Risk of rebleeding after treatment of acute hydrocephalus in patients with aneurysmal subarachnoid hemorrhage

Incidence of Rebleed Following Cerebrospinal Fluid (CSF) Drainage in Poor Grade Subarachnoid Hemorrhage: An Institutional Experience

BACKGROUND

The outcome of poor grade subarachnoid hemorrhage (SAH) is dismal. Some of these patients need cerebrospinal fluid (CSF) drainage procedure for the hydrocephalus and intraventricular hemorrhage (IVH) which may precipitate rebleeding. However, aneurysmal rebleed following CSF drainage procedure is controversial.

OBJECTIVE

Our study aimed at analyzing the effect of CSF drainage procedure on aneurysmal rebleeding.

MATERIAL AND METHODS

We retrospectively analyzed the records of all the consecutive patients diagnosed with poor grade aneurysmal SAH over three year period. Patients initially requiring either external ventricular drainage (EVD) or lumbar drain (LD) were included in the study group, and the rest (not requiring drainage) were included in the control group. Rebleeding was confirmed on computed tomography. The factors affecting rebleeding were analyzed.

RESULTS

Overall 194 patients with poor grade SAH were enrolled in the study (91 males: 103 females; mean age: 50.6 years). The study group had 91 patients (83 EVD and 8 LD) while 103 patients were in the control group. Posterior circulation aneurysms, poor grade SAH, hydrocephalus, and IVH were more common in the study group P < 0.001. The rebleeding rate was 7.6% in the study group and 8.7% in the control group. On univariate analysis size >1 cm, multiplicity, multilobularity, vasospasm, and CSF drainage were significant risk factors for rebleeding (P < 0.001). On multivariate analysis aneurysm size >1 cm, CSF overdrainage >250 ml/day were significantly associated with risk of rebleeding.

CONCLUSION

Ventricular drainage is essential to relieve acute hydrocephalus and drain IVH in SAH and we found no significant association between CSF drainage and rebleeding. However, rapid overdrainage of CSF can lead to aneurysm rupture, hence controlled controlled CSF drainage should be undertaken.

Efficacy and Safety of Lumbar Drainage before Endovascular Treatment for Ruptured Intracranial Aneurysms

Objective

Intraoperative rebleeding during endovascular treatment for ruptured intracranial aneurysms is associated with poor prognosis. Lumbar drainage is performed preoperatively to control intracranial pressure; however, it is associated with a risk of brain herniation or rebleeding because intracranial pressure may change rapidly. Therefore, this study aimed to examine the efficacy and safety of preoperative lumbar drainage.

Methods

This retrospective study enrolled 375 patients who underwent endovascular treatment of ruptured intracranial aneurysms at our institution between April 2013 and March 2018. The incidence of rebleeding and clinical outcomes were compared between patients who did and did not undergo preoperative lumbar drainage.

Results

Among the 375 patients with ruptured intracranial aneurysms, 324 (86.0%) and 51 (14.0%) patients did and did not undergo lumbar drainage, respectively. The incidence of rebleeding was 11/324 (3.4%) and 2/51 (3.9%) in lumbar drainage and nonlumbar drainage groups, respectively, with no statistical differences (p = 0.98). Of the rebleeding cases, 9/11 (81%) and 2/2 (100%) in lumbar drainage and nonlumbar drainage groups, respectively, were due to intraoperative bleeding, and 2/11 (19%) in the lumbar drainage group, the causes of the rebleeding were undetermined. The incidence of symptomatic vasospasm did not differ significantly between the groups (13.2% vs. 11.8%, P = 0.776), while the incidence of hydrocephalus (24.6% vs. 11.8%, P = 0.043) and meningitis (15.2% vs. 5.9%, P = 0.075) were slightly higher in the lumbar drainage group. Favorable clinical outcomes (modified Rankin Scale score <2) at discharge were less frequent in the lumbar drainage group (55.3% vs. 70.0%, P = 0.051). No significant differences were observed in the propensity score-matched analysis.

Conclusion

Lumbar drainage before endovascular treatment for ruptured intracranial aneurysms is a safe procedure that does not increase the incidence of rebleeding.

Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical emergency that necessitates direct transfer to a tertiary referral center specialized in the diagnosis and treatment of this condition. The initial hours after aneurysmal rupture are critical for patients with aneurysmal subarachnoid hemorrhage, both in terms of rebleeding and combating the effect of early brain injury. No good treatment options are available to reduce the risk of rebleeding before aneurysm occlusion. Lowering the blood pressure may reduce the risk of rebleeding but carries a risk of inducing delayed cerebral ischemia or aggravating the consequences of early brain injury. Early brain injury after aneurysmal rupture has an important effect on final clinical outcome. Proper cerebral perfusion is pivotal in these initial hours after aneurysmal rupture but threatened by complications such as neurogenic pulmonary edema and cardiac stunning, or by acute hydrocephalus, which may necessitate early drainage of cerebrospinal fluid.

Intracranial Pressure Monitoring and Management in Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical condition that can lead to intracranial hypertension, negatively impacting patients' outcomes. This review article explores the underlying pathophysiology that causes increased intracranial pressure (ICP) during hospitalization. Hydrocephalus, brain swelling, and intracranial hematoma could produce an ICP rise. Although cerebrospinal fluid withdrawal via an external ventricular drain is commonly used, ICP monitoring is not always consistently practiced. Indications for ICP monitoring include neurological deterioration, hydrocephalus, brain swelling, intracranial masses, and the need for cerebrospinal fluid drainage. This review emphasizes the importance of ICP monitoring and presents findings from the Synapse-ICU study, which supports a correlation between ICP monitoring and treatment with better patient outcomes. The review also discusses various therapeutic strategies for managing increased ICP and identifies potential areas for future research.

Relationship between preoperative external ventricular drainage and preoperative rebleeding in aneurysmal subarachnoid hemorrhage: A meta-analysis

OBJECTIVE

To analyze published evidence on the relationship between preoperative external ventricular drainage (preop-EVD) and preoperative rebleeding (preop-rebleeding) in aneurysmal subarachnoid hemorrhage (aSAH).

METHOD

A comprehensive search of three databases (PubMed, Ovid EMBASE, and The Cochrane Library) was conducted from their commencement to March 31, 2022. We collected studies reporting preop-EVD of rupture aneurysms while preop-rebleeding events were documented in these studies. We also extracted information on risk factors for preop-rebleeding from the studies and used Review Manager version 5.3 software to analyze.

RESULTS

A total of 3671 cases from 14 articles were enrolled in this meta-analysis. Preop-rebleeding rate was 11.04 % (106/960) and 9.22 % (250/2711) in preop-EVD group and control group, respectively. The study lacked power to conclude a clinically significant increase in preop-rebleeding risk (OR=1.60, 95 %CI:0.82-3.22). Fisher> 2 (OR=1.86), modified Fisher> 2 (OR=7.57), World Federation of Neurological Surgeons (WFNS)> 2 (OR=4.39) and aneurysm size > 1 cm (OR=3.01) were risk factors of preop-rebleeding. Patients with Hunt-Hess (HH)> 2 showed a higher preop-rebleeding trend compared to HH≤ 2, but the result did not reach a statistical difference (OR=6.79, P = 0.06). No difference in preop-rebleeding risk between anterior circulation aneurysms and posterior circulation aneurysms. Hydrocephalus had also been shown to be unrelated to higher preop-rebleeding rate.

CONCLUSIONS

Current evidence does not support that preop-EVD significantly increases the risk of rebleeding prior to aneurysm repair. Patients with poorer clinical status on admission and aneurysms size > 1 cm are at a higher risk of preop-rebleeding.

Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis

Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding.

