Early Management of Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽  
1982 ◽  
Vol 11 (3) ◽  
pp. 412-418 ◽  
Author(s):  
Bengt Ljunggren ◽  
Lennart Brandt ◽  
Göran Sundbärg ◽  
Hans Säveland ◽  
Sten Cronqvist ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Good Condition ◽  
Favorable Outcome ◽  
Neurological Deficits ◽  
Early Operation ◽  
Good Recovery ◽  
Early Management ◽  
Delayed Onset ◽  
Late Operation

Abstract The Lund Clinic serves a population of 1.46 million inhabitants. During the calendar year 1981, 72 patients presented with a ruptured supratentorial aneurysm, diagnosed either at angiography or at autopsy. Upon admission, 60% of the patients were in good condition and 40% were in poor condition. Eighty-three per cent were admitted within 72 hours after the subarachnoid hemorrhage (SAH). In the total series, 50% made a good recovery; the overall management morbidity was 19%, and the management mortality was 31%. Thirty-one patients in Grades I–III underwent early operation (43% of the total series), with a favorable outcome in 74% and 7% mortality. Of the 35 patients who were admitted early and in good condition, 71% made a good recovery, and the management mortality was 9%. These figures may be compared to the 51% favorable outcome and 27% mortality reported from the Cooperative Aneurysm Study with late operation. In the early operation cases, the incidence of significant arterial narrowing at postoperative angiography performed on Day 9 ± 2 after SAH was 30% and the incidence of permanent neurological deficits of delayed onset was 10%. Two of the early operation patients developed permanent symptomatic hydrocephalus.

Early operation and overall outcome in aneurysmal subarachnoid hemorrhage

1985 ◽  
Vol 62 (4) ◽  
pp. 547-551 ◽  
Author(s):  
Bengt Ljunggren ◽  
Hans Säveland ◽  
Lennart Brandt ◽  
Stefan Zygmunt
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Good Condition ◽  
Acute Stage ◽  
Neurological Deficits ◽  
Morbidity Rate ◽  
Intracerebral Hematoma ◽  
Content Type ◽  
Risk Patients ◽  
Life Threatening

✓ Over a 3-year period, 251 individuals in a population of 1.46 million were known to have suffered an aneurysmal subarachnoid hemorrhage (SAH). Forty-three individuals (17%) were either found dead or were dead on arrival at a hospital or forensic department. Forty-nine patients (20%) were at no stage in their clinical course considered to be surgical candidates. Six patients (2% of the total series) were initially in good condition, but subsequently deteriorated during the acute phase and were not treated surgically. Nineteen poor-risk patients (8% of the total series) underwent emergency surgery because of a life-threatening intracerebral hematoma; 105 patients (42% of the total series or 69% of the surgically treated patients) were operated on at the acute stage, and 29 patients (11% of the total series or 19% of the surgically treated patients) underwent late surgery. Of the total series, 107 patients (42%) recovered without neurological deficits; the overall morbidity rate was 19%, and the mortality rate was 39%. Of 99 Grade I to III patients who were operated on at the acute stage, 76% recovered without neurological deficits, and 4% died. It is concluded that the overall outcome in aneurysmal SAH remains poor, mainly because of the large group of patients who are permanently devastated by their initial bleed.

Plasma glucose levels and outcome after aneurysmal subarachnoid hemorrhage

1993 ◽  
Vol 79 (6) ◽  
pp. 885-891 ◽  
Author(s):  
Giuseppe Lanzino ◽  
Neal F. Kassell ◽  
Teresa Germanson ◽  
Laura Truskowski ◽  
Wayne Alves
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Plasma Glucose ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Delayed Cerebral Ischemia ◽  
Ct Scans ◽  
Good Recovery ◽  
Glucose Levels ◽  
Poor Outcome ◽  
Elevated Glucose ◽  
Mean Glucose

