Although this article is quite technical, it is worth the read.
From Medscape Education Clinical Briefs
New Guidelines for Aneurysmal Subarachnoid Hemorrhage Issued CME
News Author: Megan Brooks CME Author: Laurie Barclay, MD
Clinical Context
The American Heart Association (AHA) Stroke Council and other professional societies collaborated on a new guideline for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH), based on a formal literature search of MEDLINE from November 1, 2006, through May 1, 2010. Topics highlighted in the guideline included incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, and anesthetic management during repair. Also covered were management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.
The objective of this guideline by Connolly and colleagues was to provide recommendations for goal-directed treatment of patients with aSAH. Although aSAH is a serious medical condition, early, aggressive, and expert care can dramatically affect the outcome.
Study Synopsis and Perspective
Patients diagnosed with aSAH in hospitals that manage fewer than 10 cases per year should be considered for immediate transfer to a hospital that treats at least 35 cases a year, according to updated guidelines on management of aSAH from the AHA and the American Stroke Association (AHA/ASA).
Research has shown that 30-day death rates are significantly higher in low-volume facilities (39% in hospitals treating fewer than 10 patients compared with 27% in hospitals treating more than 35 patients each year), the AHA/ASA notes in a statement.
The new guideline, published online May 3 in Stroke, updates guidelines issued in 2009 and reported by Medscape Medical News at that time.
Rapidly Developing Field
"These guidelines are released every 2 to 3 years; nothing prompted them, they were a planned update," E. Sander Connolly Jr, MD, chair of the statement writing group, noted in an email to Medscape Medical News.
"The biggest take home message is that the field is changing fast. There are lots of new guidelines; staying on top of these is critical to patient care," added Dr. Connolly, vice-chairman of neurological surgery at Columbia University in New York City and the co-director of the neurosciences intensive care unit at New York-Presbyterian Hospital.
The writing group notes that the new update, "which is based on a mere 42 months of publications," contains 21 new recommendations (outlined in Table 4 in the paper), 5 of which are class I recommendations. There are also 9 changes in prior recommendations. In total, there are now 22 class I recommendations (outlined in Table 3).
Although it's not completely clear why outcomes are better at high-volume centers, "patients admitted to high-volume facilities have increased access to experienced cerebrovascular surgeons and endovascular specialists, as well as multidisciplinary neuro-intensive care services, such as EEG [electroencephalography] monitoring to rule out non-convulsive status seizures," Dr. Connolly noted in a statement.
Larry B. Goldstein, MD, professor of medicine (neurology) and director of the Duke Stroke Center in Durham, North Carolina, told Medscape Medical News that transfer to high-volume centers when possible "makes sense [as] there is an association between center volume and outcomes, and has been seen for some other conditions."
He noted, however, that "decisions regarding transfer of unstable patients with recent SAH is a bit more complicated, and would likely need to be determined regionally and depending on individual patient issues."
In these patients, "a multidisciplinary approach afforded in larger centers might also contribute to better outcomes. Studies have shown better outcomes for patients with hemorrhagic strokes cared for in Primary Stroke Centers, even though the focus of these centers is on non-hemorrhagic strokes. This may reflect institutional commitment to stroke care in general, and better care organization."
aSAH is responsible for about 5% of all strokes and affects more than 30,000 Americans each year, most of them aged 40 to 60 years. Prevention recommendations still center on controlling hypertension and avoiding cigarette smoking and excessive alcohol use.
The 5 new class I (level B) recommendations are as follows:
- After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment.
- Digital subtraction angiography (DSA) with 3D rotational angiography is indicated for detection of aneurysm in patients with aSAH (except when the aneurysm was previously diagnosed by noninvasive angiography) and for planning treatment (to determine whether an aneurysm is amenable to coiling or to expedite microsurgery).
- Between the time of aSAH symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk for stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure.
- In the absence of a "compelling" contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and re-treatment, by repeat coiling or clipping, should be strongly considered if there is a clinically significant (eg, growing) remnant.
- Heparin-induced thrombocytopenia and deep venous thrombosis are both infrequent but not uncommon occurrences after aSAH. Early identification and targeted treatment are recommended, but further research is needed to identify the ideal screening paradigms.