Elevated Glucose-Potassium Ratio Predicts Preoperative Rebleeding in Patients With Aneurysmal Subarachnoid Hemorrhage

Introduction: Recent reports revealed that higher serum glucose-potassium ratio (GPR) levels at admission were significantly associated with poor outcomes at 3 months following aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to investigate the association between GPR and the risk of rebleeding following aSAH. Methods: This single-center retrospective study of patients with aSAH was conducted in our hospital between January 2008 and December 2020. Patients meeting the inclusion criteria were divided into the rebleed group and the non-rebleed group. Univariate and multivariate analyses were implemented to assess the association between risk factors of rebleeding and outcomes. Results: A total of 1,367 patients experiencing aSAH, 744 patients who met the entry criteria in the study [mean age (54.89 ± 11.30) years; 60.50% female patients], of whom 45 (6.05%) developed rebleeding. The patients in the rebleed group had significantly higher GPR levels than those of patients without rebleeding [2.13 (1.56-3.20) vs. 1.49 (1.23-1.87); p < 0.001]. Multivariable analysis revealed that higher mFisher grade and GPR were associated with rebleeding [mFisher grade, odds ratios (OR) 0.361, 95% CI 0.166-0.783, p = 0.01; GPR, OR 0.254, 95% CI 0.13-0.495, p < 0.001]. The receiver operating characteristics (ROCs) analysis described that the suitable cut-off value for GPR as a predictor for rebleeding in patients with aSAH was determined as 2.09 (the area under the curve [AUC] was 0.729, 95% CI 0.696-0.761, p < 0.0001; the sensitivity was 53.33%, and the specificity was 83.98%). Pearson correlation analysis showed a significant positive correlation between GPR and mFisher grade, between GPR and Hunt-Hess grade (mFisher grade r = 0.4271, OR 0.1824, 95% CI 0.3665-0.4842, p < 0.001; Hunt-Hess grade r = 0.4248, OR 0.1836, 95% CI 0.3697-0.4854, p < 0.001). The patients in the poor outcome had significantly higher GPR levels than those of patients in the good outcome [1.87 (1.53-2.42) vs. 1.45 (1.20-1.80); p < 0.001]. Multivariable analysis demonstrated that GPR was an independent predictor for poor prognosis. The AUC of GPR was 0.709 (95% CI 0.675-0.741; p < 0.0001) (sensitivity = 77.70%; specificity = 55.54%) for poor prognosis. Conclusion: Higher preoperative serum GPR level was associated with Hunt-Hess grade, mFisher grade, rebleeding, and unfunctional outcome, and that they predicted preoperative rebleeding and the 90-days outcome of non-diabetic patients with aSAH, who had potentially relevant clinical implications in patients with aSAH.

Factors associated with rebleeding after coil embolization in patients with aneurysmal subarachnoid hemorrhage

Objective

Aneurysmal subarachnoid hemorrhage (aSAH) has a high mortality rate, and hemorrhage amounts and perioperative rebleeding importantly determines prognosis. However, despite adequate treatment, prognosis is poor in many ruptured aneurysm cases. In this study, we identified and evaluated factors related to perioperative rebleeding in patients with aSAH.

Methods

The medical and surgical records of 166 patients that underwent endovascular embolization for a ruptured cerebral aneurysm at a single institution from 2014 to 2016 were retrospectively analyzed to identify risk factors of rebleeding. All patients were examined for risk factors and evaluated for increased hemorrhage by brain computed tomography at 3 days after surgery.

Results

This series included 54 men (32.5%) and 112 women (67.5%) of mean age 58.3±14.3 years. After procedures, 26 patients (15.7%) experienced rebleeding, and 1 of these (0.6%) experienced an intraoperative aneurysmal rupture. External ventricular drainage (EVD) (odds ratio [OR] 5.389, [95% confidence interval (CI) 1.171- 24.801]) and modified Fisher grade (OR 2.037, [95% CI 1.077-3.853]) were found to be independent risk factors of rebleeding, and perioperative rebleeding was strongly associated with patient outcomes (p＜0.001).

Conclusions

We concluded the rebleeding risk after aSAH is greater in patients with large hemorrhage amounts and a high pre-operative modified Fisher grade, and thus, we caution neurosurgeons should take care in such cases.

Factors Associated With Prolonged Mechanical Ventilation in Patients With Subarachnoid Hemorrhage-The RAISE Score

OBJECTIVES

Patients suffering from spontaneous subarachnoid hemorrhage frequently require mechanical ventilation. Here, we aimed to identify factors associated with prolonged mechanical ventilation in subarachnoid hemorrhage patients and to create a new predictive score for prolonged mechanical ventilation.

DESIGN

Prospective cohort study with retrospective data analysis.

SETTING

Neurocritical care unit at a tertiary academic medical center.

