Guidelines SAH AHA

7/30/2019 Guidelines SAH AHA

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1/12/2013 2009, American Heart Association. All rights reserved.

AHA/ASA Scientific StatementGuidelines for the Management of Aneurysmal Subarachnoid

Hemorrhage (SAH)

A Statement for Healthcare Professionals from a Special Writing

Group of the Stroke Council, American Heart Association

Joshua B. Bederson, MD, Chair; E. Sander Connolly, Jr., MD, FAHAVice-Chair; H. Hunt Batjer, MD; Ralph G. Dacey, MD, FAHA;

Jacques E. Dion, MD, FRCPC; Michael N. Diringer, MD, FAHA,FCCM; John E. Duldner, Jr., MD, MS; Robert E. Harbaugh, MD,

FACS, FAHA; Aman B. Patel, MD; Robert H.Rosenwasser, MD, FACS, FAHA


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Stroke Council ProfessionalEducation Committee

This slide presentation was

developed by members of theStroke Council ProfessionalEducation committee. Opeolu Adeoye MD

Dawn Kleindorfer MD


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Citation Information Key words included in the paper:

aneurysm; angiography; cerebrovascular disorders;hemorrhage; stroke; surgery; vasospasm

Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, DionJE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB,Rosenwasser RH. Guidelines for the management ofaneurysmal subarachnoid hemorrhage: a statement for

healthcare professionals from a special writing group ofthe Stroke Council, American Heart Association. Stroke2009: published online before print January 22, 2009,10.1161/STROKEAHA.108.191395.


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This slide set was adapted from the

Guidelines for the Management ofAneurysmal Subarachnoid Hemorrhagepaper

This guideline reflects a consensus of expert opinionfollowing thorough literature review that consisted of alook at clinical trials and other evidence related to the

management of subarachnoid hemorrhage.


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Applying classification of recommendationsand levels of evidence


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Outline Introduction

Epidemiology

Acute Evaluation and MedicalManagement

Surgical and Endovascular Management

Management of Common In-HospitalSAH Complications

Summary and Conclusions


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Introduction SAH is a common and devastating

condition

SAH affects up to 30,000 personsannually in the United States (US)

Mortality rates are as high as 45% withsignificant morbidity among survivors

These recommendations summarize thebest available evidence for treatment ofpatients with aneurysmal SAH


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Stroke


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Aneurysm


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Epidemiology SAH incidence varies greatly between

countries, from 2 cases/ 100,000 in

China to 22.5/100,000 in Finland Many cases of SAH are misdiagnosed

Thus, the annual incidence ofaneurysmal SAH in the US may exceed

30,000 Incidence increases with age, occurring

most commonly between 40 and 60years of age (mean age > 50 years)


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Epidemiology SAH is ~1.6 times higher in women thanmen

Risk factors for SAH include

hypertension, smoking, female genderand heavy alcohol use

Cocaine-related SAH occurs in youngerpatients

Familial intracranial aneurysm (FIA)syndrome occurs when two first-through third-degree relatives haveintracranial aneurysms


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CT Scan non-contrast showing bloodin basal cisterns (SAH) so calledStar-Sign

CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery


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CT Scan of a 65 yo woman, Hunt andHess of 4 Subarachnoid Hemorrhage

Arrow:Hyperintensesignal.Blood in thesubarachnoidspace

CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery


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Angiogram - Giant ICA Aneurysm

Angio image courtsey: University of Texas Health Science Center at San Antonio - Department of Neurosurgery


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Prevention of SAH No randomized controlled trials haveexamined whether treatment of medicalrisk factors reduces SAH occurrence

Hypertension is a common risk factorfor hemorrhagic stroke

Indirect evidence suggests that smokingcessation reduces risk for SAH

Screening for asymptomatic intracranialaneurysms in the general population isnot supported by the available literature


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Recommendations for Preventionof SAH Class I Recommendations

The relationship between

hypertension and aneurysmal SAH isuncertain. However, treatment of highblood pressure with antihypertensivemedication is recommended to

prevent ischemic stroke andintracerebral hemorrhage, cardiac,renal, and other end-organ injury(LOE A)


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Recommendations for Preventionof SAH Class II Recommendations

Cessation of smoking is reasonable to

reduce the risk of SAH, although evidencefor this association is indirect (LOE B).