✓ Plasma glucose levels were studied in 616 patients admitted within 72 hours after subarachnoid hemorrhage (SAH). Glucose levels measured at admission showed a statistically significant association with Glasgow Coma Scale scores, Botterell grade, deposition of blood on computerized tomography (CT) scans, and level of consciousness at admission. Elevated glucose levels at admission predicted poor outcome. A good recovery, as assessed by the Glasgow Outcome Scale at 3 months, occurred in 70.2% of patients with normal glucose levels (≤ 120 mg/dl) and in 53.7% of patients with hyperglycemia (> 120 mg/dl) (p = 0.002). The death rates for these two groups were 6.7% and 19.9%, respectively (p = 0.001). The association was still maintained after adjusting for age (> or ≤ 50 years) and thickness of clot on CT scans (thin or thick) in the subset of patients who were alert/drowsy at admission. Increased mean glucose levels between Days 3 and 7 also predicted a worse outcome; good recovery was observed in 132 (73.7%) of 179 patients who had normal mean glucose levels (≤ 120 mg/dl) and 160 (49.7%) of 322 who had elevated mean glucose levels (> 120 mg/dl) (p < 0.0001). Death occurred in 6.7% and 20.8% of the two groups, respectively (p < 0.0001). It is concluded that admission plasma glucose levels can serve as an objective prognostic indicator after SAH. Elevated glucose levels during the 1st week after SAH also predict a poor outcome. However, a causal link between hyperglycemia and outcome after delayed cerebral ischemia, although suggested by experimental data, cannot be established on the basis of this study.

scholarly journals Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital without neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)

2021 ◽  
Vol 1 (1) ◽  
Author(s):  
Edoardo Picetti ◽  
Maurizio Berardino ◽  
Alessandro Bertuccio ◽  
Rita Bertuetti ◽  
Edoardo Pietro Boccardi ◽  
...  
Keyword(s):  
Intensive Care ◽  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Interventional Neuroradiology ◽  
Italian Society ◽  
Early Management ◽  
Modified Delphi ◽  
Delphi Approach ◽  
Specialized Center ◽  
Early Transfer

Abstract Background The immediate management of subarachnoid hemorrhage (SAH) patients in hospitals without neurosurgical/neurointerventional facilities and their transfer to a specialized center is challenging and not well covered in existing guidelines. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance. Methods A multidisciplinary consensus panel composed by 19 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery and interventional neuroradiology) was created. A modified Delphi approach was adopted. Results A total of 14 statements have been discussed. Consensus was reached on 11 strong recommendations and 2 weak recommendations. In one case, where consensus could not be agreed upon, no recommendation could be provided. Conclusions Management of SAH in a non-specialized setting and early transfer are difficult and may have a critical impact on outcome. Clinical advice, based on multidisciplinary consensus, might be helpful. Our recommendations cover most, but not all, topics of clinical relevance.

Positron Emission Tomographic Cerebral Perfusion Disturbances and Transcranial Doppler Findings among Patients with Neurological Deterioration after Subarachnoid Hemorrhage

Neurosurgery ◽  
2003 ◽  
Vol 52 (5) ◽  
pp. 1017-1024 ◽  
Author(s):  
Pawan S. Minhas ◽  
David K. Menon ◽  
Piotr Smielewski ◽  
Marek Czosnyka ◽  
Peter J. Kirkpatrick ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Carotid Artery ◽  
Cerebral Perfusion ◽  
Internal Carotid ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Neurological Deficits ◽  
Positron Emission Tomographic ◽  
Positron Emission ◽  
Arterial Vasospasm ◽  
The Mean

