Current and Future Treatment Considerations in the Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a type of hemorrhagic stroke that can cause significant morbidity and mortality. Although guidelines have been published to help direct the care of these patients, there is insufficient quality literature regarding the medical and pharmacological management of patients with aSAH. Treatment is divided into 3 categories: supportive therapy, prevention of complications, and treatment of complications. There are numerous pharmacological therapies that are targeted at prevention and treatment of the neurological and medical complications that may arise. Rebleeding, hydrocephalus, cerebral vasospasm, and seizures are the most common neurological complications while the most common medical complications include hyponatremia, pulmonary edema, cardiac arrhythmias, neurogenic stunned myocardium, fever, anemia, infection, hyperglycemia, and venous thromboembolism. Risk factors, clinical presentation, diagnosis, pathophysiology, as well as initial management, prevention, and treatment of complications will be the focus of this discussion.

Download Full-text

Predictors of hospital-associated complications prolonging ICU stay in patients with low-grade aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.1.jns182394 ◽

2020 ◽

Vol 132 (6) ◽

pp. 1829-1835 ◽

Cited By ~ 1

Author(s):

Nikolaos Mouchtouris ◽

Michael J. Lang ◽

Kaitlyn Barkley ◽

Guilherme Barros ◽

Justin Turpin ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

External Ventricular Drain ◽

Significant Risk ◽

Early Discharge ◽

Neurological Complications ◽

Medical Complications ◽

Low Grade ◽

Icu Stay

OBJECTIVEThe authors sought to determine the predictors of late neurological and hospital-acquired medical complications (HACs) in patients with low-grade aneurysmal subarachnoid hemorrhage (aSAH).METHODSThe authors conducted a retrospective study of 424 patients with low-grade aSAH admitted to their institution from 2008 to 2015. Data collected included patient comorbidities, Hunt and Hess (HH) grade, ICU length of stay (LOS), and complications. A logistic regression analysis was performed to determine the predictors for neurological and hospital-associated complications.RESULTSOut of 424 patients, 50 (11.8%) developed neurological complications after the first week, with a mean ICU stay of 16.3 ± 6.5 days. Of the remaining 374 patients without late neurological complications, 83 (22.2%) developed late HACs with a mean LOS of 15.1 ± 7.6 days, while those without medical complications stayed 11.8 ± 6.2 days (p = 0.001). Of the 83 patients, 55 (66.3%) did not have any HACs in the first week. Smoking (p = 0.062), history of cardiac disease (p = 0.043), HH grade III (p = 0.012), intraventricular hemorrhage (IVH) (p = 0.012), external ventricular drain (EVD) placement (p = 0.002), and early pneumonia/urinary tract infection (UTI)/deep vein thrombosis (DVT) (p = 0.001) were independently associated with late HACs. Logistic regression showed early pneumonia/UTI/DVT (p = 0.026) and increased HH grade (p = 0.057) to be significant risk factors for late medical complications.CONCLUSIONSWhile an extended ICU admission allows closer monitoring, low-grade aSAH patients develop HACs despite being at low risk for neurological complications. The characteristics of low-grade aSAH patients who would benefit from early discharge are reported in detail.

Download Full-text

Abstract P43: The Importance of Medical Complications in Determining Outcomes After Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.52.suppl_1.p43 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Sean Neifert ◽

Alexander Schupper ◽

Michael Martini ◽

Emily Chapman ◽

William Shuman ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Functional Outcome ◽

Functional Outcomes ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariable Analysis ◽

