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Aneurysmal Subarachnoid Hemorrhage: Review of the Pathophysiology and Management Strategies

  • Stroke (H. Diener, Section Editor)
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Abstract

Purpose of Review

Aneurysmal subarachnoid hemorrhage remains a devastating disease process despite medical advances made over the past 3 decades. Much of the focus was on prevention and treatment of vasospasm to reduce delayed cerebral ischemia and improve outcome. In recent years, there has been a shift of focus onto early brain injury as the precursor to delayed cerebral ischemia. This review will focus on the most recent data surrounding the pathophysiology of aneurysmal subarachnoid hemorrhage and current management strategies.

Recent Findings

There is a paucity of successful trials in the management of subarachnoid hemorrhage likely related to the targeting of vasospasm. Pathophysiological changes occurring at the time of aneurysmal rupture lead to early brain injury including cerebral edema, inflammation, and spreading depolarization. These events result in microvascular collapse, vasospasm, and ultimately delayed cerebral ischemia.

Summary

Management of aneurysmal subarachnoid hemorrhage has remained the same over the past few decades. No recent trials have resulted in new treatments. However, our understanding of the pathophysiology is rapidly expanding and will advise future therapeutic targets.

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Abbreviations

AMPA:

Α-Amino-3-Hydroxy-S-Methyl-4-Isoxazoleproprionic acid

aSAH:

Aneurysmal subarachnoid hemorrhage

CBF:

Cerebral blood flow

CPP:

Cerebral perfusion pressure

CSF:

Cerebrospinal fluid

CT:

Computed tomography

DCI:

Delayed cerebral ischemia

EBI:

Early brain injury

IL-6:

Interleukin 6

ISAT:

International subarachnoid aneurysm trial

ICP:

Intracranial pressure

MMP-9:

Matrix metalloproteinase 9

NMDA:

N-methyl-D-aspartate

SDs:

Spreading depolarizations

TCD:

Transcranial Doppler

WFNS:

World Federation of Neurologic Surgeons

aSAH:

Aneurysmal subarachnoid hemorrhage

DCI:

Delayed cerebral ischemia

EBI:

Early brain injury

ICP:

Intracranial pressure

CPP:

Cerebral perfusion pressure

CT:

Computed tomography

WFNS:

World Federation of Neurologic Surgeons

ISAT:

International subarachnoid aneurysm trial

CSF:

Cerebrospinal fluid

CBF:

Cerebral blood flow

IL-6:

Interleukin 6

MMP-9:

Matrix metalloproteinase 9

SDs:

Spreading depolarizations

NMDA:

N-methyl-D-aspartate

AMPA:

Α-amino-3-hydroxy-S-methyl-4-isoxazoleproprionic acid

TCD:

Transcranial Doppler

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Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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    Marcey L. Osgood

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Osgood, M.L. Aneurysmal Subarachnoid Hemorrhage: Review of the Pathophysiology and Management Strategies. Curr Neurol Neurosci Rep 21, 50 (2021). https://doi.org/10.1007/s11910-021-01136-9

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