PATIENTS

Two hundred ninety-seven consecutive nontraumatic adult subarachnoid hemorrhage patients.

METHODS

In patients with mechanical ventilation, we identified factors associated with mechanical ventilation greater than 48 hours, greater than 7 days, and greater than 14 days compared with mechanical ventilation less than or equal to 48 hours, less than or equal to 7 days, or less than or equal to 14 days in multivariable generalized linear models. Ventilated patients who died before 48 hours, 7 days, or 14 days and those never ventilated were excluded from the respective analysis. We incorporated those factors into a new prognostic score (the RAISE score) to predict prolonged mechanical ventilation greater than 7 days. The calculation was based on a random dataset of 60% of subarachnoid hemorrhage patients and was internally validated.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were 57 years old (interquartile range, 47-68 yr) and presented with a median Hunt and Hess grade of 3 (1-5). Two hundred forty-two patients (82%) required mechanical ventilation for 9 days (2-20 d). In multivariable analysis, a higher Acute Physiology Score was associated with mechanical ventilation greater than 48 hours, greater than 7 days, and greater than 14 days, a higher Hunt and Hess grade with greater than 7 days and greater than 14 days. Early neuroimaging findings were associated with mechanical ventilation greater than 48 hours (hydrocephalus; high-grade Subarachnoid Hemorrhage Early Brain Edema Score), greater than 7 days (high-grade Subarachnoid Hemorrhage Early Brain Edema Score, co-occurrence of intracerebral bleeding) but not with prolonged mechanical ventilation greater than 14 days. The RAISE score, including age, Acute Physiology Score, Hunt and Hess grade, Subarachnoid Hemorrhage Early Brain Edema Score, and the co-occurrence of intracerebral hemorrhage accurately stratified patients by prolonged mechanical ventilation greater than 7 days (C-statistic 0.932). A RAISE score of 12 predicted 60% likelihood of mechanical ventilation greater than 7 days.

CONCLUSIONS

Initial disease severity and neuroimaging findings detected within 24 hours after ICU admission were associated with the need for prolonged mechanical ventilation in patients with subarachnoid hemorrhage. These results may be helpful for patient families and caregivers to better anticipate the course of therapy.

Optimal timing and safety of the external ventricular drainage in patients with high-grade aneurysmal subarachnoid hemorrhage treated with endovascular coiling

The presented retrospective analysis has evaluated the optimal timing and safety of external ventricular drainage (EVD) for acute hydrocephalus after aneurysmal subarachnoid hemorrhage (aSAH). The study cohort comprised 102 patients, 49 of whom underwent EVD at 3-120 h (mean, 16 h) after the clinical onset of aSAH, either before (N = 27) or after (N = 22) ruptured aneurysm coiling. Among those treated with EVD, favorable and fair outcomes at discharge (modified Rankin Scale [mRS] scores 0-3) were noted in 14 (29%) and unfavorable (mRS scores 4-6) in 35 (71%). The former was more common among women (P = 0.019) and patients without chronic arterial hypertension (P = 0.028). The cut-off value for optimal timing of EVD was defined at 13 h after the onset of aSAH. Favorable and fair outcomes were more frequent after early (≤13 h; N = 30) than late (>13 h; N = 19) EVD (40% vs. 11%; P = 0.026), whereas did not differ significantly between those in whom such procedure was done before or after ruptured aneurysm coiling (19% vs. 41%; P = 0.083). In the entire study cohort, 2 patients had re-rupture of the aneurysm, and while both of them were treated with EVD, neither case of complication was directly associated with the procedure and, in fact, preceded it. In conclusion, EVD for management of acute hydrocephalus in patients with high-grade aSAH should be preferably applied within 13 h after the clinical onset of stroke, which may be considered sufficiently safe regardless whether it is performed before or after ruptured aneurysm coiling.

Intracranial Vascular Procedures

Anesthesia for intracranial vascular procedures is complex because it requires a balance of several competing interests and potentially can result in significant morbidity and mortality. Frequently, periods of ischemia, where perfusion must be maintained, are combined with situations that are high risk for hemorrhage. This review discusses the basic surgical approach to several common pathologies (intracranial aneurysms, arteriovenous malformations, and moyamoya disease) along with the goals for anesthetic management and specific high-yield recommendations.

