Guidelines for the Management of Aneurysmal SAH

1. Guidelines for the Management of Aneurysmal SAH Danny Aghion, MD PGY-4 CV conference 6/4/12

2. Guidelines from the AHA/ASA • Purpose: current and comprehensive recommendations for the dx and tx of aSAH • Methods: MEDLINE lit search (11/1/06-5/1/10). Evidence tables and data derived rec’s were graded. Intended to be fully updated every 3 years • Results: Evidence based guidelines are presented for aSAH. Risk factors, prevention, natural hx, outcome, dx, prevention of re-bleeding, surgical and endov. repair systems of care, anesthesia care, mgmt of vasospasm and delayed cerebral ischemia, mgmt of HCP, seizures and medical complications • Conclusions: aSAH outcome can be dramatically impacted by early, aggressive, expert care. These guidelines offer a framework for goal-directed tx of the aSAH patient.

3. Introduction • aSAH is a significant cause of M+M throughout the world • At least ¼ of pt’s with aSAH will die • ½ of survivors are left with some persistent neuro deficit • That said, fatality rates are dropping • Early aneurysm repair and aggressive mgmt of complications (HCP, DCI) is leading to improved functional outcomes

4. Incidence and prevalence • Overall spontaneous SAH: 2-16 /100,000 • USA: 2-14/10,000 • Japan and Finland: 22.5/10,000 • Lower in Central America • 12-15% die pre-hospital • Incidence increases with age (>50), women (1.24), Blacks, Hispanics

5. Etiology of SAH • Pathological condition – bleeding into the subarachnoid space • Spontaneous SAH – aneurysm, vascular malformations, idiopathic, secondary extension of ICH or IVH (hypertensive ICH), venous thrombosis, pituitary apoplexy, coagulopathies • 20% of spontaneous SAH are idiopathic, about 2/3 of these are benign perimesencephalic SAH

6. Re-bleeding • Most common in first hours after SAH and declines thereafter • 4% in first 24 hours, 1% per day for 14 days =15% cumulative in first 2 weeks • 50% re-bleed within first year, > 80% of those die • After 6 months, rebleedrate: 2-3% per year • Death: initial bleed 25-43%, within 1 year 2/3 die

7. Risk Factors and Prevention • Age (increased with advancing age) • Gender (females > males) • Smoking (3-5 fold) • Recent heavy alcohol intake • Hypertension • Cocaine • Arterial occlusions, stenosis • Presence of an unruptured aneurysm (large, pcomm, or VB) • History of prior aSAH • History of familial aneurysms (at least 1, and especially >2) • Other genetic syndromes…

8. Diseases associated with aneurysms • Fibromusculardysplasia: up to 20% of patients may have aneurysms • Autosomal dominant polycystic kidney disease: 0-40% have aneurysms • Others: Ehlers Danlos type 4Marfans syndromecoarctationof aorta sickle cell anemia

9. Avoidance of adverse effects • Avoid Hypovolemia/Hypotension • Avoid Hyponatremia • Avoid Antifibrinolytics • Avoid Hypomagnesemia • Avoid Hypocarbia/Hypoxia • Avoid Hyperthermia • Avoid Hyper or hypoglycemia • Avoid ↑ ICP • Avoid Anti-hypertensives

10. Table 3. Applying Classification of Recommendations and Level of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial inf... Bederson J B et al. Stroke 2009;40:994-1025

11. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

12. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

13. Risk Factors and prevention of aSAH: Recommendations • Tx of HTN w/ anti-HTN meds to prevent ischemic stroke, ICH, other end-organ injury (Class I; Level of Evidence A) • HTN should be treated, and such tx may reduce risk of aSAH (Class I; Level of Evidence B) • Tobacco use and Alcohol misuse should be avoided to reduce the risk of aSAH (Class I; Level of Evidence B) • Size, location, age, health status, morphology and hemodynamic chof aneurysm when discussing risk of rupture (NEW; Class IIb,; LoE B) • Diet rich in vegetables may lower aSAH risk (NEW; Class IIb, LOE B) • Offer non-invasive screening (familial or at least 1 imm) (Class IIb; LOE B) • After any repair, immediate CV imaging (NEW; Class I; Level of Evidence B)

