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Critical care management of subarachnoid hemorrhage

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Abstract

Successful critical care management of patients with aneurysmal subarachnoid hemorrhage requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal subarachnoid hemorrhage and strategies for disease management in the acute setting. Available tools for monitoring brain function are discussed.

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References and Recommended Reading

  1. King JT Jr: Epidemiology of aneurysmal subarachnoid hemorrhage. Neuroimaging Clin N Am 1997, 7:659–668.

    PubMed  Google Scholar 

  2. Johnston SC, Selvin S, Gress DR: The burden, trends, and demographics of mortality from subarachnoid hemorrhage. Neurology 1998, 50:1413–1418.

    PubMed  CAS  Google Scholar 

  3. Berman MF, Solomon RA, Mayer SA, et al.: Impact of hospital-related factors on outcome after treatment of cerebral aneurysms. Stroke 2003, 34:2200–2207.

    Article  PubMed  Google Scholar 

  4. Winn HR, Richardson AE, Jane JA: The long-term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: a 10-year evaluation of 364 patients. Ann Neurol 1977, 1:358–370.

    Article  PubMed  CAS  Google Scholar 

  5. Sundt TM Jr, Whisnant JP: Subarachnoid hemorrhage from intracranial aneurysms. Surgical management and natural history of disease. N Engl J Med 1978, 299:116–122.

    PubMed  Google Scholar 

  6. Ohkuma H, Tsurutani H, Suzuki S: Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke 2001, 32:1176–1180.

    PubMed  CAS  Google Scholar 

  7. Stornelli SA, French J: Subarachnoid hemorrhage—factors in prognosis and management. J Neurosurg 1964, 21:769–780.

    PubMed  CAS  Google Scholar 

  8. Pare L, Delfino R, Leblanc R: The relationship of ventricular drainage to aneurysmal rebleeding. J Neurosurg 1992, 76:422–427.

    PubMed  CAS  Google Scholar 

  9. Tsementzis SA, Hitchcock ER, Meyer CH: Benefits and risks of antifibrinolytic therapy in the management of ruptured intracranial aneurysms. A double-blind placebocontrolled study. Acta Neurochir 1990, 102:1–10.

    Article  CAS  Google Scholar 

  10. Kassell NF, Torner JC, Adams HP Jr: Antifibrinolytic therapy in the acute period following aneurysmal subarachnoid hemorrhage. Preliminary observations from the Cooperative Aneurysm Study. J Neurosurg 1984, 61:225–230.

    PubMed  CAS  Google Scholar 

  11. Torner JC, Kassell NF, Wallace RB, Adams HP Jr: Preoperative prognostic factors for rebleeding and survival in aneurysm patients receiving antifibrinolytic therapy: report of the Cooperative Aneurysm Study. Neurosurgery 1981, 9:506–513.

    Article  PubMed  CAS  Google Scholar 

  12. Adams HP Jr, Nibbelink DW, Torner JC, Sahs AL: Antifibrinolytic therapy in patients with aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. Arch Neurol 1981, 38:25–29.

    PubMed  Google Scholar 

  13. Hillman J, Fridriksson S, Nilsson O, et al.: Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg 2002, 97:771–778.

    PubMed  CAS  Google Scholar 

  14. Sheehan JP, Polin RS, Sheehan JM, et al.: Factors associated with hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 1999, 45:1120–1127; discussion 1127–1128.

    Article  PubMed  CAS  Google Scholar 

  15. Lin CL, Kwan AL, Howng SL: Acute hydrocephalus and chronic hydrocephalus with the need of postoperative shunting after aneurysmal subarachnoid hemorrhage. Kaohsiung J Med Sci 1999, 15:137–145.

    PubMed  CAS  Google Scholar 

  16. Suarez-Rivera O: Acute hydrocephalus after subarachnoid hemorrhage. Surg Neurol 1998, 49:563–565.

    Article  PubMed  CAS  Google Scholar 

  17. Mehta V, Holness RO, Connolly K, et al.: Acute hydrocephalus following aneurysmal subarachnoid hemorrhage. Can J Neurol Sci 1996, 23:40–45.

