Initial Management of Acute Subarachnoid Hemorrhage from Ruptured Cerebral Aneurysm

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Subarachnoid  haemorrhage  (SAH)  refers  to  presence  of  blood  in  the  fluid-filled  subarachnoid  spaces around the brain and spinal cord. The most common presentation is sudden onset of severe  novel  headache.  SAH  from  ruptured  cerebral  aneurysms  is  associated  with  high  mortality  and  morbidity  hence  clinician’s  high  index  of  suspicion  and  proper  initial  management  is  crucial  for  patient’s survival and improved functional outcome.  

Clinical presentation 

  • Severe headache (worst headache of life) 
  • Altered mental status may progress to coma
  • Focal neurological deficits
  • Seizures

Laboratory Investigations 

  • CBC, PT/PTT/INR 
  • Serial ABGs, electrolytes  
  • serum and urine osmolality   
  • Imaging investigationsCT angiography 
  • Four vessel catheter angiography/digital subtraction angiography (DSA) 
    • Perform 4-vessel catheter angiography to determine source of bleeding  
    • The timing of study takes into consideration the patient’s condition (unstable or  premorbid  patients  are  not  candidates),  the  feasibility  of  early  treatment,  the  likelihood  of  endovascular  therapy  (based  on  patient’s  age  and  predicted  aneurysm location as well as availability of required resources and expertise) 
  • CXR—monitor for pulmonary edema if in hyperdynamic therapy 

Principles of initial management of aneurysmal SAH are focused on:   

  • Initial hemodynamic stabilization and life support of the patient 
  • Prevention of rebleeding through timely coiling or surgical clipping 
  • Prevention, identification, and early management of hydrocephalus  
  • Prevention and management of delayed ischemic neurologic deficit (DIND) from vasospasm

Admitting orders 

  • Admit all aneurysmal SAH patients to ICU regardless of their initial GCS score 
  • Document initial Hunt & Hess, WFNS clinical scores, and Fisher CT scan score 
  • Bedrest with head of bed elevation at 30°.  
  • Initiate SAH precautions (low level of external stimulation, restricted visitation, dim light, no loud noises) 
  • Check neurological status every 1 hour. 
  • Bed  pan,  indwelling  Foley  catheter  if  patient  is  lethargic,  incontinent  with  strict  Inputs  & outputs measurements. 
  • Keep Nil per Oral (if in preparation for surgery or endovascular intervention)
  • Maintain  SBP  120–160mmHg  in  unsecured  (unclipped/uncoiled)  aneurysm  to  minimise rebleeding risk, consider 

D: labetalol (IV) 1mg/min until target SBP is attained. 

  • IV fluids: 0.9% NS + 20 mEq KCl/L at 2 ml/kg/hour maintenance fluid 

Prophylactic anticonvulsants:  

S:  levetiracetam  (PO/IV)  500mg  12  hourly  while  aneurysm  is  unsecured,  continue  for 1week post clipping/endovascular intervention  

OR 

C:  phenytoin  (IV)  15mg/kg  loading  dose  at  50mg/min  rate  then  100mg  8hourly  for  2-4 weeks 

Sedation (not over sedation):  

D: propofol (IV) (for intubated patients) at 25-75mcg/kg/minute 

Give  

B: dexamethasone (IV) 4mg 6 hourly for 3-5days to reduce neck pain  

AND 

S: fentanyl (IV) 25–100mcg (0.5–2 ml) every 1–2hours when required in ICU. 

Stool softener: Initiate  

C: lactulose (PO) 30mls 8hourly until aneurysm is secured. 

Anti-emetics:  

D: ondansetron (IV) 4mg over 2–5minutes, may repeat 8hourly for 1–2days.  

Prevention of vasospasm: Initiate  

S: nimodipine (PO/NGT) 60mg 4hourly, continue for 21days  

Stress ulcer prophylaxis: 

C: pantoprazole (IV) 40mg 24hourly for 1-2weeks  

Oxygenation goals (for intubated ventilated patients) 

  • pO2 > 100mm Hg, O2 saturation 100% in patients at risk for vasospasm, aim for 92% saturation in all others.  
  • To  achieve  above  goals,  increase  FiO2  and  mean  airway  pressure  (PEEP)  in ventilated patients 
  • in non-intubated patient: Give O2 2L per nasal cannula PRN (based on ABG)  

 

  • Strive for normocarbia, avoid prophylactic hyperventilation  
  • Avoid arterial hyperoxia (paO2 > 300mm Hg)- to avoid risk of vasoconstriction 
  • maintain normothermia and encourage other cooling measures to reduce and prevent fever. 

D: paracetamol (IV) 1g 8hourly for 3-5days then when required 

  • Hemoglobin and hematocrit: Transfuse whole or PRBC when Hct drops < 40%) 
  • Monitor serum glucose and maintain normoglycemia  

Surgical managementRefer  to  a  centre  that  can  handle  neurovascular  cases  for  prompt  neurosurgical  evaluation  and  subsequent  surgical  clipping  or  endovascular  intervention  (coiling  or  embolization)  to  secure  the  ruptured cerebral aneurysm.