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