====== Aneurysmal subarachnoid hemorrhage (aSAH) ====== {{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/18Ux9_JbYfAWLJHUWBDUZmljIyNHXJvVmfXDg4eaAU0Lagp1AA/?limit=15&utm_campaign=pubmed-2&fc=20240104072742}} ---- ---- [[Aneurysm]]al [[subarachnoid hemorrhage]] (aSAH) is a [[severe]] subtype of [[stroke]] occurring at a relatively young [[age]] with a significant socioeconomic [[impact]]. Treatment of aSAH includes early aneurysm [[exclusion]], [[intensive care]] management, and prevention of [[complication]]s. Once the [[aneurysm]] rupture occurs, blood spreading within the [[subarachnoid space]] triggers several molecular pathways causing early brain injury and [[delayed cerebral ischemia]]. Pathophysiologic mechanisms underlying brain injury after aSAH are not entirely characterized, reflecting the difficulties in identifying effective therapeutic targets for patients with aSAH. Although the improvements of the last decades in perioperative management, early diagnosis, aneurysm exclusion techniques, and medical treatments have increased survival, vasospasm, and delayed cerebral infarction are associated with high mortality and morbidity. Clinical practice can rely on a few specific therapeutic agents, such as nimodipine, a calcium-channel blocker proven to reduce severe neurologic deficits in these patients. Therefore, new pharmacologic approaches are needed to improve the outcome of this life-threatening condition, as well as a tailored rehabilitation plan to maintain the quality of life in aSAH survivors. Several clinical trials are investigating the efficacy and safety of emerging drugs, such as magnesium, [[clazosentan]], [[cilostazol]], [[interleukin 1]] receptor antagonists, [[deferoxamine]], [[erythropoietin]], and [[nicardipine]], and continuous [[lumbar drainage]] in the setting of aSAH ((Torregrossa F, Grasso G. Therapeutic Approaches for Cerebrovascular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: An Update and Future Perspectives. World Neurosurg. 2022 Mar;159:276-287. doi: 10.1016/j.wneu.2021.11.096. PMID: 35255629.)). ===== Aneurysmal subarachnoid hemorrhage algorithm ===== see [[Aneurysmal subarachnoid hemorrhage algorithm]]. ===== Classification ===== [[Aneurysmal subarachnoid hemorrhage classification]]. ====Miscellaneous facts about SAH==== [[Subarachnoid hemorrhage]] (SAH) following aneurysm bleeding accounts for 6% to 8% of all [[cerebrovascular accident]]s. The [[anterior communicating artery aneurysm]] cause [[aneurysmal subarachnoid hemorrhage]], about 21.0%~25.5% of percent of [[spontaneous subarachnoid hemorrhage]] ((Suzuki M, Fujisawa H, Ishihara H, Yoneda H, Kato S, Ogawa A. Side selection of pterional approach for anterior communicating artery aneurysms--surgical anatomy and strategy. Acta Neurochir (Wien) 2008;150:31–39. 39.)) ((Kimura T, Morita A, Shirouzu I, Sora S. Preoperative evaluation of unruptured cerebral aneurysms by fast imaging employing steady-state acquisition image. Neurosurgery. 2011;69:412–419. discussion 419-420.)) ((Kwon SC, Park JB, Shin SH, Sim HB, Lyo IU, Kim Y. The Efficacy of Simultaneous Bilateral Internal Carotid Angiography during Coil Embolization for Anterior Communicating Artery Aneurysms. J Korean Neurosurg Soc. 2011;49:257–261)). The peak age for aneurysmal [[subarachnoid hemorrhage]] aSAH is 55-60 years, about 20% of cases occur between ages 15-45 yrs. 30% of aSAHs occurs during sleep 50% of patients with aneurysms have warning symptoms, usually 6-20 days before SAH headache is lateralized in 30%, most to the side of the aneurysm. soft evidence suggests that rupture incidence is higher in spring and autumn patients > 70 yrs age have a higher proportion with a severe neurologic grade. ===== Epidemiology ===== see [[Aneurysmal subarachnoid hemorrhage epidemiology]]. ===== Risk factors ===== The causes of aneurysmal SAH are often related to a rupture of a [[cerebral aneurysm]]. see [[Aneurysmal subarachnoid hemorrhage risk factors]]. ==== Meteorological influence ==== The inherent variability in the