Screening of certain high-risk populationsfor unruptured aneurysms is of uncertain

value (LOE B); advances in noninvasiveimaging may be used for screening, butcatheter angiography remains the goldstandard when it is clinically imperative toknow if an aneurysm exists.


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Natural History and Outcome of anAneurysmal SAH 30-day mortality rate after SAH ranges from 33-

50%

Severity of initial hemorrhage, age, sex, time totreatment, and medical comorbidities impactSAH outcome

Aneurysm size, location in the posteriorcirculation, and morphology may also impact

outcome Endovascular services at a given institution, the

volume of SAH patients treated, and the facilitywhere the patient is first evaluated may alsoimpact outcome


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Natural History of an AneurysmalSAH: Recommendations

Class I Recommendations

The severity of the initial bleed shouldbe determined rapidly as it is the mostuseful indicator of outcome followinganeurysmal SAH and grading scales

which heavily rely on this factor arehelpful in planning future care withfamily and other physicians (LOE B)


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Class I Recommendations Case review and prospective cohorts have shown that

for untreated, ruptured aneurysms, there is at least a3% to 4% risk of re-bleeding in the first 24 hours andpossibly significantly higher, with a high percentageoccurring immediately (within 2 to 12 hours) after theinitial ictus, a 1% to 2% per day risk in the first month,

and a long-term risk of 3% per year after 3 months.Urgent evaluation and treatment of patients withsuspected SAH is therefore recommended (LOE B)


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Class II Recommendations

In triaging patients for aneurysm repair,

factors that can be useful in determiningthe risk of re-bleeding include severity ofthe initial bleed, interval to admission,blood pressure, gender, aneurysm

characteristics, hydrocephalus, earlyangiography, and the presence of aventricular drain (LOE B)


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Acute Evaluation - Diagnosis The worst headache of my life is

described by ~80% of patients

Sentinel headache is described by ~20%

Nausea/vomiting, stiff neck, loss ofconsciousness, or focal neurologicaldeficits may occur

Misdiagnosis of SAH occurred in as many

as 64% of cases prior to 1985 Recent data suggest an SAH

misdiagnosis rate of approximately 12%


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Acute Evaluation - Diagnosis Importance of recognition of a warning

or sentinel leak cannot be

overemphasized A high index of suspicion is warranted in

the ED

The diagnostic sensitivity of CT

scanning is not 100%, thus diagnosticlumbar puncture should be performed ifthe initial CT scan is negative


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Diagnosis of SAH -Recommendations Class I Recommendations

SAH is a medical emergency that isfrequently misdiagnosed. A high level

of suspicion for SAH should exist inpatients with acute onset of severeheadache (LOE B)

CT scanning for suspected SAH is

strongly recommended, and lumbarpuncture for analysis of cerebrospinalfluid is strongly recommended whenthe CT scan is negative (LOE B)


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Diagnosis of SAHRecommendations Class I Recommendations

Selective cerebral angiography to documentthe presence and anatomic features of

aneurysms is strongly recommended inpatients with documented SAH (LOE B)


MRA or CTA can serve as useful alternative

diagnostic tools when conventionalangiography cannot be performed in atimely fashion (LOE B)


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Acute EvaluationEmergency Evaluation Emergency medical services (EMS) is first

medical contact in about 2/3 of SAH

patients EMS personnel should receive continuing

education regarding signs and symptomsand the importance of rapid neurological

assessment in cases of possible SAH On-scene delays should be avoided

Rapid transport and advanced notificationof the ED should occur


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Acute EvaluationEmergency Evaluation Airway, breathing, and circulation should

be rapidly assessed and managed

Emergency care providers shouldevaluate SAH patients with an acceptedneurologic assessment scale and record itin the ED Hunt and Hess, Fisher Scale, Glasgow Coma Scale,

World Federation of Neurological Surgeons Scale.