Abstract OBJECTIVE After aneurysmal subarachnoid hemorrhage, approximately 30% of patients experience delayed neurological deficits, related in part to arterial vasospasm and dysautoregulation. Transcranial Doppler (TCD) ultrasonography is commonly used to noninvasively detect arterial vasospasm. We studied cerebral perfusion patterns and associated TCD indices for 25 patients who developed clinical signs of delayed neurological deficits. METHODS Patients were treated in a neurosurgical intensive care unit and were studied if they exhibited delayed focal or global neurological deterioration. Positron emission tomographic cerebral blood flow (CBF) studies and TCD studies measuring the mean flow velocity (FV) of the middle cerebral artery and the middle cerebral artery FV/internal carotid artery FV ratio (with the internal carotid artery FV being measured extracranially at the cranial base) were performed. Glasgow Outcome Scale scores were assessed at 6 months. RESULTS A markedly heterogeneous pattern of CBF distribution was observed, with hyperemia, normal CBF values, and reduced flow being observed among patients with delayed neurological deficits. TCD indices were not indicative of the cerebral perfusion findings. The mean CBF value was slightly lower for patients who did not survive (32.3 ml/100 g/min), compared with those who did survive (36.0 ml/100 g/min, P= 0.05). CONCLUSION Among patients who developed delayed neurological deficits after aneurysmal subarachnoid hemorrhage, a wide range of cerebral perfusion disturbances was observed, calling into question the traditional concept of large-vessel vasospasm. Commonly used TCD indices do not reflect cerebral perfusion values.

Effect of heparin on secondary brain injury in patients with subarachnoid hemorrhage: an additional ‘H’ therapy in vasospasm treatment

2017 ◽  
Vol 9 (7) ◽  
pp. 659-663 ◽  
Author(s):  
Markus Bruder ◽  
Sae-Yeon Won ◽  
Sepide Kashefiolasl ◽  
Marlies Wagner ◽  
Nina Brawanski ◽  
...  
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Brain Injury ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Favorable Outcome ◽  
Matched Pair ◽  
Control Group ◽  
High Morbidity ◽  
Secondary Brain Injury ◽  
Heparin Group ◽  
Vasomotor Function

ObjectiveSecondary brain injury leads to high morbidity and mortality rates in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, evidence-based treatment strategies are sparse. Since heparin has various effects on neuroinflammation, microthromboembolism and vasomotor function, our objective was to determine whether heparin can be used as a multitarget prophylactic agent to ameliorate morbidity in SAH.MethodsBetween June 1999 and December 2014, 718 patients received endovascular treatment after rupture of an intracranial aneurysm at our institution; 197 of them were treated with continuous unfractionated heparin in therapeutic dosages after the endovascular procedure. We performed a matched pair analysis to evaluate the effect of heparin on cerebral vasospasm (CVS), cerebral infarction (CI), and outcome.ResultsThe rate of severe CVS was significantly reduced in the heparin group compared with the control group (14.2% vs 25.4%; p=0.005). CI and multiple ischemic lesions were less often present in patients with heparin treatment. These effects were enhanced if patients were treated with heparin for >48 hours, but the difference was not significant. Favorable outcome at 6-month follow-up was achieved in 69% in the heparin group and in 65% in the control group.ConclusionsPatients receiving unfractionated continuous heparin after endovascular aneurysm occlusion have a significant reduction in the rate of severe CVS, have CI less often, and tend to have a favorable outcome more often. Our findings support the potential beneficial effects of heparin as a multitarget therapy in patients with SAH, resulting in an additional ‘H’ therapy in vasospasm treatment.

Use of the Extracranial-Intracranial Arterial Bypass in the Management of Refractory Vasospasm: A Case Report

Neurosurgery ◽  
1985 ◽  
Vol 17 (3) ◽  
pp. 474-479 ◽  
Author(s):  
Jacob Rosenstein ◽  
Hunt H. Batjer ◽  
Duke S. Samson
Keyword(s):  
Case Report ◽  
Subarachnoid Hemorrhage ◽  
Arterial Hypertension ◽  
Volume Expansion ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Morbidity And Mortality ◽  
Neurological Deficits ◽  
Collateral Flow ◽  
Intravascular Volume ◽  
Arterial Vasospasm

Abstract Cerebral arterial vasospasm after aneurysmal subarachnoid hemorrhage remains one of the major causes of morbidity and mortality in patients surviving the initial hemorrhage. Once established, no known method has been shown to reverse this process in humans. Although intravascular volume expansion and induced arterial hypertension have been shown to be effective in the reversal of neurological deficits secondary to vasospasm, a large proportion of patients remain refractory to these methods. We report one such case successfully managed by the estalishment of an extracranial-intracranial anastomosis in an attempt to augment collateral flow.