incidence and presentation of ruptured cerebral aneurysms has been investigated in association with seasonality, circadian rhythm, lunar cycle, and climate factors. Rosenbaum et al., aimed to identify an association between solar activity (solar flux and sunspots) and the incidence of aneurysmal SAH, all of which appear to behave in periodic fashions over long time periods. The Nationwide Inpatient Sample (NIS) provided longitudinal, retrospective data on patients hospitalized with SAH in the United States, from 1988 to 2010, who underwent aneurysmal clipping or coiling. Solar activity and SAH incidence data were modeled with the cosinor methodology and a 10-year periodic cycle length. The NIS database contained 32,281 matching hospitalizations from 1988 to 2010. The acrophase (time point in the cycle of highest amplitude) for solar flux and for sunspots were coincident. The acrophase for aneurysmal SAH incidence was out of phase with solar activity determined by non-overlapping 95% confidence intervals (CIs). Aneurysmal SAH incidence peaks appear to be delayed behind solar activity peaks by 64 months (95% CI; 56-73 months) when using a modeled 10-year periodic cycle. Solar activity (solar flux and sunspots) appears to be associated with the incidence of aneurysmal SAH. As solar activity reaches a relative maximum, the incidence of aneurysmal SAH reaches a relative minimum. These observations may help identify future trends in aneurysmal SAH on a population basis. ((Rosenbaum BP, Weil RJ. Aneurysmal Subarachnoid Hemorrhage: Relationship to Solar Activity in the United States, 1988-2010. Astrobiology. 2014 Jun 30. [Epub ahead of print] PubMed PMID: 24979701.)). ---- By using high-quality meteorological data analyzed with a sophisticated and robust statistical method no clearly identifiable meteorological influence for the SAH events considered can be found. Further studies on the influence of the investigated parameters on SAH incidence seem redundant ((Neidert MC, Sprenger M, Wernli H, Burkhardt JK, Krayenbühl N, Bozinov O, Regli L, Woernle CM. Meteorological influences on the incidence of aneurysmal subarachnoid hemorrhage - a single center study of 511 patients. PLoS One. 2013 Dec 2;8(12):e81621. doi: 10.1371/journal.pone.0081621. eCollection 2013. PubMed PMID: 24312565; PubMed Central PMCID: PMC3847045.)). ===== Pathogenesis ===== [[Aneurysmal subarachnoid hemorrhage pathogenesis]]. ===== Pathophysiology ===== [[Aneurysmal subarachnoid hemorrhage pathophysiology]] ===== Clinical features ===== see [[Subarachnoid hemorrhage clinical features]] ===== Diagnosis ===== see [[Subarachnoid hemorrhage diagnosis]]. ===== Scales ===== [[Subarachnoid hemorrhage scales]]. ===== Biomarkers ===== [[Aneurysmal subarachnoid hemorrhage biomarkers]] ===== Prognosis ===== see [[Aneurysmal subarachnoid hemorrhage prognosis]] ===== Intracerebral hematoma and aneurysmal subarachnoid hemorrhage ===== see [[Intracerebral hematoma and aneurysmal subarachnoid hemorrhage]]. ===== Complications ===== see [[Aneurysmal subarachnoid hemorrhage complications]]. ===== Prevention ===== [[Aneurysmal subarachnoid hemorrhage prevention]]. ===== Management ===== The management of an aneurysmal subarachnoid hemorrhage (aSAH) involves a combination of emergency medical care, neuroimaging, and neurosurgical intervention. Here are the key aspects of the management: Emergency Medical Care: Stabilization: Provide immediate medical attention to stabilize the patient, including airway management, ventilation support, and hemodynamic stabilization. Pain Control: Manage pain and discomfort using appropriate analgesics. ==== Blood Pressure Management after aneurysmal subarachnoid hemorrhage ==== [[Blood Pressure Management after aneurysmal subarachnoid hemorrhage]]. Neuroimaging: CT Scan: Conduct a non-contrast CT scan of the head to confirm the diagnosis of subarachnoid hemorrhage and identify the location and size of the aneurysm. Cerebral Angiography: Perform a cerebral angiogram (digital subtraction angiography - DSA) to