Elsevier

The Lancet Neurology

Volume 9, Issue 5, May 2010, Pages 504-519
The Lancet Neurology

Review
Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage

https://doi.org/10.1016/S1474-4422(10)70087-9Get rights and content

Summary

The management of patients with aneurysmal subarachnoid haemorrhage demands expertise to anticipate, recognise, and promptly treat the many neurological and systemic complications. For this reason, these patients are best cared for in high-volume medical centres with multidisciplinary teams and should preferably be treated in a specialised intensive care unit. Endovascular occlusion and surgical clipping provide complementary alternatives for the treatment of aneurysms. Perfusion scans are redefining the way we detect delayed ischaemia as a growing body of evidence indicates that monitoring vessel diameter is insufficient to prevent cerebral infarctions. Statins, endothelin antagonists, and magnesium sulfate infusion are among the novel strategies being tested for neuroprotection and attenuation of vasospasm. The effectiveness of these treatments is supported by strong experimental data and they represent a new generation of therapeutic options developed from the understanding that vasospasm is primarily caused by endothelial dysfunction.

Introduction

The rupture of an intracranial aneurysm is a neurological emergency. The urgency of the situation might not seem intuitively obvious because many patients present only with a headache and initially have a nearly normal neurological examination. In the first 24 h, rebleeding is a major risk and can lead to early morbidity or even brain death. After the aneurysm is secured (ie, excluded from the circulation), the patient enters a new phase punctuated by cerebral vasospasm and decreased cerebral perfusion. Avoiding secondary damage then becomes the primary goal of care. Some patients present in a much worse clinical condition, requiring complex management of pulmonary oedema, cardiac failure, and arrhythmias. Other patients need emergency evacuation of a cerebral haematoma or decompressive craniectomy to control mass effect.

There has been a notable change in the management of aneurysmal subarachnoid haemorrhage (aSAH) over the past decade. In this era of neurointervention and neurointensive care, a multidisciplinary team is required to respond to the needs of the patient. Mortality from aSAH is decreasing1 and we are making progress in the understanding of its complex pathophysiology. Furthermore, new management strategies have emerged and their use might enable more patients to return to a good or even a full level of functioning.

In this Review, we first provide a practical overview of the care of patients with aSAH from the time of their first hospital assessment. Second, we highlight recent diagnostic and therapeutic advances and discuss promising new treatment options. This Review is not intended to be a guideline or to represent practice recommendations and we do not strictly follow the rules of evidence-based medicine. When evidence is available, we present a critical assessment of its strengths and weaknesses; when there is no evidence available, we offer recommendations based on our experience.

Section snippets

In the emergency department

The acute physiological abnormalities caused by the rupture of an intracranial aneurysm can be devastating. Probably no other acute neurological illness provokes the extent of sudden increase in intracranial pressure and sympathetic outflow as that produced by aSAH. Sudden death occurs in 10–15% of individuals at the time of rupture.2, 3 Coma from intracranial hypertension and cardiopulmonary complications caused by neurocardiogenic injury are common among survivors with extensive haemorrhage.

Surgical clipping versus endovascular coiling

Surgical clipping and endovascular coiling are both effective methods to exclude the ruptured aneurysm from the circulation. There has been much debate on the relative merits of these interventions, with some neurointerventionalists firmly preferring one technique over the other. These techniques should not be seen to be in competition with each other but rather as complementary. Certain aneurysms are best approached with open surgery (eg, those with a very wide neck or that incorporate

Management of patients with poor clinical grade

Management of poor-grade patients is particularly challenging because these patients are most often intubated and sedated. Thus, physical examination cannot be reliably used to recognise signs of delayed ischaemia. Invasive and non-invasive brain monitoring techniques can be used for these patients. Measurements and techniques include venous oximetry (by jugular bulb catheters), brain tissue oxygen tension (by probes such as the Licox catheter, GMS, Kiel-Mielkendorf, Germany), cerebral

