Neurocritical Care Society Aneurysmal SAH Guidelines

Author: Brit Long, MD (@long_brit) // Reviewed by: Alex Koyfman, MD (@EMHighAK) and Manpreet Singh, MD (@MPrizzleER) 

Aneurysmal subarachnoid hemorrhage (aSAH) can be deadly.  Several recent studies on the management of aSAH have been published, requiring an update of current guidelines. This post will look at the Neurocritical Care Society guidelines for the management of aSAH.

Recommendations:

1. In patients with aSAH, what is the impact of blood pressure reduction compared with no blood pressure reduction before aneurysm treatment on mortality, mRS score, Glasgow outcome scale (GOS) score, new cerebral infarction, rebleeding, and delayed cerebral ischemia (DCI)?

• There is insufficient evidence to recommend a blood pressure reduction goal for the treatment of hypertension before aneurysm treatment in aSAH. Lack of evidence to recommend a specific blood pressure reduction goal does not necessarily imply that blood pressure reduction is not helpful before aneurysm treatment.

2. In patients with aSAH, what is the impact of administering antifibrinolytics (e.g., TXA) prior to aneurysm treatment compared with no antifibrinolytics on mortality, mRS, GOS, new cerebral infarction, rebleeding, DCI, and thrombotic events?

• We recommend against the administration of antifibrinolytic therapy to prevent rebleeding of ruptured aneurysms in patients with aSAH (strong recommendation, high-moderate quality of evidence).

3. In patients with aSAH, what is the impact of administering calcium channel blockers compared with no calcium channel blockers on mortality, mRS, GOS, new cerebral infarction, and prevention of DCI?

• We recommend the administration of oral nimodipine in patients with aSAH to reduce DCI and cerebral infarction, and to improve functional outcome (strong recommendation, moderate quality of evidence).
• We recommend against the administration of intravenous (IV) nicardipine for the prevention of DCI because of increased risk of adverse effects (strong recommendation, moderate quality of evidence).
• There is insufficient evidence to recommend for or against the administration of calcium channel blocker other than nicardipine by IV or intraventricular routes.

4. In patients with aSAH, what is the impact of endothelin antagonists compared with no endothelin antagonists on mortality, mRS, GOS, new cerebral infarction, and prevention of DCI?

• We recommend against endothelin receptor antagonist administration because of lack of benefit on mortality and functional outcomes and an increased risk of adverse events (strong recommendation, high quality of evidence).

5. In patients with aSAH, what is the impact of statin treatment compared with no statins on mortality, mRS, GOS, new cerebral infarction, and prevention of DCI?

• We recommend against starting statin treatment to reduce DCI or improve functional outcomes in aSAH because of lack of benefit (strong recommendation, high quality of evidence).

6. In patients with aSAH, what is the impact of targeted therapeutic hypermagnesemia compared with no targeted hypermagnesemia on mortality, mRS, GOS, new cerebral infarction, and prevention of DCI?

• We recommend against the use of targeted hypermagnesemia to improve outcomes in aSAH due to lack of benefit (strong recommendation, moderate quality evidence).

7. In patients with aSAH at risk for DCI, what is the impact of high volume (liberal, targeting hypervolemia) fluid administration compared with conventional fluid management, targeting euvolemia, on mortality, mRS, GOS, new cerebral infarction, DCI, and pulmonary edema?

• We suggest against liberal fluid administration because of an increased risk of pulmonary edema (Conditional recommendation, low quality of evidence).
• We suggest using targeted fluid administration to achieve euvolemia, which may include goal-directed hemodynamic therapy, to reduce the risk of pulmonary edema, prevent DCI, and improve functional outcome (conditional recommendation, very low quality of evidence).

8. In patients with aSAH at risk for DCI or diagnosed with DCI, what is the impact of blood pressure and/or cardiac output augmentation compared with no blood pressure or cardiac output augmentation on mortality, mRS, GOS, new cerebral infarction, DCI prevention, pulmonary edema, myocardial infarction, and arrhythmia?

• There are insufficient quality data to recommend for or against blood pressure or cardiac output augmentation for the prevention and treatment of DCI. Due to the associated risks, use of these interventions should be judicious and tailored to the patient’s individual hemodynamic profile.

9. In patients with aSAH, is treatment triggered by change in examination plus advanced neuroimaging (Computed Tomography (CT) Angiography, CT Perfusion, transcranial Doppler) versus examination alone superior in improving mortality, mRS, GOS, and preventing new cerebral infarction?

• There is insufficient evidence to provide a recommendation on the optimal trigger (change in neurological examination plus findings on advanced neuroimaging vs. change in examination alone) for interventional procedures for the treatment of DCI.

10. In patients with aSAH, what is the impact of treatment with mineralocorticoids compared with no treatment with mineralocorticoids on mortality, mRS, GOS, new cerebral infarction, serum sodium levels, and fluid balance?

• There is insufficient evidence to support mineralocorticoid administration to maintain normal serum sodium concentrations and/or even fluid balance or to improve functional outcome.

11. In patients with aSAH, is a more aggressive transfusion strategy (to keep a hemoglobin > 10 g/dL) more effective than a conservative transfusion strategy (to keep a hemoglobin > 7 g/dL) to improve mortality, mRS, GOS, new cerebral infarction, DCI prevention, and transfusion related complications?

• There is insufficient evidence to provide a recommendation for using a transfusion threshold higher than a hemoglobin of > 7 g/dL in patients with aSAH.

12. In patients with aSAH and an indwelling external ventricular drain (EVD), is a strategy based on direct clamping superior to gradual weaning on mortality, mRS, GOS, new cerebral infarction, incidence of ventriculoperitoneal (VP) shunt placement, rate of infection, and EVD complications?

• There is insufficient evidence to provide a recommendation on direct clamping versus gradual weaning strategy for EVD removal for the management of hydrocephalus in patients with aSAH.

Summary:

Reference:

Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care. 2023 May 18. doi: 10.1007/s12028-023-01713-5.

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