Expedient transfer to an appropriatereferral center should be considered ifnecessary


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Emergency EvaluationRecommendations


The degree of neurologicalimpairment using an accepted SAHgrading system can be useful forprognosis and triage (LOE B)

A standardized ED managementprotocol for the evaluation of patientswith headaches and other symptomsof potential SAH does not currentlyexist and needs development (LOE C)


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Acute Evaluation PreventingRe-bleeding

Up to 14% of SAH patients may

experience re-bleeding within 2 hours ofthe initial hemorrhage

Re-bleeding was more common in thosewith a systolic blood pressure

>160mm Hg Anti-fibrinolytic therapy may reduce re-

bleeding but has not been shown toimprove outcomes


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Preventing Re-bleeding -Recommendations


Blood pressure should be monitored andcontrolled to balance the risk of strokes,hypertension-related re-bleeding, andmaintenance of cerebral perfusion pressure(LOE B)

Class II Recommendations Bed rest alone is not enough to prevent re-

bleeding after SAH. It may be considered asa component of a broader treatment strategyalong with more definitive measures (LOE B)


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Preventing Re-bleeding -Recommendations


Recent evidence suggests that earlytreatment with antifibrinolytic agents,when combined with a program ofearly aneurysm treatment followed by

discontinuation of the antifibrinolyticand prophylaxis against hypovolemiaand vasospasm (LOE B)


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Preventing Re-bleedingClass II Recommendations

Antifibrinolytic therapy to prevent

rebleeding may be considered incertain clinical situations, e.g.,patients with a low risk ofvasospasm and/or a beneficialeffect of delaying surgery (LOE B)


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Surgical and EndovascularManagement of SAH Occluding aneurysms using

endovascular coils was described in

1991 Improved outcomes have been linked tohospitals that provide endovascularservices

Use of endovascular versus surgical

techniques varies greatly across centers Coil embolization is associated with a

2.4% risk of aneurysmal perforation andan 8.5% risk of ischemic complications


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Surgical and EndovascularManagement of SAH

A study of 431 patients undergoingcoiling of a ruptured aneurysm found anearly re-bleeding rate of 1.4%, with 100%mortality

The ISAT Trial reported a 1-year re-

hemorrhage rate of ~2.9% in aneurysmstreated with endovascular therapy

Aneurysm size is an important predictorof hemorrhage risk


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The Cooperative Study evaluated 979patients who underwent intracranialsurgery only

Nine of 453 patients (2%) rebled aftersurgery

Nearly half (n=4) of these hemorrhagesoccurred in patients with multipleaneurysms


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In the International Subarachnoid

Aneurysm Trial (ISAT) post-treatmentSAH occurred at an annualized rate of0.9% with surgical clipping, compared to2.9% with endovascular treatment

The rate of incomplete obliteration andrecurrence appears significantly lowerwith surgical clipping than withendovascular treatment


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Surgical and EndovascularManagement of SAH Increased time to treatment is

associated with increased rates of

preoperative re-bleeding 0 to 3 days, 5.7% 4 to 6 days, 9.4% 7 to 10 days, 12.7% 11 to 14 days, 13.9% 15 to 32 days, 21.5%

Postoperative re-bleeding did not differamong time intervals (1.6% overall)


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Estimating the consequences of

complications attributable to anoperation may be possible from dataregarding surgery for unrupturedaneurysms

In-hospital mortality rates vary from1.8% to 3.0% in large multicenter studies

Adverse outcomes in survivors varyfrom 8.9% to 22.4%


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The only large prospective, randomized

trial to date comparing surgery andendovascular techniques is ISAT

At one year, there was no significantdifference in mortality rates (8.1% vs.

10.1% endovascular vs. surgical) Disability rates were greater in surgical

versus endovascular patients (21.6% vs.15.6%)


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Surgical and EndovascularManagement of SAH Combined morbidity and mortality was

significantly greater in surgically treatedpatients than in those treated with

endovascular techniques (30.9% vs. 23.5%;absolute risk reduction 7.4%, P= 0.0001)

During the short follow-up period in ISAT there-bleeding rate for coiling was 2.9% versus0.9% for surgery

There have been no randomized comparisonsof coiling versus clipping for unrupturedaneurysms


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Clipping


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Left image arrow -Angio with Large aneurysmRight image arrow Angio showing aneurysm post clipping

Angio Image Courtsey: The University of Texas Health Science Center at San Antonio Department of Neurosurgery


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Surgical and Endovascular

Management --Recommendations Class I Recommendations

Surgical clipping or endovascular coiling isstrongly recommended to reduce the rate ofrebleeding after aneurysmal SAH (LOE B)