    PubMed  CAS  Google Scholar 

  18. Rajshekhar V, Harbaugh RE: Results of routine ventriculostomy with external ventricular drainage for acute hydrocephalus following subarachnoid haemorrhage. Acta Neurochir 1992, 115:8–14.

    Article  CAS  Google Scholar 

  19. Hasan D, Vermeulen M, Wijdicks EF, et al.: Management problems in acute hydrocephalus after subarachnoid hemorrhage. Stroke 1989, 20:747–753.

    PubMed  CAS  Google Scholar 

  20. Milhorat TH: Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. Neurosurgery 1987, 20:15–20.

    Article  PubMed  CAS  Google Scholar 

  21. Rhoney DH, Tipps LB, Murry K R, et al.: Anticonvulsant prophylaxis and timing of seizures after aneurysmal subarachnoid hemorrhage. Neurology 2000, 55:258–265.

    PubMed  CAS  Google Scholar 

  22. Dennis LJ, Claassen J, Hirsch LJ, et al.: Nonconvulsive status epilepticus after subarachnoid hemorrhage. Neurosurgery 2002, 51:1136–1143; discussion 1144.

    Article  PubMed  Google Scholar 

  23. Rose FC, Sarner M: Epilepsy after ruptured intracranial aneurysm. Br Med J 1965, 1(5426):18–21.

    Google Scholar 

  24. Ukkola V, Heikkinen ER: Epilepsy after operative treatment of ruptured cerebral aneurysms. Acta Neurochir 1990, 106:115–118.

    Article  CAS  Google Scholar 

  25. Cabral RJ, King TT, Scott DF: Epilepsy after two different neurosurgical approaches to the treatment of ruptured intracranial aneurysm. J Neurol Neurosurg Psychiatry 1976, 39:1052–1056.

    Article  PubMed  CAS  Google Scholar 

  26. Kvam DA, Loftus CM, Copeland B, Quest DO: Seizures during the immediate postoperative period. Neurosurgery 1983, 12:14–17.

    Article  PubMed  CAS  Google Scholar 

  27. Kotila M, Waltimo O: Epilepsy after stroke. Epilepsia 1992, 33:495–498.

    Article  PubMed  CAS  Google Scholar 

  28. Ohman J: Hypertension as a risk factor for epilepsy after aneurysmal subarachnoid hemorrhage and surgery. Neurosurgery 1990, 27:578–581.

    Article  PubMed  CAS  Google Scholar 

  29. Naidech AM, Kreiter KT, Janjua N, et al.: Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage. Stroke 2005, 36:583–587.

    Article  PubMed  CAS  Google Scholar 

  30. Haley EC Jr, Kassell NF, Torner JC: The International Cooperative Study on the Timing of Aneurysm Surgery. The North American experience. Stroke 1992, 23:205–214.

    PubMed  Google Scholar 

  31. Haley EC Jr, Kassell NF, Apperson-Hansen C, et al.: A randomized, double-blind, vehicle-controlled trial of tirilazad mesylate in patients with aneurysmal subarachnoid hemorrhage: a cooperative study in North America. J Neurosurg 1997, 86:467–474.

    PubMed  CAS  Google Scholar 

  32. Kassell NF, Boarini DJ, Adams HP Jr, et al.: Overall management of ruptured aneurysm: comparison of early and late operation. Neurosurgery 1981, 9:120–128.

    PubMed  CAS  Google Scholar 

  33. Fisher CM, Roberson GH, Ojemann RG: Cerebral vasospasm with ruptured saccular aneurysm—the clinical manifestations. Neurosurgery 1977, 1:245–248.

    Article  PubMed  CAS  Google Scholar 

  34. Heros RC, Zervas NT, Varsos V: Cerebral vasospasm after subarachnoid hemorrhage: an update. Ann Neurol 1983, 14:599–608.

    Article  PubMed  CAS  Google Scholar 

  35. Fisher CM, Kistler JP, Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 1980, 6:1–9.

    Article  PubMed  CAS  Google Scholar 

  36. Stein SC, Levine JM, Nagpal S, LeRoux PD: Vasospasm as the sole cause of cerebral ischemia: how strong is the evidence? Neurosurg Focus 2006, 21:E2.

