Aneurysmal subarachnoid hemorrhage treatment [Neurosurgery Wiki]

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====== Aneurysmal subarachnoid hemorrhage treatment ======

Early treatment varies between treatment on day 0, within 24 h, 48 h, or 72 h after the SAH ictus
((Ultra-early microsurgical treatment within 24 h of SAH improves prognosis of poor-grade aneurysm combined with intracerebral hematoma Oncol Lett, 11 (5) (2016), pp. 3173-3178))
((J.R. Linzey, C. Williamson, V. Rajajee, K. Sheehan, B.G. Thompson, A.S. Pandey
Twenty-four–hour emergency intervention versus early intervention in aneurysmal subarachnoid hemorrhage
J Neurosurg, 128 (5) (2018), pp. 1297-1303))
((Y.-C. Luo, C.-S. Shen, J.-L. Mao, C.-Y. Liang, Q. Zhang, Z.-J. He
Ultra-early versus delayed coil treatment for ruptured poor-grade aneurysm
Neuroradiology, 57 (2) (2015), pp. 205-210))
((J. Park, H. Woo, D.-H. Kang, et al.
Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes J Neurosurg, 122 (2) (2015), pp. 383-391))
((T.J. Phillips, R.J. Dowling, B. Yan, J.D. Laidlaw, P.J. Mitchell
Does treatment of ruptured intracranial aneurysms within 24 hours improve clinical outcome?
Stroke, 42 (7) (2011), pp. 1936-1945))
((A. Sonig, H. Shallwani, S.K. Natarajan, et al.
Better outcomes and reduced hospitalization cost are associated with ultra-early treatment of ruptured intracranial aneurysms: a US nationwide data sample studyNeurosurgery, 82 (4) (2018), pp. 497-505))

Also, ultra-early treatment has been defined as treatment within 48 h
((Y. Egashira, S. Yoshimura, Y. Enomoto, M. Ishiguro, T. Asano, T. Iwama
Ultra-early endovascular embolization of ruptured cerebral aneurysm and the increased risk of hematoma growth unrelated to aneurysmal rebleeding
J Neurosurg, 118 (5) (2013), pp. 1003-1008
View in ScopusGoogle Scholar
11
J.-W. Pan, R.-Y. Zhan, L. Wen, Y. Tong, S. Wan, Y.-Y. Zhou
Ultra-early surgery for poor-grade intracranial aneurysmal subarachnoid hemorrhage: a preliminary study
Yonsei Med J, 50 (4) (2009), p. 521)).
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[[Thiopental]] and [[decompressive craniectomy]] are important integrated last-tier treatment options, but careful patient selection is needed due to the risk of saving many patients a state of suffering
((Björk S, Hånell A, Ronne-Engström E, Stenwall A, Velle F, Lewén A, Enblad P, Svedung Wettervik T. Thiopental and decompressive craniectomy as last-tier ICP-treatments in aneurysmal subarachnoid hemorrhage: is functional recovery within reach? Neurosurg Rev. 2023 Sep 7;46(1):231. doi: 10.1007/s10143-023-02138-6. PMID: 37676578.)).

===== Guidelines =====

[[Aneurysmal Subarachnoid Hemorrhage Guidelines]]

===== Surgery =====

see [[Intracranial aneurysm treatment]].

see [[Intracranial aneurysm surgery]].




===== Sedation =====
Sedation in the acute phase of the disease and prolonged sedation to reduce cerebral metabolism over days are frequently used as therapeutic approaches to manage secondary brain damage and have become an integral part of neurocritical care in the treatment of SAH
((Hawryluk GWJ, Aguilera S, Buki A, Bulger E, Citerio G, Cooper DJ, Arrastia RD, Diringer M, Figaji A, Gao G, Geocadin R, Ghajar J, Harris O, Hoffer A, Hutchinson P, Joseph M, Kitagawa R, Manley G, Mayer S, Menon DK, Meyfroidt G, Michael DB, Oddo M, Okonkwo D, Patel M, Robertson C, Rosenfeld JV, Rubiano AM, Sahuquillo J, Servadei F, Shutter L, Stein D, Stocchetti N, Taccone FS, Timmons S, Tsai E, Ullman JS, Vespa P, Videtta W, Wright DW, Zammit C, Chesnut RM. A management algorithm for patients with intracranial pressure monitoring: the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC). Intensive Care Med. 2019 Dec;45(12):1783-1794. doi: 10.1007/s00134-019-05805-9. Epub 2019 Oct 28. PMID: 31659383; PMCID: PMC6863785.))

===== Aneurysmal subarachnoid hemorrhage medical treatment =====

see [[Aneurysmal subarachnoid hemorrhage medical treatment]].

===== Intracranial pressure monitoring =====
There are no conclusive [[recommendations]] in [[intracranial pressure monitoring for aneurysmal subarachnoid hemorrhage]].
New protocols establishing the indications for ICP monitoring in aSAH are needed. Given the high heterogeneity of the studies included, they cannot provide clinical recommendations regarding this issue
((Florez WA, García-Ballestas E, Deora H, Agrawal A, Martinez-Perez R, Galwankar
S, Keni R, Menon GR, Joaquim A, Moscote-Salazar LR. [[Intracranial hypertension]] in 
patients with [[aneurysmal subarachnoid hemorrhage]]: a [[systematic review]] and
[[meta-analysis]]. Neurosurg Rev. 2020 Feb 1. doi: 10.1007/s10143-020-01248-9. [Epub 
ahead of print] Review. PubMed PMID: 32008128.)).

Baggiani et al. report 69% of ICP monitored patients (inter-center variability from 6.4 to 82.1%), and out of them, 54.9% had external ventricular catheters; in poor grades (WFNS IV–V), the percentage is 73%. Intracranial hypertension is recorded in 54.7% of cases; in patients with DVE, the incidence of ICP > 20 mmHg is lower (46 vs. 75%). 

**ICP monitoring appears to be associated with lower rates of unfavorable outcomes**
((Baggiani M, Graziano F, Rebora P, Robba C, Guglielmi A, Galimberti S, Giussani C, Suarez JI, Helbok R, Citerio G. Intracranial Pressure Monitoring Practice, Treatment, and Effect on Outcome in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care. 2022 Dec 5. doi: 10.1007/s12028-022-01651-8. Epub ahead of print. PMID: 36471182.)).

===== External ventricular drain for hydrocephalus after aneurysmal subarachnoid hemorrhage =====

[[External ventricular drain for hydrocephalus after aneurysmal subarachnoid hemorrhage]].

===== Nicotine Replacement Therapy =====
[[Nicotine Replacement Therapy]].

===== Rehabilitation =====


Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit [[impairment]]s in [[memory]] and [[executive function]] and report high rates of [[depression]] and [[anxiety]] that ultimately affect daily living, [[return to work]], and [[quality of life]]. Given the rise in SAH [[survivor]]s, [[rehabilitation]] post-SAH to optimize patient outcomes becomes crucial
((Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. J Vasc Dis. 2023 Jun;2(2):197-211. doi: 10.3390/jvd2020014. Epub 2023 Apr 1. PMID: 37082756; PMCID: PMC10111247.))
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