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Critical care of patients with subarachnoid hemorrhage
1Neurovascular Section, University of California, Los Angeles School of Medicine.
Insights
Critical care for subarachnoid hemorrhage (SAH) focuses on preventing complications like vasospasm and rebleeding. Prompt interventions, including surgical or endovascular procedures and intensive monitoring, are crucial for improving patient outcomes.
Area of Science:
- Neurology
- Neurosurgery
- Intensive Care Medicine
Background:
- Subarachnoid hemorrhage (SAH) presents significant risks due to potential complications.
- Key sequelae adversely affecting patient outcomes include vasospasm, rebleeding, hydrocephalus, and seizures.
Purpose of the Study:
- To outline critical care strategies for managing patients with aneurysmal SAH.
- To emphasize the importance of preventing and treating common SAH complications.
Main Methods:
- Early surgical or endovascular intervention to reduce rebleeding.
- CT scan assessment to identify vasospasm risk.
- Intensive care unit (ICU) monitoring with serial neurological exams and transcranial Doppler (TCD).
- Prophylactic use of calcium channel blockers and volume expansion.
- Aggressive treatment for symptomatic vasospasm (hypertensive, hemodilutional, hypervolemic therapy).
- External or internal cerebrospinal fluid diversion for hydrocephalus.
- Prophylactic anticonvulsants to prevent seizures.
Main Results:
- Early intervention significantly lessens rebleeding frequency.
- CT findings correlate with vasospasm risk, necessitating close monitoring.
- Multimodal therapies effectively manage vasospasm, hydrocephalus, and seizures.
- Aggressive ICU care and advanced techniques improve outcomes.
Conclusions:
- Comprehensive critical care, focusing on preventing and treating SAH sequelae, is essential.
- Early detection and management of complications like vasospasm and hydrocephalus improve prognosis.
- Advancements in endovascular techniques, surgical precision, and ICU management enhance outcomes for aneurysmal SAH patients.
Abstract:
Critical care of a patient with SAH should focus on the prevention or immediate treatment of the common sequelae of this disorder that adversely affect outcome: vasospasm, rebleeding, hydrocephalus, seizures, and associated medical problems. The frequency of rebleeding can be lessened by early surgical or endovascular intervention. The extent of SAH on the CT scan can identify those patients at highest risk for vasospasm, and all patients must be closely monitored in the ICU with serial neurological examinations and transcranial Doppler studies. Regional CBF examinations and continuous EEG may also be helpful. Calcium channel blocking agents and volume expansion are recommended prophylatically for all patients. Aggressive hypertensive, hemodilutional, hypervolemic therapy (including pulmonary artery catheter placement) is indicated for symptomatic vasospasm. Transluminal angioplasty can be used in selected patients with vasospasm refractory to these measures. Hydrocephalus can occur in the days, weeks, or months following SAH and is treated effectively with external (acute hydrocephalus) or internal cerebrospinal fluid diversion. Seizures, which can cause intracranial and systemic hypertension, high cerebral metabolic demand, and delayed neurological injury, should be prevented with prophylactic use of anticonvulsants. In addition, early recognition and treatment of associated medical complications are critical. Novel endovascular approaches, meticulous surgical technique, and aggressive ICU care will undoubtedly lead to improved outcome following aneurysmal SAH.