Early management of aneurysmal subarachnoid hemorrhage

1981 ◽  
Vol 54 (2) ◽  
pp. 141-145 ◽  
Author(s):  
Harold P. Adams ◽  
Neal F. Kassell ◽  
James C. Torner ◽  
Donald W. Nibbelink ◽  
Adolph L. Sahs
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Medical Management ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Aneurysm Rupture ◽  
Early Management ◽  
Neurological Sequelae ◽  
Content Type ◽  
Antifibrinolytic Therapy ◽  
Effective Reduction ◽  
Fine Print

✓ The overall results are presented of early medical management and delayed operation among 249 patients studied during the period 1974 to 1977, treated within 3 days of subarachnoid hemorrhage (SAH) and evaluated 90 days after aneurysm rupture. The results included 36.2% mortality, 17.9% survival with serious neurological sequelae, and 46% with a favorable outcome. Of the patients admitted in good neurological condition, 28.7% had died and only 55.7% had a favorable recovery at 90 days after SAH. These figures represent the results despite effective reduction in early rebleeding by antifibrinolytic therapy and successful surgery in those patients reaching operation. Further therapeutic advances are needed for patients hospitalized within a few days after SAH.

Delayed neurological deficits detected by an ischemic pattern in the extracellular cerebral metabolites in patients with aneurysmal subarachnoid hemorrhage

2004 ◽  
Vol 100 (1) ◽  
pp. 8-15 ◽  
Author(s):  
Jane Skjøth-Rasmussen ◽  
Mette Schulz ◽  
Soren Risom Kristensen ◽  
Per Bjerre
Keyword(s):  
Subarachnoid Hemorrhage ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Cerebral Metabolism ◽  
Brain Infarction ◽  
Neurological Deficits ◽  
Parent Artery ◽  
Glycerol Concentration ◽  
Microdialysis Probe ◽  
Content Type ◽  
Fine Print

Object. In the treatment of patients with aneurysmal subarachnoid hemorrhage (SAH), early occlusion of the aneurysm is necessary as well as monitoring and treatment of complications following the primary bleeding episode. Monitoring with microdialysis has been studied for its ability to indicate and predict the occurrence of delayed ischemic neurological deficits (DINDs) in patients with SAH. Methods. In 42 patients with aneurysmal SAH microdialysis monitoring of metabolites was performed using a 0.3-µl/minute perfusion flow over several days, and the results were correlated to clinical events and to brain infarction observed on computerized tomography scans. The microdialysis probe was inserted into the territory of the parent artery of the aneurysm. The authors defined an ischemic pattern as increases in the lactate/glucose (L/G) and lactate/pyruvate (L/P) ratios that were greater than 20% followed by a 20% increase in glycerol concentration. This ischemic pattern was found in 17 of 18 patients who experienced a DIND and in three of 24 patients who did not experience a delayed clinical deterioration. The ischemic pattern preceded the occurrence of a DIND by a mean interval of 11 hours. Maximum L/G and L/P ratios did not correlate with the presence of DIND or outcome, and there was no association between the glycerol level and subsequent brain infarction. Conclusions. Microdialysis monitoring of the cerebral metabolism in patients with SAH may predict with high sensitivity and specificity the occurrence of a DIND. Whether an earlier diagnosis results in better treatment of DINDs and, therefore, in overall better outcomes remains to be proven, as it is linked to an efficacious treatment of cerebral vasospasm.

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