Wrapped or coated aneurysms as well asincompletely clipped or coiled aneurysmshave an increased risk of re-hemorrhagecompared to those completely occluded andtherefore require long-term follow-upangiography. Complete obliteration of theaneurysm is recommended wheneverpossible (LOE B)


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Management --Recommendations Class I Recommendations

For patients with ruptured aneurysms judged by an

experienced team of cerebrovascular surgeons andendovascular practitioners to be technicallyamenable to both endovascular coiling andneurosurgical clipping, endovascular coiling can bebeneficial (LOE B)


Individual characteristics of the patient and theaneurysm must be considered in deciding the bestmeans of repair, and management of patients incenters offering both techniques is probablyrecommended (LOE B)


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Coiling


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Coil system embolization: immediateresultAngio showing large ICAaneurysm Same aneurysm - Post GDC Coiling

Angio Image Courtsey: The University of Texas Health Science Center at San Antonio Department of Neurosurgery


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Management -Recommendations


Although previous studies showed thatoverall outcome was not different for earlyversus delayed surgery after SAH, earlytreatment reduces the risk of rebleedingafter SAH, and newer methods may increase

the effectiveness of early aneurysmtreatment. Early aneurysm treatment isreasonable and is probably indicated in themajority of cases (LOE B)


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Hospital/Systems of Care Treatment volume is an important

determinant of outcome for intracranialaneurysms higher volume equals

lower mortality This effect may be more important for

patients with unruptured aneurysmsthan for those with ruptured aneurysms

It is uncertain whether the benefits ofreceiving care at a high-volume centerwould outweigh the costs and risks oftransfer


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Hospital/Systems of Care --Recommendations


Early referral to high-volume centersthat have both experiencedcerebrovascular surgeons andendovascular specialists is

reasonable (LOE B)


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Management of Common In-Hospital SAH Complications

Common issues related to in-

hospital management of SAHinclude: Anesthetic Management Cerebral Vasospasm

Hydrocephalus Seizures Hyponatremia


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Anesthetic Management During

Surgical and EndovascularTreatments

Goals of intraoperative anesthetic

management during aneurysm treatmentinclude:

limiting the risk of intraproceduralaneurysm rupture

protecting the brain against ischemicinjury


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Anesthetic Management --Recommendations

Class II Recommendations Minimizing the degree and duration of

intraoperative hypotension during aneurysmsurgery is probably indicated (LOE B)

There are insufficient data onpharmacological strategies and inducedhypertension during temporary vessel

occlusion to make specificrecommendations, but there may beinstances where their use can be consideredreasonable (LOE C)


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Anesthetic Management --Recommendations

Class III Recommendations

Induced hypothermia duringaneurysm surgery may be areasonable option in some cases butis not routinely recommended (LOE B)


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Management of CerebralVasospasm after SAH

Following aneurysmal SAH, angiographicvasospasm is seen in 30% to 70% of patients

Typical onset is 3 to 5 days after thehemorrhage, maximal narrowing at 5 to 14 days,and a gradual resolution over 2 to 4 weeks

15% to 20% of patients with delayed neurologicdeficits suffer stroke or die from vasospasm

despite maximal therapy The index of suspicion needs to be higher in

poor grade patients even with subtle changesin neurological exam


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The literature is inconclusive regardingthe sensitivity and specificity of TCDmonitoring

However, severe spasm can beidentified with fairly high reliability usingTCD monitoring

Other modalities such as diffusionperfusion, MRI, and xenon-CT cerebralperfusion studies may becomplementary in guiding management


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Hypertensive hypervolemichemodilution (HHH) therapy has becomea mainstay in the management ofcerebral vasospasm

Only one randomized study has beenperformed to assess its efficacy

Two small single-center prospectiverandomized studies strongly suggestthat avoiding hypovolemia is advisable,but there is no evidence for prophylactichyperdynamic therapy


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Calcium-channel blockers, particularlynimodipine, have been approved for usefor treatment of vasospasm

However, the reduction in morbidity andimprovement in functional outcome mayhave been due more to cerebralprotection than actual effect on the

cerebral vasculature Intravenous nicardipine interestingly

showed a 30% reduction in spasm butno improvement in outcome


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Balloon angioplasty has been shown tobe effective in reversing cerebral

vasospasm in large proximal conductingvessels but has not been shown toimprove ultimate outcome

