AHA/ASA Scientific Statement

2. AHA/ASA Scientific Statement Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (SAH) A Statement for Healthcare Professionals from a Special Writing Group of the Stroke Council, American Heart Association Joshua B. Bederson, MD, Chair; E. Sander Connolly, Jr., MD, FAHA Vice-Chair; H. Hunt Batjer, MD; Ralph G. Dacey, MD, FAHA; Jacques E. Dion, MD, FRCPC; Michael N. Diringer, MD, FAHA, FCCM; John E. Duldner, Jr., MD, MS; Robert E. Harbaugh, MD, FACS, FAHA; Aman B. Patel, MD; Robert H. Rosenwasser, MD, FACS, FAHA

3. Stroke Council Professional Education Committee • This slide presentation was developed by members of the Stroke Council Professional Education committee. • Opeolu Adeoye MD • Dawn Kleindorfer MD

4. Citation Information • Key words included in the paper: aneurysm; angiography; cerebrovascular disorders; hemorrhage; stroke; surgery; vasospasm Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH. 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. Stroke 2009: published online before print January 22, 2009, 10.1161/STROKEAHA.108.191395.

5. This slide set was adapted from the Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage paper This guideline reflects a consensus of expert opinion following thorough literature review that consisted of a look at clinical trials and other evidence related to the management of subarachnoid hemorrhage.

6. Applying classification of recommendations and levels of evidence

7. Outline • Introduction • Epidemiology • Acute Evaluation and Medical Management • Surgical and Endovascular Management • Management of Common In-Hospital SAH Complications • Summary and Conclusions

8. Introduction • SAH is a common and devastating condition • SAH affects up to 30,000 persons annually in the United States (US) • Mortality rates are as high as 45% with significant morbidity among survivors • These recommendations summarize the best available evidence for treatment of patients with aneurysmal SAH

9. Stroke

10. Aneurysm

11. Epidemiology • SAH incidence varies greatly between countries, from 2 cases/ 100,000 in China to 22.5/100,000 in Finland • Many cases of SAH are misdiagnosed • Thus, the annual incidence of aneurysmal SAH in the US may exceed 30,000 • Incidence increases with age, occurring most commonly between 40 and 60 years of age (mean age > 50 years)

12. Epidemiology • SAH is ~1.6 times higher in women than men • Risk factors for SAH include hypertension, smoking, female gender and heavy alcohol use • Cocaine-related SAH occurs in younger patients • Familial intracranial aneurysm (FIA) syndrome occurs when two first- through third-degree relatives have intracranial aneurysms

13. CT Scan non-contrast showing blood in basal cisterns (SAH) – so called “Star-Sign” CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery

14. CT Scan of a 65 yo woman, Hunt and Hess of 4 Subarachnoid Hemorrhage Arrow: Hyperintense signal. Blood in the subarachnoid space CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery

15. Angiogram - Giant ICA Aneurysm Angio image courtsey: University of Texas Health Science Center at San Antonio - Department of Neurosurgery

16. Prevention of SAH • No randomized controlled trials have examined whether treatment of medical risk factors reduces SAH occurrence • Hypertension is a common risk factor for hemorrhagic stroke • Indirect evidence suggests that smoking cessation reduces risk for SAH • Screening for asymptomatic intracranial aneurysms in the general population is not supported by the available literature

17. Recommendations for Prevention of SAH • Class I Recommendations • The relationship between hypertension and aneurysmal SAH is uncertain. However, treatment of high blood pressure with antihypertensive medication is recommended to prevent ischemic stroke and intracerebral hemorrhage, cardiac, renal, and other end-organ injury (LOE A)

18. Recommendations for Prevention of SAH • Class II Recommendations • Cessation of smoking is reasonable to reduce the risk of SAH, although evidence for this association is indirect (LOE B). • Screening of certain high-risk populations for unruptured aneurysms is of uncertain value (LOE B); advances in noninvasive imaging may be used for screening, but catheter angiography remains the “gold standard” when it is clinically imperative to know if an aneurysm exists.