Timelines and rebleeds in patients admitted into neurosurgical care for aneurysmal subarachnoid haemorrhage

Background

Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid.

Methods

Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013–31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay.

Results

We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1–95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair.

Conclusions

The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00701-020-04673-3.

Impact of COVID-19 pandemic on patients with intracranial aneurysm rupture

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We noticed higher rate of patients with ruptured aneurysm who had deteriorated neurological presentation on admission during COVID-19 pandemic.

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Indeed, rates of poor neurological presentation and severe radiological presentation on hospital admission were higher (p < 0.05).

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Likewise, the delayed hospital admission was longer (p = 0.005). Therefore, vasospasm’s rate on presentation was also higher (p = 0.04).

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During pandemic, patients with only sudden headache may have feared immediate hospital admission because of potential COVID-19 contamination.

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In case of recurrence, educating population concerning specific symptoms such as sudden headache or neurological deficit should be emphasized.

Background/objectives

The present study aimed at evaluating the impact on the early outcome of patients with ruptured intracranial aneurysms.

Methods

Our study prospectively included 26 consecutive patients with ruptured intracranial aneurysm managed at our institution in context of COVID-19 pandemic between March 1st, 2020 and April, 26th, 2020 (2020 group). A group control included other 28 consecutive patients managed at the same institution for the same disease in 2019, during the same time frame (2019 group). On admission, poor neurological status was defined as WFNS score >3. Severe radiological status was defined by the presence of intracerebral hematoma, or/and acute hydrocephalus requiring further EVD or/and the presence of vasospasm on presentation. Statistical analysis was performed to compare the 2 distinct groups.

Results

Rates of poor neurological presentation and severe radiological presentation on hospital admission were higher in the 2020 group (p = 0.01 and p = 0.02, respectively). The delayed hospital admission was 2.7 days in 2020 group and 0.75 days in 2019 group (p = 0.005). Therefore, vasospasm’s rate on presentation was also higher in the 2020 group (p = 0.04).

Conclusion

To our knowledge, this is one of the first studies demonstrating influence of the COVID-19 pandemic on patients with urgent and severe intracranial aneurysmal disease. In case of recurrent COVID-19 pandemic, educating the population concerning specific symptoms such as sudden headache, neurological deficit or even sudden chest pain should be emphasized.

Functional Outcome Following Ultra-Early Treatment for Ruptured Aneurysms in Patients with Poor-Grade Subarachnoid Hemorrhage

BACKGROUND

Little is known regarding functional outcome following poor-grade (World Federation of Neurosurgical Societies grades IV and V) aneurysmal subarachnoid hemorrhage (aSAH), especially in individuals treated aggressively in the early phase after ictus.

METHODS

We provided patients with aSAH with ultra-early definitive treatment, coiling or clipping, within 6 hours from arrival as per protocol. We classified the patients into 3 groups according to their computed tomography findings: Group 1, intraventricular hemorrhage with obstructive hydrocephalus; Group 2, massive intracerebral hemorrhage with brain herniation; and Group 3, neither Group 1 nor Group 2. We retrospectively evaluated patients with poor-grade aSAH who were admitted to our department between January 2013 and December 2016. We evaluated functional outcome at 6 months, defining modified Rankin Scale (mRS) scores of 0-2 as good and those of 3-6 as poor outcomes.

RESULTS

A good functional outcome was observed in 39.4% (28/71) of all cases. All-cause mortality at 6 months was 15.5% (11/71). A good outcome in Group 3 was significantly higher than that in the other two groups (Group 1 and 2 vs. Group 3, 20.8% vs. 48.9%, p = 0.02), even after adjustment with a multiple logistic regression analysis (odds ratio 6.1, 95% confidence interval 1.1 to 34.8).

CONCLUSIONS

Approximately 40% of patients with poor-grade aSAH became functionally independent, and approximately half of the patients with poor-grade aSAH who had neither intraventricular hemorrhage with obstructive hydrocephalus nor with brain herniation had good functional outcomes. Although further trials are required to confirm our results, ultra-early surgery may be considered for patients with poor-grade aSAH.