Angioplasty is not effective or safe indistal perforating branches beyond

second-order segments Angioplasty is effective in reducing

angiographic spasm, promoting anincrease in CBF, and reducing deficits


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Cerebral Vasospasm --Recommendations


Oral nimodipine is stronglyrecommended to reduce pooroutcome related to aneurysmalsubarachnoid hemorrhage (LOE A)

The value of other calciumantagonists, whether administeredorally or intravenously, remainsuncertain


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Class II Recommendations Treatment of cerebral vasospasm begins

with early management of the rupturedaneurysm, and in most cases maintainingnormal circulating blood volume andavoiding hypovolemia is probably indicated(LOE B)

One reasonable approach to symptomaticcerebral vasospasm is volume expansion,induction of hypertension and hemodilution[Triple-H therapy] (LOE B)


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Alternatively, cerebral angioplastyand/or selective intraarterialvasodilator therapy may also bereasonable, either following, together

with, or in the place of, Triple-Htherapy depending on the clinicalscenario (LOE B)


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Management of HydrocephalusAssociated With SAH

Acute hydrocephalus (ventricular enlargementwithin 72 hours) occurs in about 20% to 30% of

SAH patients The ventricular enlargement is often, but not

always, accompanied by intraventricular blood Acute hydrocephalus is more frequent in

patients with poor clinical grade, and higher

Fischer Scale scores Two single-center series suggested that routine

fenestration of the lamina terminalis reducesthe incidence of chronic hydrocephalus


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Management of Hydrocephalus --Recommendations

Class I Recommendation

Temporary or permanent CSF diversion isrecommended in symptomatic patients withchronic hydrocephalus following SAH(LOE B)

Class II Recommendation

Ventriculostomy can be beneficial in patientswith ventriculomegaly and diminished levelof consciousness following acute SAH(LOE B)


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Management of SeizuresAssociated With SAH

A large number of seizure-like episodes areassociated with aneurysmal rupture

It is unclear, however, whether all theseepisodes are truly epileptic

Retrospective reviews report that early seizuresoccur in 6% to 18% of SAH patients

Non-convulsive seizures may occur in 19% ofstuporous or comatose SAH patients

The relationship between seizures and outcomeis uncertain


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Management of Seizures --Recommendations

Class II Recommendations The administration of prophylactic

anticonvulsants may be considered in theimmediate posthemorrhagic period (LOE B)

Class III Recommendations The routine long-term use of anticonvulsants

is not recommended (LOE B) but may be considered for patients with risk

factors such as prior seizure, parenchymalhematoma, infarct, or MCA aneurysms(Class II, LOE B)


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Management of Hyponatremiaand Volume Contraction

Hyponatremia occurs in 10-30% of SAHpatients

Hyponatremia has been associated withexcessive natriuresis and volumecontraction

Volume contraction has been linked tosymptomatic vasospasm

Administration of large amounts offluids (hypervolemic therapy)ameliorates volume contraction


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Management of Hyponatremia --Recommendations

Class I Recommendations Administration of large volumes of

hypotonic fluids and intravascular volumecontraction should generally be avoidedfollowing SAH (LOE B)

Class II Recommendations Monitoring volume status in certain patients

with recent SAH using some combination ofcentral venous pressure, pulmonary arterywedge pressure, fluid balance, and bodyweight is reasonable as is treatment ofvolume contraction with isotonic fluids(LOE B)


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Management of Hyponatremia --Recommendations


The use of fludrocortisone acetateand hypertonic saline is reasonablefor correcting hyponatremia (LOE B)

In some instances, it may be

reasonable to reduce fluidadministration to maintain aeuvolemic state (LOE B)


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The current standard of practice calls for

microsurgical clipping or endovascularcoiling of the aneurysm neck wheneverpossible

Treatment morbidity is determined bynumerous factors, including patient,aneurysm, and institutionalfactors


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Favorable outcomesare more likely ininstitutions that treat high volumes of

patients with SAH, in institutions thatoffer endovascular services, and inselected patients whose aneurysms arecoiled rather than clipped

Optimal treatment requires availability of

both experienced cerebrovascularsurgeons and endovascular surgeonsworking in a collaborative effort toevaluate each case of SAH

Documents

Guidelines SAH AHA