Kidney Injury ◽

Medical Complications ◽

Clinical Registry ◽

Good Functional Outcome ◽

Individual Contributions

Introduction: Despite their high prevalence, prospective data on medical complications after aneurysmal subarachnoid hemorrhage (aSAH) and their contribution to functional outcome are sparse. We review rates of such events and correlate them to functional outcomes in three prospective datasets of patients with aSAH. Methods: Patients from two clinical trials (NEWTON-2, CONSCIOUS-1) and one clinical registry (Subarachnoid Hemorrhage Outcomes Project) were included. A good functional outcome was defined as a Glasgow Outcomes Scale (GOS) score of 4 or 5. Seventeen medical complications were assessed and their association with functional outcomes was determined with multivariable logistic regression. The variance in outcome explained by medical complications was calculated using difference in Nagelkerke’s R-squared. Results: Among the 1,430 patients, the most common complications were fever (564, 39%), anemia (410, 29%), and pneumonia (341, 24%). Patients who suffered any complication (OR: 0.45; 95% CI: 0.36 to 0.57; p<0.001) were less likely to have a good functional outcome in unadjusted analyses. In multivariable analysis, complications independently associated with lower rates of good functional outcome were anemia (OR: 0.60; 95% CI: 0.44 to 0.80; p<0.001), cardiac arrest (OR: 0.14; 95% CI: 0.05 to 0.37; p<0.001), pneumonia (OR: 0.48; 95% CI: 0.35 to 0.66; p<0.001), pulmonary edema (OR: 0.67; 95% CI: 0.45 to 0.99; p=0.047), and acute kidney injury (OR: 0.34; 95% CI: 0.12 to 0.98; p=0.047). A panel of eleven medical complications explained 8% of the variation in functional outcomes. Conclusions: Medical complications contribute to functional outcomes after aSAH, but their individual contributions to outcomes are relatively small. This should be noted when considering trials directed at preventing or treating any one complication and raises the question of studying comprehensive neurointensive care packages in the future.

Download Full-text

Pulmonary function and radiographic abnormalities related to neurological outcome after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1998.88.1.0028 ◽

1998 ◽

Vol 88 (1) ◽

pp. 28-37 ◽

Cited By ~ 43

Author(s):

Andreas Gruber ◽

Andrea Reinprecht ◽

Harald Görzer ◽

Peter Fridrich ◽

Thomas Czech ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Lung Injury ◽

Pulmonary Function ◽

Neurological Outcome ◽

Cerebral Perfusion ◽

Perfusion Pressure ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Medical Complications ◽

Content Type ◽

Fine Print

Object. This observational study is based on a consecutive series of 207 patients with aneurysmal subarachnoid hemorrhage who were treated within 7 days of their most recent bleed. The purpose of the study was to evaluate the effect of respiratory failure on neurological outcome. Methods. Pulmonary function was assessed by determination of parameters describing pulmonary oxygen transport and exchange, by using composite scores for quantification of lung injury (lung injury score [LIS]) and mechanical ventilator settings (PIF score). Pulmonary function was related to the Hunt and Hess (H & H) grade assigned to the patient at hospital admission (p < 0.001). The pattern and time course of lung injury differed significantly between patients with H & H Grade I or II, Grade III, and Grade IV or V. Hunt and Hess grade, Fisher computerized tomography grade, intracranial pressure, cerebral perfusion pressure, LIS, ratio of PaO2 to the fraction of inspired oxygen (FiO2), and the ratio of the alveolar-minus-arterial oxygen tension difference (AaDO2) to FiO2 were related to neurological outcome (p < 0.001). The LIS on the day of maximum lung injury remained an independent predictor of outcome (p = 0.01) in a stepwise logistic regression analysis. The probability of poor neurological outcome significantly increased with both decreasing cerebral perfusion pressure and increasing severity of lung injury. Conclusions. The overall mortality rate was 22.2% (46 of 207 patients). Subarachnoid hemorrhage and its neurological sequelae accounted for the principal mortality in this series. Medical (nonneurological and nontreatment-related) complications accounted for 37% of all deaths. Systemic inflammatory response syndrome with associated multiple organ dysfunction syndrome was the leading cause of death from medical complications. The authors conclude that respiratory failure is related to neurological outcome, although it is not commonly the primary cause of death from medical complications.

Download Full-text

815 Troponin Trend Can Differentiate “Stunned” Myocardium Associated with Aneurysmal Subarachnoid Hemorrhage vs. Myocardial Infarction

Neurosurgery ◽

10.1227/00006123-200108000-00179 ◽

2001 ◽

Vol 49 (2) ◽

pp. 540-541

Author(s):

Ketan R. Bulsara ◽

Matt McGirt ◽

Lawrence Liao ◽

Alan T. Villavicencio ◽

Cecil Borel ◽

...