19. Natural History and Outcome of an Aneurysmal SAH • 30-day mortality rate after SAH ranges from 33-50% • Severity of initial hemorrhage, age, sex, time to treatment, and medical comorbidities impact SAH outcome • Aneurysm size, location in the posterior circulation, and morphology may also impact outcome • Endovascular services at a given institution, the volume of SAH patients treated, and the facility where the patient is first evaluated may also impact outcome

20. Natural History of an Aneurysmal SAH: Recommendations • Class I Recommendations • The severity of the initial bleed should be determined rapidly as it is the most useful indicator of outcome following aneurysmal SAH and grading scales which heavily rely on this factor are helpful in planning future care with family and other physicians (LOE B)

21. Natural History of an Aneurysmal SAH: Recommendations • Class I Recommendations • Case review and prospective cohorts have shown that for untreated, ruptured aneurysms, there is at least a 3% to 4% risk of re-bleeding in the first 24 hours and possibly significantly higher, with a high percentage occurring immediately (within 2 to 12 hours) after the initial ictus, a 1% to 2% per day risk in the first month, and a long-term risk of 3% per year after 3 months. Urgent evaluation and treatment of patients with suspected SAH is therefore recommended (LOE B)

22. Natural History of an Aneurysmal SAH: Recommendations • Class II Recommendations • In triaging patients for aneurysm repair, factors that can be useful in determining the risk of re-bleeding include severity of the initial bleed, interval to admission, blood pressure, gender, aneurysm characteristics, hydrocephalus, early angiography, and the presence of a ventricular drain (LOE B)

23. Acute Evaluation - Diagnosis • “The worst headache of my life” is described by ~80% of patients • “Sentinel” headache is described by ~20% • Nausea/vomiting, stiff neck, loss of consciousness, or focal neurological deficits may occur • Misdiagnosis of SAH occurred in as many as 64% of cases prior to 1985 • Recent data suggest an SAH misdiagnosis rate of approximately 12%

24. Acute Evaluation - Diagnosis • Importance of recognition of a warning or sentinel leak cannot be overemphasized • A high index of suspicion is warranted in the ED • The diagnostic sensitivity of CT scanning is not 100%, thus diagnostic lumbar puncture should be performed if the initial CT scan is negative

25. Diagnosis of SAH -Recommendations • Class I Recommendations • SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for SAH should exist in patients with acute onset of severe headache (LOE B) • CT scanning for suspected SAH is strongly recommended, and lumbar puncture for analysis of cerebrospinal fluid is strongly recommended when the CT scan is negative (LOE B)

26. Diagnosis of SAH –Recommendations • Class I Recommendations • Selective cerebral angiography to document the presence and anatomic features of aneurysms is strongly recommended in patients with documented SAH (LOE B) • Class II Recommendations • MRA or CTA can serve as useful alternative diagnostic tools when conventional angiography cannot be performed in a timely fashion (LOE B)

27. Acute Evaluation – Emergency Evaluation • Emergency medical services (EMS) is first medical contact in about 2/3 of SAH patients • EMS personnel should receive continuing education regarding signs and symptoms and the importance of rapid neurological assessment in cases of possible SAH • On-scene delays should be avoided • Rapid transport and advanced notification of the ED should occur

28. Acute Evaluation – Emergency Evaluation • Airway, breathing, and circulation should be rapidly assessed and managed • Emergency care providers should evaluate SAH patients with an accepted neurologic assessment scale and record it in the ED • Hunt and Hess, Fisher Scale, Glasgow Coma Scale, World Federation of Neurological Surgeons Scale. • Expedient transfer to an appropriate referral center should be considered if necessary

29. Emergency Evaluation Recommendations • Class II Recommendations • The degree of neurological impairment using an accepted SAH grading system can be useful for prognosis and triage (LOE B) • A standardized ED management protocol for the evaluation of patients with headaches and other symptoms of potential SAH does not currently exist and needs development (LOE C)

30. Acute Evaluation – Preventing Re-bleeding • Up to 14% of SAH patients may experience re-bleeding within 2 hours of the initial hemorrhage • Re-bleeding was more common in those with a systolic blood pressure >160mm Hg • Anti-fibrinolytic therapy may reduce re-bleeding but has not been shown to improve outcomes

31. Preventing Re-bleeding - Recommendations • Class I Recommendations • Blood pressure should be monitored and controlled to balance the risk of strokes, hypertension-related re-bleeding, and maintenance of cerebral perfusion pressure (LOE B) • Class II Recommendations • Bed rest alone is not enough to prevent re-bleeding after SAH. It may be considered as a component of a broader treatment strategy along with more definitive measures (LOE B)

32. Preventing Re-bleeding - Recommendations • Class II Recommendations • Recent evidence suggests that early treatment with antifibrinolytic agents, when combined with a program of early aneurysm treatment followed by discontinuation of the antifibrinolytic and prophylaxis against hypovolemia and vasospasm (LOE B)

33. Preventing Re-bleeding – Class II Recommendations • Antifibrinolytic therapy to prevent rebleeding may be considered in certain clinical situations, e.g., patients with a low risk of vasospasm and/or a beneficial effect of delaying surgery (LOE B)