Aneurysmal subarachnoid hemorrhage: current concepts and updates

ABSTRACT Aneurysmal subarachnoid hemorrhage is a condition with a considerable incidence variation worldwide. In Brazil, the exact epidemiology of aneurysmal SAH is unknown. The most common presenting symptom is headache, usually described as the worst headache ever felt. Head computed tomography, when performed within six hours of the ictus, has a sensitivity of nearly 100%. It is important to classify the hemorrhage based on clinical and imaging features as a way to standardize communication. Classification also has prognostic value. In order to prevent rebleeding, there still is controversy regarding the ideal blood pressure levels and the use of antifibrinolytic therapy. The importance of definitely securing the aneurysm by endovascular coiling or surgical clipping cannot be overemphasized. Hydrocephalus, seizures, and intracranial pressure should also be managed. Delayed cerebral ischemia is a severe complication that should be prevented and treated aggressively. Systemic complications including cardiac and pulmonary issues, sodium abnormalities, fever, and thromboembolism frequently happen and may have na impact upon prognosis, requiring proper management.

Management of Subarachnoid Hemorrhage

Subarachnoid hemorrhage is an often devastating intracranial hemorrhage resulting from acute bleeding into the subarachnoid space. Although its overall incidence is less than that of acute ischemic stroke, sub-arachnoid hemorrhage carries increased risks of both mortality and disability. Although many patients with subarachnoid hemorrhage are transferred to specialty centers, they might initially present to small community-based hospitals. Treatment for these patients is complex, requiring specialized care and knowledge, and various complications can occur quickly and without warning. Therefore, all members of the health care team who care for these patients must understand proper management. Nurses in the intensive care unit play an important role in influencing outcomes, as they are best positioned to recognize neurological decline and provide rapid intervention. This article discusses the anatomy relevant to, and the epidemiology and pathophysiology of, subarachnoid hemorrhage and provides an overview of current evidence and clinical guidelines for managing this brain injury.

Carbon monoxide attenuates vasospasm and improves neurobehavioral function after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating form of hemorrhagic stroke and is a serious medical condition caused by bleeding usually due to a ruptured aneurysm. Oxidative stress and inflammation from hemoglobin and heme released from lysed red blood cells are some postulated causes of vasospasm during SAH, which could lead to delayed cerebral ischemia. At low amounts, carbon monoxide (CO) gas may be neuroprotective through anti-inflammation, anti-cell death, and restoration of normal blood flow. Hence, this study focuses on a noninvasive strategy to treat SAH by using CO as a therapeutic medical gas. Mice were treated with 250 ppm CO or air for 1h started at 2h after SAH. Various anatomical and functional outcomes were monitored at 1 and 7d after SAH. CO decreased neurological deficit score (47.4 ± 10.5%) and increased activity (30.0 ± 9.1%) and stereotypic counts (261.5 ± 62.1%) at 7d. There was a significant increase in lumen area/wall thickness ratio in the middle cerebral artery (173.5 ± 19.3%), which tended to increase in the anterior cerebral artery (25.5 ± 4.3%) at 7d. This is the first report to demonstrate that CO minimizes delayed SAH-induced neurobehavioral deficits, which suggests that post-treatment with CO gas or CO-donors can be further tested as a potential therapy against SAH.

Early Brain Injury After Poor-Grade Subarachnoid Hemorrhage

PURPOSE OF REVIEW

Over the last years, the focus of clinical and animal research in subarachnoid hemorrhage (SAH) shifted towards the early phase after the bleeding based on the association of the early injury pattern (first 72 h) with secondary complications and poor outcome. This phase is commonly referenced as early brain injury (EBI). In this clinical review, we intended to overview commonly used definitions of EBI, underlying mechanisms, and potential treatment implications.

RECENT FINDINGS

We found a large heterogeneity in the definition used for EBI comprising clinical symptoms, neuroimaging parameters, and advanced neuromonitoring techniques. Although specific treatments are currently not available, therapeutic interventions are aimed at ameliorating EBI by improving the energy/supply mismatch in the early phase after SAH. Future research integrating brain-derived biomarkers is warranted to improve our pathophysiologic understanding of EBI in order to ameliorate early injury patterns and improve patients' outcomes.