    Article  PubMed  Google Scholar 

  37. van den Bergh WM, Algra A, van Kooten F, et al.: Magnesium sulfate in aneurysmal subarachnoid hemorrhage: a randomized controlled trial. Stroke 2005, 36:1011–1015.

    Article  PubMed  CAS  Google Scholar 

  38. Allen GS, Ahn HS, Preziosi TJ, et al.: Cerebral arterial spasm—a controlled trial of nimodipine in patients with subarachnoid hemorrhage. N Engl J Med 1983, 308:619–624.

    PubMed  CAS  Google Scholar 

  39. Mayberg MR, Batjer HH, Dacey R, et al.: Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994, 25:2315–2328.

    PubMed  CAS  Google Scholar 

  40. Haley EC Jr, Kassell NF, Torner JC, et al.: A randomized trial of two doses of nicardipine in aneurysmal subarachnoid hemorrhage. A report of the Cooperative Aneurysm Study. J Neurosurg 1994, 80:788–796.

    Article  PubMed  Google Scholar 

  41. Zabramski JM, Spetzler RF, Lee KS, et al.: Phase I trial of tissue plasminogen activator for the prevention of vasospasm in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 1991, 75:189–196.

    PubMed  CAS  Google Scholar 

  42. Tseng MY, Czosnyka M, Richards H, et al.: Effects of acute treatment with pravastatin on cerebral vasospasm, autoregulation, and delayed ischemic deficits after aneurysmal subarachnoid hemorrhage: a phase II randomized placebo-controlled trial. Stroke 2005, 36:1627–1632.

    Article  PubMed  CAS  Google Scholar 

  43. Tseng MY, Hutchinson PJ, Czosnyka M, et al.: Effects of acute pravastatin treatment on intensity of rescue therapy, length of inpatient stay, and 6-month outcome in patients after aneurysmal subarachnoid hemorrhage. Stroke 2007, 38:1545–1550.

    Article  PubMed  CAS  Google Scholar 

  44. Claassen J, Hirsch LJ, Kreiter KT, et al.: Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage. Clin Neurophysiol 2004, 115:2699–2710.

    Article  PubMed  Google Scholar 

  45. Cloft HJ, Joseph GJ, Dion JE: Risk of cerebral angiography in patients with subarachnoid hemorrhage, cerebral aneurysm, and arteriovenous malformation: a meta-analysis. Stroke 1999, 30:317–320.

    PubMed  CAS  Google Scholar 

  46. Tamatani S, Sasaki O, Takeuchi S, et al.: Detection of delayed cerebral vasospasm, after rupture of intracranial aneurysms, by magnetic resonance angiography. Neurosurgery 1997, 40:748–753; discussion 753–754.

    Article  PubMed  CAS  Google Scholar 

  47. Otawara Y, Ogasawara K, Ogawa A, et al.: Evaluation of vasospasm after subarachnoid hemorrhage by use of multislice computed tomographic angiography. Neurosurgery 2002, 51:939–942; discussion 942–943.

    Article  PubMed  Google Scholar 

  48. Anderson GB, Ashforth R, Steinke DE, Findlay JM: CT angiography for the detection of cerebral vasospasm in patients with acute subarachnoid hemorrhage. AJNR Am J Neuroradiol 2000, 21:1011–1015.

    PubMed  CAS  Google Scholar 

  49. Wintermark M, Ko NU, Smith WS, et al.: Vasospasm after subarachnoid hemorrhage: utility of perfusion CT and CT angiography on diagnosis and management. AJNR Am J Neuroradiol 2006, 27:26–34.

    PubMed  CAS  Google Scholar 

  50. Sloan MA, Haley EC Jr, Kassell NF, et al.: Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology 1989, 39:1514–1518.

    PubMed  CAS  Google Scholar 

  51. Assessment: transcranial Doppler. Report of the American Academy of Neurology, Therapeutics and Technology Assessment Subcommittee. Neurology 1990, 40:680–681.

  52. Manno EM, Gress DR, Schwamm LH, et al.: Effects of induced hypertension on transcranial Doppler ultrasound velocities in patients after subarachnoid hemorrhage. Stroke 1998, 29:422–428.