visualize the blood vessels and precisely locate the aneurysm. This is crucial for surgical planning. Neurosurgical Intervention: Aneurysm Clipping: One common method is surgical clipping, where a small metal clip is placed around the neck of the aneurysm to prevent rupture. Endovascular Coiling: Another option is endovascular coiling, a less invasive procedure where platinum coils are inserted into the aneurysm to promote blood clotting and prevent further bleeding. Monitoring: Neurological Monitoring: Continuously monitor neurological status, including Glasgow Coma Scale (GCS), to assess the severity of brain injury and guide management decisions. Intracranial Pressure Monitoring: In severe cases, intracranial pressure may be monitored to manage elevated pressure and prevent secondary brain injury. Complications Management: Vasospasm Prevention: Administer nimodipine to prevent or minimize cerebral vasospasm, a common complication associated with aSAH. Hydrocephalus Management: Address hydrocephalus, which can occur due to the blockage of cerebrospinal fluid flow. This may involve placing a ventriculostomy drain. Rehabilitation: Physical and Cognitive Rehabilitation: Once the acute phase is managed, rehabilitation efforts are initiated to help patients recover physical and cognitive function. Long-Term Follow-up: Monitoring and Surveillance: Regular follow-up with neuroimaging and clinical assessments to monitor for recurrence or other complications. The management of aSAH requires a multidisciplinary approach involving neurosurgeons, neurologists, intensivists, and rehabilitation specialists. The specific treatment plan will depend on the individual patient's condition, the location and size of the aneurysm, and other associated factors. Early intervention is crucial to improve outcomes and reduce the risk of complications. ===== Treatment ===== see [[Aneurysmal subarachnoid hemorrhage treatment]]. ====Anticonvulsant in aneurysmal subarachnoid hemorrhage==== [[Anticonvulsant in aneurysmal subarachnoid hemorrhage]] ====Croatia==== Evidence based information on the epidemiology, risk factors and prognosis, as well as recommendations on diagnostic work up, monitoring and management are provided, with regard to treatment possibilities in Croatia in the article of Solter et al. ((Solter VV, Breitenfeld T, Roje-Bedeković M, Supanc V, Lovrencić-Huzjan A, Serić V, Antoncić I, Basić S, Beros V, Bielen I, Soldo SB, Kadojić D, Lusić I, Maldini B, Marović A, Paladino J, Poljaković Z, Radanović B, Rados M, Rotim K, Vukić M, Zadravec D, Kes VB. General recommendations for the management of aneurysmal subarachnoid hemorrhage. Acta Clin Croat. 2014 Mar;53(1):139-52. PubMed PMID: 24974676. )) ((Solter VV, Roje-Bedeković M, Breitenfeld T, Supanc V, Lovrencić-Huzjan A, Serić V, Antoncić I, Basić S, Beros V, Bielen I, Soldo SB, Kadojić D, Lusić I, Maldini B, Marović A, Paladino J, Poljaković Z, Radanović B, Rados M, Rotim K, Vukić M, Zadravec D, Kes VB. Recommendations for the management of medical complications in patients following aneurysmal subarachnoid hemorrhage. Acta Clin Croat. 2014 Mar;53(1):113-38. PubMed PMID: 24974675.)). ====Spain==== There is high variability in the election of treatment modality among centres in Spain. Endovascular treatment allows more patients to have their aneurysm treated. Guideline adherence is moderate ((Lagares A, Munarriz PM, Ibáñez J, Arikán F, Sarabia R, Morera J, Gabarrós A, Horcajadas Á; el Grupo de Patología Vascular de la SENEC. [Variability in the management of aneurysmal subarachnoid haemorrhage in Spain: Analysis of the prospective multicenter database from the Working Group on Neurovascular Diseases of the Spanish Society of Neurosurgery.]. Neurocirugia (Astur). 2015 Jan 15. pii: S1130-1473(14)00153-5. doi: 10.1016/j.neucir.2014.11.005. [Epub ahead of print] Spanish. PubMed PMID: 25599868. )). ===== Guidelines ===== see [[Aneurysmal Subarachnoid Hemorrhage Guidelines]]. ===== Case series ===== [[Aneurysmal subarachnoid hemorrhage case series]].