Diagnosis of vasospasm

The risk of vasospasm increases between 3 and 7 days after aSAH, although earlier vasospasm can occur and might be associated with poor outcome.6 Fewer than 4% of deficits occur after day 13. More than 60% of patients with aSAH develop cerebral vasospasm during the hospital course, but only about 30% will become symptomatic. Cerebral vasospasm tends to be more severe in younger patients with poor neurological grade, thick subarachnoid clot, intraventricular haemorrhage, and history of smoking.7

New therapies for prevention of cerebral ischaemia and neuroprotection

Substantial progress is being made in the understanding of the pathophysiology of cerebral vasospasm, which is increasingly regarded as a disorder that predominantly affects the endothelial function and microcirculation.133 Robust theoretical rationale and strong experimental data have led to the design of clinical trials that investigate novel therapies for vasospasm and protection against delayed ischaemic damage. Panel 2 summarises the current state of the evidence for various therapeutic

Conclusions and future directions

The care of patients with aSAH is undergoing changes that hold great promise for improving patient outcomes. Over the past few years, we have learned about the value of endovascular coil occlusion and embraced its use, enhanced our understanding of the mechanisms leading to secondary brain ischaemia, and found new ways to identify brain tissue at risk of ischaemic damage through perfusion scans. We are now learning how to optimise the use of these new diagnostic modalities and how to evaluate

Search strategy and selection criteria

References for this Review were identified through searches of PubMed with the search terms “subarachnoid hemorrhage”, “treatment”, “management”, “cerebral aneurysm”, and “vasospasm” from 1970 to February, 2010. Articles were also identified through searches of the Cochrane library and searches of the authors' own files. Only papers published in English were reviewed.

References (195)

  • J Huang et al.

    The probability of sudden death from rupture of intracranial aneurysms: a meta-analysis

    Neurosurgery

    (2002)
  • N van der Wee et al.

    Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?

    J Neurol Neurosurg Psychiatry

    (1995)
  • CM Fisher et al.

    Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning

    Neurosurgery

    (1980)
  • J Claassen et al.

    Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited

    Stroke

    (2001)
  • AH Kramer et al.

    A comparison of 3 radiographic scales for the prediction of delayed ischemia and prognosis following subarachnoid hemorrhage

    J Neurosurg

    (2008)
  • A Hijdra et al.

    Grading the amount of blood on computed tomograms after subarachnoid hemorrhage

    Stroke

    (1990)
  • SA Dupont et al.

    Prediction of angiographic vasospasm after aneurysmal subarachnoid hemorrhage: value of the Hijdra sum scoring system

    Neurocrit Care

    (2009)
  • SA Dupont et al.

    Timing of computed tomography and prediction of vasospasm after aneurysmal subarachnoid hemorrhage

    Neurocrit Care

    (2009)
  • JA Edlow et al.

    Avoiding pitfalls in the diagnosis of subarachnoid hemorrhage

    N Engl J Med

    (2000)
  • WN van der et al.

    Detection of subarachnoid haemorrhage on early CT: is lumbar puncture still needed after a negative scan?

    J Neurol Neurosurg Psychiatry

    (1995)
  • P Mitchell et al.

    Detection of subarachnoid haemorrhage with magnetic resonance imaging

    J Neurol Neurosurg Psychiatry

    (2001)
  • WE Hunt et al.

    Surgical risk as related to time of intervention in the repair of intracranial aneurysms

    J Neurosurg

    (1968)
  • Report of World Federation of Neurological Surgeons Committee on a universal subarachnoid hemorrhage grading scale

    J Neurosurg

    (1988)
  • JB Bederson et al.

    Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association

    Stroke

    (2009)
  • GJE Rinkel

    Medical management of patients with aneurysmal subarachnoid haemorrhage

    Int J Stroke

    (2009)
  • NS Bardach et al.

    Regionalization of treatment for subarachnoid hemorrhage: a cost-utility analysis

    Circulation

    (2004)
  • J van Gijn et al.