14. What we do at RIH • Tx HTN w/ anti-HTN meds • HTN should be treated, and may reduce risk of aSAH • Size, location, age, health status, morphology of aneurysm when discussing risk of rupture

15. Proposed changes: risk factors and prevention • Continue to treat HTN • Tobacco/Alcohol counseling • Include discussion on hemodynamic characteristics of aneurysm when discussing risk of rupture • Promote diet rich in vegetables on d/c paper work • Discuss screening and offer MRA’s for familial SAH or at least 1 immediate family member with aneurysm/SAH • Immediate CV imaging after any aneurysm repair

16. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

17. Natural history and Outcome of aSAH: Recommendations • Initial clinical severity should be rapidly determined, Hunt/Hess or World Federation of NS, b/c it is the most useful indicator of outcome after aSAH (Class I; Level of Evidence B) • The risk of early re-bleeding is high and is associated with poor outcomes, therefore, URGENT eval and treatment is recommended (Class I; Level of Evidence B) • After d/c, it is reasonable to refer pt to cognitive, behavioral, and psychosocial assessments (NEW; Class IIa; LOE B)

18. What we do at RIH • Use Hunt/Hess scale (just be sure to document in chart for comp stroke ctr status) • URGENT evaluation in ED and prompt treatment in VIR, 6INC, OR, etc.

19. Proposed changes: Natural history and Outcome of aSAH • Continue to use Hunt/Hess • Get down to the ED, VIR, ICU fast, early • Utilize CM for referral or outpatient cognitive, behavioral, and psychosocial assessments

20. Add 1 for severe systemic disease or severe vasospasm

21. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

22. Clinical Manifestations and Diagnosis: Recommendations • aSAH is an emergency, often misdiagnosed, have high level of suspicion (Class I; Level of Evidence B) • CT followed by LP if negative (Class I; Level of Evidence B) • Consider CTA (?aid in repair) but Angio is gold standard (except in BPM SAH). (Class IIb; Level of Evidence C) • MRI may be helpful in Dx in neg CT, but if neg still need LP (NEW; Class IIb; Level of Evidence C) • Angio with 3D is indicated for aneurysm detection in patients with SAH and for planning treatment (NEW; Class I; LOE B)

23. What we do at RIH • aSAH is an emergency, often misdiagnosed by ED, have high level of suspicion • CT followed by LP if negative • We tend to consider CTA (if allowed by ED rads attending) • MRI (FLAIR, DWI, Gradiant Echo) may be helpful in Dxif neg CT, but we/ED still get LP • Angio is our test of choice in patients with SAH

24. Proposed changes: Clinical Manifestations and Diagnosis • aSAH is an emergency, get down to ED fast, have high level of suspicion in acute onset worst HA • CT followed by LP if negative-we already do this • CTA in aneurysmal vs trauma cases (chicken or egg) • No use for MRI if pt getting admitted or if Angio will be performed anyway • Always get 3D rotational images for surgical purposes and for educational purposes

25. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

26. Medical Measures to prevent rebleeding: Recommendations • b/w time of symptoms and securing aneurysm, BP should be controlled with titrateable agent to balance risk of stroke, HTN related re-bleeding, and maint of CPP (NEW; Class I; LOE B) • Magnitude of BP control to reduce risk of re-bleeding has not been established, but keep SBP<160 (NEW; Class IIa; LOE C) • For patients w/ unavoidable delay in securing aneurysm, a significant re-bleeding risk, and no contraindications, short term (<72hrs) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce risk of early re-bleeding (Revised; Class IIa, Level of Evidence B)

27. What we do at RIH • Control BP b/w symptoms onset and aneurysm securing. We tend to use Cardenegtt • Maintain SBP <140 until aneurysm is secured • Have never used tranexamicacid and have only heard of using aminocaproic acid

28. Proposed changes: Medical Measures to prevent rebleeding • Use Cardenegtt as titrateableagent to balance risk of stroke, HTN related re-bleeding, and maintenance of CPP • Maintain SBP <160 until aneurysm is secured. No evidence to support our SBP<140 • Rare but for patients w/ unavoidable delay in securing aneurysm, a significant re-bleeding risk, and no contraindications, short term (<72hrs) therapy with aminocaproicacid is reasonable and can be considered

29. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

30. Surgical and endovascular methods for treatment of ruptured aneurysms: Recommendations • Clipping or coiling should be done ASAP (Class I; LOE B) • Complete obliteration whenever possible (Class I; LOE B) • Determination of tx should be multidisciplinary decision based on patient and aneurysm (Revised; Class I; LOE C) • Ruptured aneurysms amenable to both Clip or Coil, Coiling should be considered (Revised; Class I; Level of Evidence B) • Pt’s who undergo coil or clip or ruptured aneurysm should have f/u imaging and re-treatment if significant remnant (NEW; I; B) • Consider clipping large MCA aneurysms with large IPH (>50cc)Consider coiling in elderly (>70), poor grade, basilar apex (IIb; C)

31. What we do at RIH • Clipping or coiling done ASAP (no night cases) • Complete obliteration whenever possible • multidisciplinary decision VIR + NSGY • Ruptured aneurysms amenable to both Clip or Coil, we usually favor coiling • Pt’s who undergo coil or clip or ruptured aneurysm DO have f/u imaging and re-treatment if significant remnant • Usually clip large MCA aneurysms with large IPH (clot evac)and usually coil elderly and poor grade

32. Proposed changes: Surgical and endovascular methods for treatment of ruptured aneurysms • Continue to clip or coil ASAP. Continue with NO night cases • Continue with complete obliteration whenever possible • Continue multidisciplinary decision and CV conference • Consider coiling ruptured aneurysms amenable to both Clip or Coil • Continue to provide f/u imaging (Angiovs MRA) and treatment for Pt’swho undergo coil or clip or ruptured aneurysm • Continue to clip large MCA aneurysms with clot and coil elderly (>70), poor grade, basilar apex

33. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

34. Hospital Characteristics and Systems of care: Recommendations • Low volume hospitals (<10 aSAH cases/yr) should transfer early to high volume centers (>35 aSAH cases/yr) with VIR, NSGY, NCC (Revised; Class I; Level of Evidence B) • Annual monitoring of complication rates for OR and VIR procedures is reasonable (NEW; Class IIa; Level of Evidence C) • Hospital credentialing process to ensure that proper training standards have been met by treating physicians is reasonable (NEW; Class IIa; Level of Evidence C)

35. What we do at RIH • We get all the transfers. • We treat >35 aSAHcases/yr • We have M+M and other measures to monitor complication rates for OR and VIR procedures • There is a hospital credentialing process for the attendings

36. Proposed changes: Hospital Characteristics and Systems of care • Continue to get all SAH cases transferred to RIH • Ensure we log all VIR and operative cases for ACGME/RRC credit • Set up annualmonitoring of complication rates • Develop, thr hospital credentialing process to ensure that only attendings capable of performing Vascular related procedures are doing them

37. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

38. Anesthetic management during surgical and endovascular treatment of ruptured aneurysm: Recommendations • Minimize degree and duration of intra-op hypotension (IIa; B) • Insufficient data on induced hypertension during temporary vessel occlusion to make a recommendation but may be reasonable (Class IIb; Level of Evidene C) • Induced hypothermia is not routinely recommended, but may be a reasonable option in select cases (Class III; LOE B) • Prevention of intra-op hyperglycemia is probably indicated (Class IIa; Level of Evidence B) • The use of general anesthesia in endovascular tx of ruptured aneurysms can be beneficial in select patients (Class IIa; LOE C)

39. What we do at RIH • Attempt to keep normotensive • Keep normotensive during temporary vessel occlusion (SBP 110) • Never induce hypothermia (32-35 deg) • Prevention of intra-op hyperglycemia • PaO2 >130 is neuro-protective • Now, ALWAYS general anesthesia in VIR (but not in strokes to avoid hypotension)

40. Proposed changes: Anesthetic management during surgical and endovascular treatment of ruptured aneurysm • Minimize degree and duration of intra-op hypotension and temp fluctuations • Continue with normotension to hypertensive during temporary clipping (avoid hypotension) • Avoid hypothermia, goal is euthermia • Continue with intra-op glucose and Sodium checks • Continue GETA in emergent (and elective) endovascular tx of ruptured aneurysms

41. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

42. Management of Vasospasm and DCI after aSAH: Recommendations • Oral Nimodipine should be given to all aSAH (improves OUTCOME, not vasospasm) (Class I; Level of Evidence A) • Maintenance of Euvolemia is recommended to prevent DCI (Revised, Class I; Level of Evidence B) • Prophylactic hypervolemia or balloon angioplasty before development of angiographic spasm is NOT recommended (NEW; Class III, Level of Evidence B) • TCD’s reasonable to monitor for VS (NEW; Class IIa; LOE B) • CT or MR perfusion can be useful to id regions of potential brain ischemia (NEW; Class IIa; Level of Evidence B) • Induced HTN is recommended for pt’s w/ DCI unless baseline elevated BP or cardiac status precludes it (Revised; Class I; Level of Evidence B) • Angioplasty or IA dilator is reasonable in symptomatic vasospasm, particularly those not responding to HTN therapy (Revised; Class IIa; Level of Evidence B)

43. What we do at RIH • Oral Nimodipineis given to all aSAH x 21 days • Maintain Euvolemia in 6INC • Usually do not prophylactically use hypervolemia or balloon angioplasty • Daily TCD’s x 14-21 days to monitor for Vasospasm • Rarely utilize CT or MR perfusion to identify regions of potential brain ischemia • Induce HTN for pt’sw/ DCI unless cardiac status precludes it • Send patient to VIR for Angioplasty or IA cardene for symptomatic vasospasm if not responsive to induced hypertension

44. Proposed changes: Management of Vasospasm and DCI after aSAH • Continue oral Nimodipine to all aSAHx 21 days • Continue to maintaneEuvolemic status to prevent DCI • Do NOT prophylactically send pt’s to VIR for balloon angioplasty • Continue TCD’s to monitor for vasospasm • Can consider CT or MR perfusion to identify regions of potential brain ischemia compared to other regions • Continue to induce HTN for pt’s w/ DCI unless cardiac status precludes it • Continue to send pt’s to VIR for Angioplasty or IA dilator in symptomatic vasospasm, particularly those not responding to HTN therapy

45. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

46. Management of Hydrocephalus after aSAH: Recommendations • aSAH associated symptomatic HCP should be managed by CSF diversion (EVD or LD) (Revised; Class I; Level of Evidence B) • aSAH associated chronic symptomatic HCP should be managed by permanent CSF diversion (Revised; Class I; LOE C) • Weaning EVD over >24 hrs does NOT appear to be effective in reducing need for shunt (NEW; Class III, Level of Evidence B) • Routine fenestration of Lamina Terminalis is NOT useful for reducing the rate of shunt dependent HCP, and, therefore, should not be performed (NEW; Class III; Level of Evidence B)

47. What we do at RIH • aSAH associated symptomatic HCP is managed by EVD. LD has been used after EVD infection. • aSAH associated chronic symptomatic HCP is managed by VPS • Usually wean EVD over >24 hrs • Usually do NOT intentionally fenestrate theLamina Terminalis

48. Proposed changes: Management of Hydrocephalus after aSAH • aSAH associated symptomatic HCP should be managed by CSF diversion (EVD or LD). LD- less vasospasm. Do not use in obstructed HCP or if large IP clot present b/c can cause herniation • aSAH associated chronic symptomatic HCP should be managed by VPS/VAS • Continue to wean EVD over >24 hrsunless ventriculitis present (NEW; Class III, Level of Evidence B) (4 or 5 saves!) • Do NOT routinely fenestrate Lamina Terminalis

49. Risk factors and prevention • Natural History and Outcome • Clinical Manifestations and Diagnosis • Medical Measures to prevent re-bleeding • Surgical and endovascular methods for treatment of ruptured aneurysms • Hospital characteristics and systems of care • Anesthetic management during surgery and endovascular tx • Management of Vasospasm and DCI after aSAH • Management of HCP associated with aSAH • Management of Seizures associated with aSAH • Management of Medical complications associated with aSAH

50. Management of Seizures associated with aSAH: Recommendations • The use of prophylactic anticonvulsants may be considered in the immediate post-hemorrhagic period (Class IIb; LOE B) • Routine long term use of AED is not recommended (Class III; LOE B) but may be considered for pt’s with known risk factors for delayed seizure d/o such as prior seizure, Intracerebral hematoma, intractable HTN, Infarction, or MCA aneurysm (Class IIb; Level of Evidence B)