    PubMed  CAS  Google Scholar 

  53. Lindegaard KF, Nornes H, Bakke SJ, et al.: Cerebral vasospasm diagnosis by means of angiography and blood velocity measurements. Acta Neurochir 1989, 100:12–24.

    Article  CAS  Google Scholar 

  54. Ekelund A, Saveland H, Romner B, Brandt L: Is transcranial Doppler sonography useful in detecting late cerebral ischaemia after aneurysmal subarachnoid haemorrhage? Br J Neurosurg 1996, 10:19–25.

    Article  PubMed  CAS  Google Scholar 

  55. Mizuno M, Nakajima S, Sampei T, et al.: Serial transcranial Doppler flow velocity and cerebral blood flow measurements for evaluation of cerebral vasospasm after subarachnoid hemorrhage. Neurol Med Chir (Tokyo) 1994, 34:164–171.

    Article  CAS  Google Scholar 

  56. Vespa PM, Nuwer MR, Juhasz C, et al.: Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring. Electroencephalogr Clin Neurophysiol 1997, 103:607–615.

    Article  PubMed  CAS  Google Scholar 

  57. Polin RS, Coenen VA, Hansen CA, et al.: Efficacy of transluminal angioplasty for the management of symptomatic cerebral vasospasm following aneurysmal subarachnoid hemorrhage. J Neurosurg 2000, 92:284–290.

    PubMed  CAS  Google Scholar 

  58. Higashida RT, Halbach VV, Cahan LD, et al.: Transluminal angioplasty for treatment of intracranial arterial vasospasm. J Neurosurg 1989, 71(5 Pt 1):648–653.

    Google Scholar 

  59. Higashida RT, Halback VV, Dormandy B, et al.: Endovascular treatment of intracranial aneurysms with a new silicone microballoon device: technical considerations and indications for therapy. Radiology 1990, 174(3 Pt 1):687–691.

    PubMed  CAS  Google Scholar 

  60. Higashida RT, Halbach VV, Dowd CF, et al.: Intravascular balloon dilatation therapy for intracranial arterial vasospasm: patient selection, technique, and clinical results. Neurosurg Rev 1992, 15:89–95.

    Article  PubMed  CAS  Google Scholar 

  61. Kassell NF, Helm G, Simmons N, et al.: Treatment of cerebral vasospasm with intra-arterial papaverine. J Neurosurg 1992, 77:848–852.

    PubMed  CAS  Google Scholar 

  62. Feng L, Fitzsimmons BF, Young WL, et al.: Intraarterially administered verapamil as adjunct therapy for cerebral vasospasm: safety and 2-year experience. AJNR Am J Neuroradiol 2002, 23:1284–1290.

    PubMed  Google Scholar 

  63. Badjatia N, Topcuoglu MA, Pryor JC, et al.: Preliminary experience with intra-arterial nicardipine as a treatment for cerebral vasospasm. AJNR Am J Neuroradiol 2004, 25:819–826.

    PubMed  Google Scholar 

  64. Biondi A, Ricciardi GK, Puybasset L, et al.: Intra-arterial nimodipine for the treatment of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage: preliminary results. AJNR Am J Neuroradiol 2004, 25:1067–1076.

    PubMed  Google Scholar 

  65. Fraticelli AT, Cholley BP, Losser MR, et al.: Milrinone for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 2008, 39:893–898.

    Article  PubMed  CAS  Google Scholar 

  66. McAuliffe W, Townsend M, Eskridge JM, et al.: Intracranial pressure changes induced during papaverine infusion for treatment of vasospasm. J Neurosurg 1995, 83:430–434.

    PubMed  CAS  Google Scholar 

  67. Hasan D, Wijdicks EF, Vermeulen M: Hyponatremia is associated with cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. Ann Neurol 1990, 27:106–108.

    Article  PubMed  CAS  Google Scholar 

  68. Qureshi AI, Suri MF, Sung GY, et al.: Prognostic significance of hypernatremia and hyponatremia among patients with aneurysmal subarachnoid hemorrhage. Neurosurgery 2002, 50:749–755; discussion 755–756.

    Article  PubMed  Google Scholar 

  69. Sayama T, Inamura T, Matsushima T, et al.: High incidence of hyponatremia in patients with ruptured anterior communicating artery aneurysms. Neurol Res 2000, 22:151–155.

