehensive reviews of the literature combined with expert consensus opinions. These articles note that there is a paucity of prospective, randomized, placebo-controlled trials in the literature showing that an intervention improves outcome, which might aid in guiding the management of aSAH. In fact, the use of nimodipine (Nimotop) is the only such intervention supported by level 1A class evidence. As such, much of the management of this disease is left to the interpretation of the literature by an experienced clinician. The goal of this article is to review the pertinent literature in a condensed format, in combination with our own experiences in managing these patients, in an attempt to provide a practical aid to those managing this challenging disease in the NCCU.
In addition to reviewing the evidence behind the current management of aSAH in the NCCU, this article is also meant to serve as a practical reference to those who are involved in the day-to-day management of these patients (ie, residents and fellows). To this end a table is included to aid with admission orders, and which can be used as a quick reference on daily NCCU rounds. In their NCCU, we often use a “systems-based” method of rounding, and have organized the table and article in this manner ( Table 1 ).
Related posts:
Moderate and Severe Traumatic Brain Injury
Neurocritical Care in Neurosurgery
Management of Acute Spinal Cord Injury in the Neurocritical Care Unit
Seizures and the Neurosurgical Intensive Care Unit
Microdialysis in the Neurocritical Care Unit
Parenchymal Brain Oxygen Monitoring in the Neurocritical Care Unit
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
