Purpose—The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods—A formal literature s...

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

The International Cooperative Study on the Timing of Aneurysm Surgery evaluated the results of surgical and medical management in 3521 patients between December, 1980, and July, 1983. At admission, 75% of patients were in good neurological condition and surgery was performed in 83%. At the 6-month evaluation, 26% of the patients had died and 58% exhibited a complete recovery. Vasospasm and rebleeding were the leading causes of morbidity and mortality in addition to the initial bleed. Predictors for mortality included the patient's decreased level of consciousness and increased age, thickness of the subarachnoid hemorrhage clot on computerized tomography, elevated blood pressure, preexisting medical illnesses, and basilar aneurysms. The results presented here document the status of management in the 1980's.

The International Cooperative Study on the Timing of Aneurysm Surgery. Part 1 Overall management results

Subarachnoid hemorrhage (SAH) is a common and frequently devastating condition, accounting for ≈5% of all strokes and affecting as many as 30 000 Americans each year.1,2 The American Heart Association (AHA) previously published “Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage.”3 Since then, considerable advances have been made in endovascular techniques, diagnostic methods, and surgical and perioperative management paradigms. Nevertheless, outcome for patients with SAH remains poor, with population-based mortality rates as high as 45% and significant morbidity among survivors.4–9 Several multicenter, prospective, randomized trials and prospective cohort analyses have influenced treatment protocols for SAH. However, rapid evolution of newer treatment modalities, as well as other practical and ethical considerations, has meant that rigorous clinical scientific assessment of the treatment protocols has not been feasible in several important areas.

To address these issues, the Stroke Council of the AHA formed a writing group to reevaluate the recommendations for management of aneurysmal SAH. A consensus committee reviewed existing data in this field and prepared the recommendations in 1994.3 In an effort to update those recommendations, a systematic literature review was conducted based on a search of MEDLINE to identify all relevant randomized clinical trials published between June 30, 1994, and November 1, 2006 (search terms: subarachnoid hemorrhage , cerebral aneurysm , trial ; Table 1). Each identified article was reviewed by at least 2 members of the writing group. Selected articles had to meet one of the following criteria to be included: randomized trial or nonrandomized concurrent cohort study. Case series and nonrandomized historical cohort studies were reviewed if no studies with a higher level of evidence were available for a particular topic covered in the initial guidelines. These were chosen on the basis of sample size and the relevance of the particular studies to subjects that …

https://www.ahajournals.org/doi/pdf/10.1161/01.STR.25.11.2315

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

The incidence of subarachnoid haemorrhage (SAH) is stable, at around six cases per 100 000 patient years. Any apparent decrease is attributable to a higher rate of CT scanning, by which other haemorrhagic conditions are excluded. Most patients are <60 years of age. Risk factors are the same as for stroke in general; genetic factors operate in only a minority. Case fatality is approximately 50% overall (including pre-hospital deaths) and one-third of survivors remain dependent. Sudden, explosive headache is a cardinal but non-specific feature in the diagnosis of SAH: in general practice, the cause is innocuous in nine out of 10 patients in whom this is the only symptom. CT scanning is mandatory in all, to be followed by (delayed) lumbar puncture if CT is negative. The cause of SAH is a ruptured aneurysm in 85% of cases, non-aneurysmal perimesencephalic haemorrhage (with excellent prognosis) in 10%, and a variety of rare conditions in 5%. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. A poor clinical condition on admission may be caused by a remediable complication of the initial bleed or a recurrent haemorrhage in the form of intracranial haematoma, acute hydrocephalus or global brain ischaemia. Occlusion of the aneurysm effectively prevents rebleeding, but there is a dearth of controlled trials assessing the relative benefits of early operation (within 3 days) versus late operation (day 10-12), or that of endovascular treatment versus any operation. Antifibrinolytic drugs reduce the risk of rebleeding, but do not improve overall outcome. Measures of proven value in decreasing the risk of delayed cerebral ischaemia are a liberal supply of fluids, avoidance of antihypertensive drugs and administration of nimodipine. Once ischaemia has occurred, treatment regimens such as a combination of induced hypertension and hypervolaemia, or transluminal angioplasty, are plausible, but of unproven benefit.

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Subarachnoid haemorrhage: diagnosis, causes and management

A prospective, observational clinical trial was conducted by the International Cooperative Study on the Timing of Aneurysm Surgery to determine the best time in relation to the hemorrhage for surgical treatment of ruptured intracranial aneurysms. Sixty-eight centers contributed 3521 patients in a 2 1/2-year period beginning in December, 1980. Analysis by a prespecified "planned" surgery interval demonstrated that there was no difference in early (0 to 3 days after the bleed) or late surgery (11 to 14 days). Outcome was worse if surgery was performed in the 7 to 10-day post-bleed interval. Surgical results were better for patients operated on after 10 days. Patients alert on admission fared best; however, alert patients had a mortality rate of 10% to 12% when undergoing surgery prior to Day 11 compared with 3% to 5% when surgery was performed after Day 10. Patients drowsy on admission had a 21% to 25% mortality rate when operated on up to Day 11 and 7% to 10% with surgery thereafter. Overall, early surgery was neither more hazardous nor beneficial than delayed surgery. The postoperative risk following early surgery is equivalent to the risk of rebleeding and vasospasm in patients waiting for delayed surgery.