    PubMed  CAS  Google Scholar 

  70. Singh S, Bohn D, Carlotti AP, et al.: Cerebral salt wasting: truths, fallacies, theories, and challenges. Crit Care Med 2002, 30:2575–2579.

    Article  PubMed  Google Scholar 

  71. Wijdicks EF, Vermeulen M, ten Haaf JA, et al.: Volume depletion and natriuresis in patients with a ruptured intracranial aneurysm. Ann Neurol 1985, 18:211–216.

    Article  PubMed  CAS  Google Scholar 

  72. Chung HM, Kluge R, Schrier RW, Anderson RJ: Clinical assessment of extracellular fluid volume in hyponatremia. Am J Med 1987, 83:905–908.

    Article  PubMed  CAS  Google Scholar 

  73. Suarez JI, Qureshi AI, Parekh PD, et al.: Administration of hypertonic (3%) sodium chloride/acetate in hyponatremic patients with symptomatic vasospasm following subarachnoid hemorrhage. J Neurosurg Anesthesiol 1999, 11:178–184.

    Article  PubMed  CAS  Google Scholar 

  74. Hasan D, Lindsay KW, Wijdicks EF, et al.: Effect of fludrocortisone acetate in patients with subarachnoid hemorrhage. Stroke 1989, 20:1156–1161.

    PubMed  CAS  Google Scholar 

  75. Mori T, Katayama Y, Kawamata T, Hirayama T: Improved efficiency of hypervolemic therapy with inhibition of natriuresis by fludrocortisone in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 1999, 91:947–952.

    PubMed  CAS  Google Scholar 

  76. Ghali JK, Koren, MJ, Taylor JR, et al.: Efficacy and safety of oral conivaptan: a V1A/V2 vasopressin receptor antagonist, assessed in a randomized, placebo-controlled trial in patients with euvolemic or hypervolemic hyponatremia. J Clin Endocrinol Metab 2006, 91:2145–2152.

    Article  PubMed  CAS  Google Scholar 

  77. Wijdicks EF, Vermeulen M, Hijdra A, et al.: Hyponatremia and cerebral infarction in patients with ruptured intracranial aneurysms: ss fluid restriction harmful? Ann Neurol 1985, 17:137–140.

    Article  PubMed  CAS  Google Scholar 

  78. Kopelnik A, Zaroff JG: Neurocardiogenic injury in neurovascular disorders. Crit Care Clin 2006, 22:733–752; abstract ix–x.

    Article  PubMed  Google Scholar 

  79. Andreoli A, di Pasquale G, Pinelli G, et al.: Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase. Stroke 1987, 18:558–564.

    PubMed  CAS  Google Scholar 

  80. Di Pasquale G, Pinelli G, Andreoli A, et al.: Holter detection of cardiac arrhythmias in intracranial subarachnoid hemorrhage. Am J Cardiol 1987, 59:596–600.

    Article  PubMed  Google Scholar 

  81. Solenski NJ, Haley EC Jr, Kassell NF, et al.: Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med 1995, 23:1007–1017.

    Article  PubMed  CAS  Google Scholar 

  82. Kothavale A, Banki NM, Kopelnik A, et al.: Predictors of left ventricular regional wall motion abnormalities after subarachnoid hemorrhage. Neurocrit Care 2006, 4:199–205.

    Article  PubMed  Google Scholar 

  83. Banki N, Kopelnik A, Tung P, et al.: Prospective analysis of prevalence, distribution, and rate of recovery of left ventricular systolic dysfunction in patients with subarachnoid hemorrhage. J Neurosurg 2006, 105:15–20.

    Article  PubMed  Google Scholar 

  84. Tung P, Kopelnik A, Banki N, et al.: Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke 2004, 35:548–551.

    Article  PubMed  Google Scholar 

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  1. Neurocritical Care Program, Hospital of the University of Pennsylvania, 3 West Gates Building, 3400 Spruce Street, Philadelphia, PA, 19103, USA

    Joshua M. Levine

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Levine, J.M. Critical care management of subarachnoid hemorrhage. Curr Neurol Neurosci Rep 8, 518–525 (2008). https://doi.org/10.1007/s11910-008-0082-2

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