34. Surgical and Endovascular Management of SAH • Occluding aneurysms using endovascular coils was described in 1991 • Improved outcomes have been linked to hospitals that provide endovascular services • Use of endovascular versus surgical techniques varies greatly across centers • Coil embolization is associated with a 2.4% risk of aneurysmal perforation and an 8.5% risk of ischemic complications

35. Surgical and Endovascular Management of SAH • A study of 431 patients undergoing coiling of a ruptured aneurysm found an early re-bleeding rate of 1.4%, with 100% mortality • The ISAT Trial reported a 1-year re-hemorrhage rate of ~2.9% in aneurysms treated with endovascular therapy • Aneurysm size is an important predictor of hemorrhage risk

36. Surgical and Endovascular Management of SAH • The Cooperative Study evaluated 979 patients who underwent intracranial surgery only • Nine of 453 patients (2%) rebled after surgery • Nearly half (n=4) of these hemorrhages occurred in patients with multiple aneurysms

37. Surgical and Endovascular Management of SAH • In the International Subarachnoid Aneurysm Trial (ISAT) post-treatment SAH occurred at an annualized rate of 0.9% with surgical clipping, compared to 2.9% with endovascular treatment • The rate of incomplete obliteration and recurrence appears significantly lower with surgical clipping than with endovascular treatment

38. Surgical and Endovascular Management of SAH • Increased time to treatment is associated with increased rates of preoperative re-bleeding • 0 to 3 days, 5.7% • 4 to 6 days, 9.4% • 7 to 10 days, 12.7% • 11 to 14 days, 13.9% • 15 to 32 days, 21.5% • Postoperative re-bleeding did not differ among time intervals (1.6% overall)

39. Surgical and Endovascular Management of SAH • Estimating the consequences of complications attributable to an operation may be possible from data regarding surgery for unruptured aneurysms • In-hospital mortality rates vary from 1.8% to 3.0% in large multicenter studies • Adverse outcomes in survivors vary from 8.9% to 22.4%

40. Surgical and Endovascular Management of SAH • The only large prospective, randomized trial to date comparing surgery and endovascular techniques is ISAT • At one year, there was no significant difference in mortality rates (8.1% vs. 10.1% endovascular vs. surgical) • Disability rates were greater in surgical versus endovascular patients (21.6% vs. 15.6%)

41. Surgical and Endovascular Management of SAH • Combined morbidity and mortality was significantly greater in surgically treated patients than in those treated with endovascular techniques (30.9% vs. 23.5%; absolute risk reduction 7.4%, P = 0.0001) • During the short follow-up period in ISAT the re-bleeding rate for coiling was 2.9% versus 0.9% for surgery • There have been no randomized comparisons of coiling versus clipping for unruptured aneurysms

42. Clipping

43. Left image arrow -Angio with Large aneurysmRight image arrow – Angio showing aneurysm post clipping Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery

44. Surgical and Endovascular Management -- Recommendations • Class I Recommendations • Surgical clipping or endovascular coiling is strongly recommended to reduce the rate of rebleeding after aneurysmal SAH (LOE B) • Wrapped or coated aneurysms as well as incompletely clipped or coiled aneurysms have an increased risk of re-hemorrhage compared to those completely occluded and therefore require long-term follow-up angiography. Complete obliteration of the aneurysm is recommended whenever possible (LOE B)

45. Surgical and Endovascular Management -- Recommendations • Class I Recommendations • For patients with ruptured aneurysms judged by an experienced team of cerebrovascular surgeons and endovascular practitioners to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling can be beneficial (LOE B) • Class II Recommendations • Individual characteristics of the patient and the aneurysm must be considered in deciding the best means of repair, and management of patients in centers offering both techniques is probably recommended (LOE B)

46. Coiling

47. Coil system embolization: immediate result Angio showing large ICA aneurysm Same aneurysm - Post GDC Coiling Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery

48. Surgical and Endovascular Management - Recommendations • Class II Recommendations • Although previous studies showed that overall outcome was not different for early versus delayed surgery after SAH, early treatment reduces the risk of rebleeding after SAH, and newer methods may increase the effectiveness of early aneurysm treatment. Early aneurysm treatment is reasonable and is probably indicated in the majority of cases (LOE B)

49. Hospital/Systems of Care • Treatment volume is an important determinant of outcome for intracranial aneurysms – higher volume equals lower mortality • This effect may be more important for patients with unruptured aneurysms than for those with ruptured aneurysms • It is uncertain whether the benefits of receiving care at a high-volume center would outweigh the costs and risks of transfer

50. Hospital/Systems of Care -- Recommendations • Class II Recommendations • Early referral to high-volume centers that have both experienced cerebrovascular surgeons and endovascular specialists is reasonable (LOE B)