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Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

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A Response to Letter To The Editor to this article was published on 03 August 2023

A Letters to the editor to this article was published on 03 August 2023

An Invited Commentary to this article was published on 18 May 2023

This article has been updated

Abstract

Background

The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology.

Methods

The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case–control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the “Risk of Bias In Nonrandomized Studies – of Interventions” tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations.

Results

The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation.

Conclusions

These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.

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Change history

  • 18 July 2023

    The original article has been updated to correct the copyright line.

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Authors and Affiliations

  1. Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA

    Miriam M. Treggiari

  2. Department of Neurology, Mayo Clinic, Rochester, MI, USA

    Alejandro A. Rabinstein

  3. Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA

    Katharina M. Busl

  4. Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA

    Steven Deem

  5. Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA

    Michael Diringer

  6. Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA

    Elizabeth Fox

  7. Neurocritical Care, University of Washington, Seattle, WA, USA

    Sarah Livesay

  8. Department of Neurology, Yale University, New Haven, CT, USA

    Kevin N. Sheth

  9. Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Jose I. Suarez

  10. Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA

    Stavropoula Tjoumakaris

  11. Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA

    Meghan M. Caylor

  12. School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy

    Giuseppe Citerio

  13. NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy

    Giuseppe Citerio

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Conceptualization: All authors. Data abstraction: All authors. Funding acquisition: None. Methodology: SL. Resources: Neurocritical Care Society. Software: Distiller. Supervision: MMT and AAR (co-chairs). Validation: All authors. Writing (original draft): MMT and AAR. Writing (review and editing): All authors. All authors approve of the final manuscript.

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Treggiari, M.M., Rabinstein, A.A., Busl, K.M. et al. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 39, 1–28 (2023). https://doi.org/10.1007/s12028-023-01713-5

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