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Aneurysmal subarachnoid hemorrhage : recent updates

Yasser B. Abulhasan, MBChB, FRCPC Assistant 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.

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Aneurysmal subarachnoid hemorrhage : recent updates

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  1. Yasser B. Abulhasan, MBChB, FRCPC Assistant 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 Aneurysmal subarachnoid hemorrhage : recent updates

  2. Disclosure • No conflict of interest relevant to this lecture

  3. Outline • Overview and Epidemiology • Early Patient Care • Recommendations

  4. 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)

  5. 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

  6. 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.

  7. Natural History • 10% die immediately • 25% die within 24 hours • 40% die in the first 30 days • Mortality and severe morbidity 60%

  8. Early Patient Care • Prevention of rebleeding • Seizure prophylaxis • Treatment of acute hydrocephalus • ICP control • Analgesia • Cardiopulmonary Complications • Intravascular Volume Status • Glucose management

  9. Early Patient Care • Prevention of rebleeding • Seizure prophylaxis • Treatment of acute hydrocephalus • ICP control • Analgesia • Cardiopulmonary Complications • Intravascular Volume Status • Glucose management

  10. 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.

  11. 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.

  12. Preventing Rebleeding • Early securing the ruptured aneurysm (< 4 days) • Coil embolization • Microsurgical exclusion • Delays in aneurysmal repair

  13. 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?

  14. 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

  15. 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.

  16. Antifibrinolytics • 2002 – 2010, 1 randomized trial, 2 case studies • Early, short course of antifibrinolytics reduced rebleeding • Risk reduction 2.5 – 11% Starke, R.M. and E.S. Connolly, Jr., Neurocritical care, 2011. 15(2): p. 241-6.

  17. 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)

  18. 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

  19. 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.

  20. 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.

  21. 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)

  22. 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

  23. Thank you for your attentive attendance

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