The International Cooperative Study on the Timing of Aneurysm Surgery. Part 2: Surgical results.

The proper treatment of multiple and incidental aneurysms remains controversial because the long-term result of different modes of management is unclear. This report evaluates the long-term outcome (follow-up period averaged 7.7 years) in 182 patients with multiple aneurysms who suffered a subarachnoid hemorrhage (SAH) to document the incidence of late bleeding. Of the 182 patients, 132 were treated by bed rest and 50 by surgery (craniotomy) directed at only the ruptured aneurysm. Seventy of the patients with bed rest were alive after 6 months. Twenty-one of these conservatively treated patients (30%) suffered a late hemorrhage, which is equal to the previously reported average yearly rebleed rate (3%) with a single aneurysm of the anterior circulation. There was no evidence that a previously intact aneurysm had ruptured in SAH patients treated with bed rest, indicating that late hemorrhage was due to rerupture from the original aneurysm. Patients who were hypertensive and who had a large aneurysm had an increased risk of late rehemorrhage. A linear discriminant analysis was developed to predict late rebleeding. The fate of intact aneurysms was evaluated by following patients with multiple aneurysms treated by craniotomy directed only at the ruptured aneurysm. Of the 50 craniotomy patients, 38 were alive after 6 months. In this group, the minimal risk of rupture of an intact aneurysm is approximately 1% per year. The presence of hypertension increased the risk of late hemorrhage. In conclusion, patients with multiple untreated aneurysms managed by bed rest have a late rehemorrhage rate equal to that observed in patients with a single cerebral aneurysm; the data indicate that rupture of intact aneurysms is not insignificant.

The long-term outcome in patients with multiple aneurysms. Incidence of late hemorrhage and implications for treatment of incidental aneurysms

Three hundred sixty-four patients who suffered a subarachnoid hemorrhage from an aneurysm in either the posterior communicating or anterior communicating artery and who were not surgically treated have been followed for up to 21 years in order to determine the frequency of subsequent hemorrhage. For patients surviving six months: (1) rebleeding occurs on the average of 3.5% per year during the first decade; (2) the mortality associated with a late rebleed is 67%; (3) high blood pressure and female sex predispose to late rebleeding in posterior communicating artery aneurysms; (4) young patients take longer to rebleed than older patients but do so at the same rate; and (5) increase in aneurysm size as judged by routine arteriography six months after the initial hemorrhage did not correlate with rebleeding, although an increase in size had occurred in all patients who were studied angiographically at the time of their late rebleed.

The long‐term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: A 10‐year evaluation of 364 patients

1 In the first 6 months, at least 50% of the patients with untreated anterior and posterior communicating artery aneurysms will rebleed 2 Thereafter, the rate of rebleeding is not less than 3%/year with two-thirds of these late hemorrhages resulting in a mortality 3 Carotid ligation for posterior communicating aneurysms protects against a high rate of rebleeding for 6 months, but thereafter the rate is not different from the course of untreated aneurysms 4 On the basis of these first three points and a review of the literature, a theory is proposed that incidental and symptomatic unruptured aneurysms, multiple unruptured aneurysms, and subarachnoid hemorrhage where no lesion is demonstrable, have a natural history similar to that of the untreated aneurysm that survives at 6 months Namely, we would predict a yearly rebleed rate of not less than 3%/year

The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management.

Late morbidity and mortality in cerebral aneurysms: a ten-year follow-up of 364 conservatively treated patients with a single cerebral aneurysm.

Three hundred and sixty-four patients who suffered a subarachnoid haemorrhage from an aneurysm at either the anterior (ACA) or posterior (PCA) communicating artery location and who were not surgically treated have been followed for up to 21 years in order to study the late morbidity and mortality. For the 213 patients surviving to six months or longer : (1) little improvement in morbidity was noted during the many years of subsequent follow-up; (2) in general, ACA patients fared better than PCA patients; (3) the neurological state on original admission was strongly correlated with the degree of morbidity; (4) other factors measured at the time of original haemorrhage which adversely affected morbidity included the level of blood pressure or the presence of clot or spasm ; (5) rebleeding occurs on the average of 3.5% per year during the first decade; (6) the mortality associated with a late rebleed is 67%; (7) if deaths from late haemorrhage are excluded, cardiovascular causes account for the majority of subsequent deaths ; and (8) the risk of dying from all causes is increased when compared to a population matched by age and sex.

H R Winn

Papers

The long-term outcome in patients with multiple aneurysms. Incidence of late hemorrhage and implications for treatment of incidental aneurysms

The long‐term prognosis in untreated cerebral aneurysms: I. The incidence of late hemorrhage in cerebral aneurysm: A 10‐year evaluation of 364 patients

The natural history of intracranial aneurysms: rebleeding rates during the acute and long term period and implication for surgical management.

Late morbidity and mortality in cerebral aneurysms: a ten-year follow-up of 364 conservatively treated patients with a single cerebral aneurysm.

The late morbidity and mortality in ruptured single anterior circulation aneurysms treated by non-surgical therapy.