    Acute hydrocephalus after aneurysmal subarachnoid hemorrhage

    J Neurosurg

    (1985)
  • J Claassen et al.

    Global cerebral edema after subarachnoid hemorrhage: frequency, predictors, and impact on outcome

    Stroke

    (2002)
  • PD Le Roux et al.

    Intracranial aneurysms and subarachnoid hemorrhage management of the poor grade patient

    Acta Neurochir Suppl

    (1999)
  • H Ohkuma et al.

    Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management

    Stroke

    (2001)
  • SM Dorhout Mees et al.

    Calcium antagonists for aneurysmal subarachnoid haemorrhage

    Cochrane Database Syst Rev

    (2007)
  • AM Naidech et al.

    Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage

    Stroke

    (2005)
  • S Koch et al.

    Phenytoin and cognitive decline

    Stroke

    (2005)
  • LJ Dennis et al.

    Nonconvulsive status epilepticus after subarachnoid hemorrhage

    Neurosurgery

    (2002)
  • AS Little et al.

    Nonconvulsive status epilepticus in patients suffering spontaneous subarachnoid hemorrhage

    J Neurosurg

    (2007)
  • Y Roos et al.

    Antifibrinolytic therapy for aneurysmal subarachnoid hemorrhage: a major update of a cochrane review

    Stroke

    (2003)
  • J Hillman et al.

    Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study

    J Neurosurg

    (2002)
  • JB Bederson et al.

    Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association

    Stroke

    (2009)
  • AM McKinney et al.

    Detection of aneurysms by 64-section multidetector CT angiography in patients acutely suspected of having an intracranial aneurysm and comparison with digital subtraction and 3D rotational angiography

    AJNR Am J Neuroradiol

    (2008)
  • R Agid et al.

    Acute subarachnoid hemorrhage: using 64-slice multidetector CT angiography to “triage” patients' treatment

    Neuroradiology

    (2006)
  • R Agid et al.

    Negative CT angiography findings in patients with spontaneous subarachnoid hemorrhage: when is digital subtraction angiography still needed?

    AJNR Am J Neuroradiol

    (2009)
  • AA Rabinstein

    A long-term view at clipping versus coiling for ruptured aneurysm

    Neurocrit Care

    (2009)
  • A Campi et al.

    Retreatment of ruptured cerebral aneurysms in patients randomized by coiling or clipping in the International Subarachnoid Aneurysm Trial (ISAT)

    Stroke

    (2007)
  • Rates of delayed rebleeding from intracranial aneurysms are low after surgical and endovascular treatment

    Stroke

    (2006)
  • M Ryttlefors et al.

    International subarachnoid aneurysm trial of neurosurgical clipping versus endovascular coiling: subgroup analysis of 278 elderly patients

    Stroke

    (2008)
  • P Mitchell et al.

    Could late rebleeding overturn the superiority of cranial aneurysm coil embolization over clip ligation seen in the International Subarachnoid Aneurysm Trial?

    J Neurosurg

    (2008)
  • J Claassen et al.

    Prognostic significance of continuous EEG monitoring in patients with poor-grade subarachnoid hemorrhage

    Neurocrit Care

    (2006)
  • R Ramakrishna et al.

    Brain oxygen tension and outcome in patients with aneurysmal subarachnoid hemorrhage

    J Neurosurg

    (2008)
  • C Samuelsson et al.

    Relationship between intracranial hemodynamics and microdialysis markers of energy metabolism and glutamate-glutamine turnover in patients with subarachnoid hemorrhage. Clinical article

    J Neurosurg

    (2009)
  • PG Al Rawi et al.

    Hypertonic saline in patients with poor-grade subarachnoid hemorrhage improves cerebral blood flow, brain tissue oxygen, and pH

    Stroke

    (2010)
  • Cited by (149)

    • Management of subarachnoid haemorrhage

      2023, Anaesthesia and Intensive Care Medicine
    • Translational research in delayed cerebral ischemia

      2022, Perioperative Neuroscience: Translational Research
    View all citing articles on Scopus
    View full text