The 9 revised recommendations are as follows:
- For patients with an unfavorable delay in obliteration of aneurysm, a significant risk for rebleeding, and no compelling medical contraindications, short-term (< 72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk for early aneurysm rebleeding. (Class IIa, Level B)
- Experienced cardiovascular surgeons and endovascular specialists should determine a multidisciplinary treatment approach based on characteristics of the patient and the aneurysm. (Class I, Level C)
- For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered. (Class I, Level B)
- Low-volume hospitals should consider early transfer of patients with aSAH to high-volume centers. (Class I, Level B)
- Maintaining euvolemia and normal circulating blood volume is recommended to prevent disseminated intravascular coagulation. (Revised, Class I, Level B)
- Induction of hypertension is recommended for patients with disseminated intravascular coagulation unless blood pressure is elevated at baseline or cardiac status precludes it. (Class I, Level B)
- Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is "reasonable" in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy. (Class IIa, Level B)
- aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario). (Class I, Level B)
- aSAH-associated chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion. (Class I, Level B)
In this "fast-developing field," frequent revision of these guidelines is "clearly needed [and] the data presented here only begin to scratch the surface of the burgeoning knowledge," the writing group concludes. "Those faced with managing these patients will thus do well to use these guidelines as merely a starting point for doing everything possible to improve the outcomes of patients with aSAH."
Dr. Connolly has disclosed no relevant financial relationships. A complete list of disclosures for members of the guideline writing group is published with the original article. Dr. Goldstein has disclosed no relevant financial relationships.
Stroke. Published online May 3, 2012. Abstract
Study Highlights
- New class I, level B recommendations include the following:
- Immediate cerebrovascular imaging should be performed after any aneurysm repair to detect remnants or recurrence of the aneurysm that may require treatment.
- Except for aneurysms previously diagnosed by noninvasive angiography, DSA with 3D rotational angiography is indicated to detect aneurysms in patients with aSAH. DSA with 3D rotational angiography is also indicated for planning treatment, to determine whether an aneurysm is amenable to coiling or to expedite microsurgery.
- To balance the risk for stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure, blood pressure should be controlled with a titratable agent from the time of onset of aSAH symptoms to obliteration of the aneurysm.
- Unless there is a compelling contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging, with individualized timing and modality. For these patients found to have a clinically significant, growing remnant, retreatment by subsequent coiling or microsurgical clipping should be strongly considered.
- After aSAH, heparin-induced thrombocytopenia and deep venous thrombosis occur infrequently but not uncommonly. Early identification and targeted treatment are recommended, but further research is needed to identify the optimal screening strategy.
- New class IIa, level B recommendations include the following:
- After discharge, it is reasonable to refer patients with aSAH for a comprehensive assessment, including cognitive, behavioral, and psychosocial evaluation.
- Transcranial Doppler is a reasonable test to monitor for the development of arterial vasospasm.
- Perfusion imaging with computed tomography or magnetic resonance imaging can help detect regions of potential brain ischemia.
- In the acute phase of aSAH, it is reasonable to aggressively control fever to a goal of normothermia using standard or advanced temperature-modulating systems.
- New class IIa, level C recommendations include the following:
- Although the intensity of blood pressure control needed to lower the risk of rebleeding has not been determined, it is reasonable to aim for a systolic blood pressure of less than 160 mm Hg.
- It is reasonable to monitor annually for complication rates of surgical and interventional procedures.
- It is reasonable to establish a hospital credentialing process to ensure that proper training standards have been met by individual clinicians treating brain aneurysms.
- New class IIb, level B recommendations include the following:
- When evaluating the risk for aneurysm rupture, it might be reasonable to consider morphologic and hemodynamic characteristics of the aneurysm as well as aneurysm size and location and patient age and health status.
- High vegetable intake may lower the risk for aSAH.
- In patients with aSAH who are at risk for cerebral ischemia, the use of packed red blood cell transfusion to treat anemia might be reasonable, although the optimal hemoglobin goal is still undetermined.
Clinical Implications
- This updated guideline for management of aSAH was based on only 42 months of publications but resulted in 21 new recommendations. Frequent revision of these guidelines is clearly needed, and the guideline authors intend to do so every 3 years. Immediate cerebrovascular imaging is indicated after any aneurysm repair, and DSA with 3D rotational angiography is indicated to detect aneurysms in patients with aSAH.
- This updated guideline for management of aSAH is intended as the starting point to do everything possible to improve the outcomes of patients with aSAH, which can be markedly affected by early, aggressive, expert care. Transcranial Doppler is useful to monitor for the development of arterial vasospasm, and perfusion imaging with computed tomography or magnetic resonance can help detect regions of potential brain ischemia.
American Stroke Association Abstract: http://stroke.ahajournals.org/content/early/2012/05/03/STR.0b013e3182587839