Keyword(s):

Myocardial Infarction ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Stunned Myocardium

Download Full-text

Unresolved Issues in the Management of Aneurysmal Subarachnoid Hemorrhage

AACN Advanced Critical Care ◽

10.4037/nci.0b013e31824ebcfa ◽

2012 ◽

Vol 23 (2) ◽

pp. 175-185

Author(s):

Cynthia Bautista

Keyword(s):

Subarachnoid Hemorrhage ◽

Patient Outcomes ◽

Arterial Wall ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Management Strategies ◽

The United States ◽

Critical Care Nurses ◽

Evidence Based ◽

Complex Care ◽

Prevention And Treatment

A cerebral aneurysm is an outpouching of a weakened arterial wall, usually at a bifurcation of one of the larger vessels of the Circle of Willis. When the outpouching ruptures, arterial pressure forces blood into the subarachnoid space. The annual incidence of aneurysmal subarachnoid hemorrhage is 8 to 10 per 100 000 in the United States. The outcome varies for this patient population. New management strategies have emerged; some practices are evidence based, whereas others are based on anecdotal experiences. This variation has resulted in a number of unresolved issues in caring for patients with an aneurysmal subarachnoid hemorrhage. This article discusses some of these unresolved issues, including the use of medications such as nimodipine, antifibrinolytics, statins, and magnesium; coiling or clipping for aneurysm securement; and the prevention and treatment of potential complications. Critical care nurses must conduct detailed assessments and provide complex care to optimize patient outcomes.

Download Full-text

The impact of body habitus on outcomes after aneurysmal subarachnoid hemorrhage: a Nationwide Inpatient Sample analysis

Journal of Neurosurgery ◽

10.3171/2016.4.jns152562 ◽

2017 ◽

Vol 127 (1) ◽

pp. 36-46 ◽

Cited By ~ 11

Author(s):

Hormuzdiyar H. Dasenbrock ◽

Michael O. Nguyen ◽

Kai U. Frerichs ◽

Donovan Guttieres ◽

William B. Gormley ◽

...

Keyword(s):

Morbid Obesity ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Neurological Complications ◽

Infectious Complications ◽

Medical Complications ◽

Morbidly Obese ◽

Obese Patients ◽

Body Habitus ◽

Nonobese Patients ◽

Aneurysm Repair

OBJECTIVEAlthough the prevalence of obesity is increasing rapidly both nationally and internationally, few studies have analyzed outcomes among obese patients undergoing cranial neurosurgery. The goal of this study, which used a nationwide data set, was to evaluate the association of both obesity and morbid obesity with treatment outcomes among patients with aneurysmal subarachnoid hemorrhage (SAH); in addition, the authors sought to analyze how postoperative complications for obese patients with SAH differ by the treatment modality used for aneurysm repair.METHODSClinical data for adult patients with SAH who underwent microsurgical or endovascular aneurysm repair were extracted from the Nationwide Inpatient Sample (NIS). The body habitus of patients was classified as nonobese (body mass index [BMI] < 30 kg/m2), obese (BMI ≥ 30 kg/m2 and ≤ 40 kg/m2), or morbidly obese (BMI > 40 kg/m2). Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality rate, complications, discharge disposition, and poor outcome as defined by the composite NIS-SAH outcome measure. Covariates included patient demographics, comorbidities (including hypertension and diabetes), health insurance status, the NIS-SAH severity scale, treatment modality used for aneurysm repair, and hospital characteristics.RESULTSIn total, data from 18,281 patients were included in this study; the prevalence of morbid obesity increased from 0.8% in 2002 to 3.5% in 2011. Obese and morbidly obese patients were significantly younger and had a greater number of comorbidities than nonobese patients (p < 0.001). Mortality rates for obese (11.5%) and morbidly obese patients (10.5%) did not significantly differ from those for nonobese patients (13.5%); likewise, no differences in neurological complications or poor outcome were observed among these 3 groups. Morbid obesity was associated with significantly increased odds of several medical complications, including venous thromboembolic (OR 1.52, 95% CI 1.01–2.30, p = 0.046) and renal (OR 1.64, 95% CI: 1.11–2.43, p = 0.01) complications and infections (OR 1.34, 95% CI 1.08–1.67, p = 0.009, attributable to greater odds of urinary tract and surgical site infections). Moreover, morbidly obese patients had higher odds of a nonroutine hospital discharge (OR 1.33, 95% CI 1.03–1.71, p = 0.03). Patients with milder obesity had decreased odds of some medical complications, including cardiac, pulmonary, and infectious complications, primarily among patients who had undergone coil embolization.CONCLUSIONSIn this study involving a nationwide administrative database, milder obesity was not significantly associated with increased mortality rates, neurological complications, or poor outcomes after SAH. Morbid obesity, however, was associated with increased odds of venous thromboembolic, renal, and infectious complications, as well as of a nonroutine hospital discharge. Notably, milder obesity was associated with decreased odds of some medical complications, primarily in patients treated with coiling.

Download Full-text