ANEURYSMAL SUBARACHNOID

HEMORRHAGE : RECENT UPDATESYasser B. Abulhasan, MBChB, FRCPCAssistant Professor of Anesthesiology

Faculty of Medicine, Kuwait University

Specialist in Neuroanethesiolgy and Neurocritical Care

Department of Anesthesia and Intensive Care Unit, Ibn Sinai Hospital, Kuwait

Disclosure

No conflict of interest relevant to this lecture

Outline

Overview and Epidemiology

Early Patient Care

Recommendations

Background

aSAH is a devastating neurological emergency, can have long term consequences

The major cause of morbidity and mortality Initial hemorrhage (ictus)Rebleeding (1-3 days)Cerebral ischemia due to vasospasm (4 – 14 days)

Definitions Delayed neurological deterioration (DND): clinically

detectable neurological deterioration in a SAH patient following initial stabilization

Vasospasm: arterial narrowing after SAH demonstrated by radiographic images or sonography

Delayed Cerebral Ischemia (DCI): neurological deterioration (e.g. hemiparesis, aphasia, altered consciousness) presumed related to ischemia / hypoperfusion for more than an hour – cerebral infarction

Epidemiology

6 - 21 per 100,000 patient years

5% of acute cerebrovascular events

27.3% of all stroke-related years of potential mortality <65

Johnston, S.C., et al. Neurology, 1998. 50(5): p. 1413-8.van Gijn, J., R.S. Kerr, and G.J. Rinkel. Lancet, 2007. 369(9558): p. 306-18.Lloyd-Jones, D., et al. Circulation, 2009. 119(3): p. e21-181.

Natural History

10% die immediately

25% die within 24 hours

40% die in the first 30 days

Mortality and severe morbidity 60%

Early Patient Care Prevention of rebleeding

Seizure prophylaxis

Treatment of acute hydrocephalus

ICP control

Analgesia

Cardiopulmonary Complications

Intravascular Volume Status

Glucose management

Early Patient Care Prevention of rebleeding

Seizure prophylaxis

Treatment of acute hydrocephalus

ICP control

Analgesia

Cardiopulmonary Complications

Intravascular Volume Status

Glucose management

GRADE system

Keeps quality of data and recommendations explicitly separate

Allows for strong recommendations in the setting of lower quality evidence

Useful in the ICU

Atkins, D., et al., BMJ, 2004. 328(7454): p. 1490.

Rebleeding

Common 5 – 10% within the first 72 hours Mortality as high as 80% in patients who

rebleed

Risk factors○ Larger aneurysms○ Poor grade SAH○ Presenting with LOC or sentinel bleeds○ Catheter angiography within 3 hours of ictus

Molyneux, A.J., et al., (ISAT). Lancet, 2005. 366(9488): p. 809-17.

Preventing Rebleeding

Early securing the ruptured aneurysm (< 4 days)

Coil embolizationMicrosurgical exclusion

○ Delays in aneurysmal repair

Preventing Rebleeding Does stringent BP reduction reduce the incidence

or rebleeding in patients awaiting definitive management?

Do any medical interventions reduce the incidence of rebleeding in patients awaiting definitive management of their ruptured aneurysm?

Preventing Rebleeding

Does stringent BP reduction reduce the incidence or rebleeding in patients awaiting definitive management?

No systematic data addressing BP levels

Consensus - modest BP elevation (SBP <160 or MAP <110) is acceptable

Preventing Rebleeding Do any medical interventions reduce the incidence

of rebleeding in patients awaiting definitive management of their ruptured aneurysm?

Antifibrinolytics (TXA, EACA)

Prior to 2002, 9 studies showed no benefit on poor outcome or death despite significant reduction in rebleeding

○ Higher incidence of cerebral ischemia Weeks of therapy Late start

Harrigan, M.R., et al., Neurosurgery, 2010. 67(4): p. 935-9; discussion 939-40.Hillman, J., et al., Journal of neurosurgery, 2002. 97(4): p. 771-8.Starke, R.M., et al., Stroke; a journal of cerebral circulation, 2008. 39(9): p. 2617-21.

Antifibrinolytics2002 – 2010, 1 randomized trial, 2 case

studies ○ Early, short course of antifibrinolytics reduced

rebleedingRisk reduction 2.5 – 11%

Starke, R.M. and E.S. Connolly, Jr., Neurocritical care, 2011. 15(2): p. 241-6.

Recommendations “Delayed (>48 h after the ictus) or prolonged antifibrinolytic

therapy exposes patients to side effects of therapy when the risk of rebleeding is sharply reduced and should be avoided” (High quality evidence: Strong recommendation)

Antifibrinolytic therapy is relatively contraindicated in patients with risk factors for thromboembolic complications (Moderate quality evidence: Strong recommendation)

An early, short course of antifibrinolytic therapy should be considered (Low quality evidence: Weak recommendation)

Seizures and Prophylactic Anticonvulsants Does anticonvulsant prophylaxis influence the incidence

or convulsive and non-convulsive seizures after aSAH?

Seizure-like activities are common True seizure versus posturing at ictus

Incidence 1 – 7 % and often manifestation of re-rupture

Risk factors Surgical aneurysm repair in patients >65 Thick subarachnoid clot Intraparenchymal hematoma or infarction

Seizures and Prophylactic Anticonvulsants Prophylactic treatment with anticonvulsants is

common place

Outcome studies have showed worsened long term outcome (phenytoin)

Other anticonvulants’ impact is less clear

In patients with no history of seizure, “a short course (72hrs) of anticonvulsant medications seems as effective as a more prolonged course in preventing seizures”

Chumnanvej, S.. Neurosurgery, 2007. 60(1): p. 99-102; discussion 102-3.

Seizures and Prophylactic Anticonvulsants

In poor grade SAH patients

Non-convulsize seizures, worsened outcome

cEEG may detect 10 – 20%

Impact of successful treatment has not been studied

In higher risk groups, short course (3-7 days) seems considerable

Evidential seizure (epileptic focus) should be treated for 3 – 6 months.

Recommendation Routine use of anticonvulsant prophylaxis with

phenytoin is not recommended after SAH

“Continuous EEG monitoring should be considered in patients with poor-grade SAH who fail to improve or have neurological deterioration of undetermined etiology”

(low quality evidence – strong recommendation)

Conclusion

aSAH is a devastating neurological emergency, can have long term consequences

Recommendation from the consensus conference are a first step towards improving patient care of aSAH patients

Thank you for your attentive attendance