External Ventricular Drainage before Endovascular Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage in Acute Period: Its Relation to Hemorrhagic Complications

PURPOSE

The purpose of this study was to report the authors' experience with external ventricular drainage (EVD) before endovascular treatment (EVT) in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its relation to hemorrhagic complications.

MATERIALS AND METHODS

Between March 2010 and December 2017, a total of 122 patients were recruited who had an aSAH, underwent EVT to secure the ruptured aneurysm, and had EVD performed within 72 hours of rupture. The pre-embo EVD group (n=67) comprised patients who underwent EVD before EVT, and the post-embo EVD group (n=55) comprised those who underwent EVD after EVT.

RESULTS

Overall, EVD-related hemorrhage occurred in 18 patients (14.8%): six (8.9%) in the pre-embo EVD group and 12 (21.8%) in the post-embo EVD group (P=0.065). No rebleeding occurred between EVD and EVT in the pre-embo EVD group. Clinical outcomes at discharge did not differ significantly between groups (P=0.384). At discharge, the final modified Rankin Scale score in patients who experienced pre-embo rebleeding was better in the pre-embo EVD group than in the post-embo EVD group (P=0.041). Current use of an antiplatelet agent or anticoagulant on admission (odds ratio [OR], 2.928; 95% confidence interval [CI], 1.234-7.439; P=0.042) and stent use (OR, 2.430; 95% CI, 1.524-7.613; P=0.047) remained independent risk factors for EVD-related hemorrhagic complications.

CONCLUSION

EVD before EVT in patients with aSAH in acute period did not increase the rate of rebleeding as well as EVD-related hemorrhagic complications. Thus, performing EVD before EVT may be beneficial by normalizing increased intracranial pressure. Especially in patients with rebleeding before the ruptured aneurysm is secured, pre-embo EVD may improve clinical outcomes at discharge.

Serial lumbar puncture reduces cerebrospinal fluid (CSF) infection during removal of hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling

The present study aimed to compare the complications and clinical outcomes of serial lumbar puncture (LP) and lumbar cerebrospinal fluid (CSF) drainage (LD) of patients with aneurysmal subarachnoid hemorrhage and provide more evidence to guide clinical management. In this retrospective study, 41 and 39 aneurysmal subarachnoid hemorrhage patients were enrolled in the LP and LD group, respectively. Clinical outcomes, including CSF infection, intracerebral hemorrhage, vasospasm, hydrocephalus, death, length of stay, duration of drainage and the Glasgow Outcome Scale score were compared between the two groups. By comparing with the LP group, the LD group showed a significantly higher rate of CSF infection (P=0.029) and shorter duration of drainage (P<0.001). Both groups displayed similar rates of vasospasm, hydrocephalus, intracerebral hemorrhage, the Glasgow Outcome Scale score one month after endovascular coiling and length of stay (P>0.05, respectively). In conclusion, both LD and serial LP are effective methods in the treatment of aneurysmal subarachnoid hemorrhage; besides, serial LP can reduce the incidence of CSF infection in draining hemorrhagic CSF in aneurysmal subarachnoid hemorrhage after endovascular coiling.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

Levels of Interleukin-1β, Interleukin-18, and Tumor Necrosis Factor-α in Cerebrospinal Fluid of Aneurysmal Subarachnoid Hemorrhage Patients May Be Predictors of Early Brain Injury and Clinical Prognosis

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular accident with high morbidity and mortality. The aim of this study is to investigate the relationship between level of inflammatory cytokines in cerebrospinal fluid (CSF) of aSAH patients, the severity of aSAH, and the outcome of aSAH patients.

METHODS

aSAH patients were prospectively included and followed-up for 6 months. CSF samples were collected at 1-3, 4-6, and 7-9 days after aSAH onset. Levels of interleukin (IL)-1β, IL-18, and tumor necrosis factor-α (TNF-α) in the CSF of aSAH patients were measured by enzyme-linked immunosorbent assay.

RESULTS

Eighty-one aSAH patients were enrolled. The levels of IL-1β, IL-18 and TNF-α in the CSF were especially higher in the group of aSAH patients with cerebral edema, cerebral vasospasm, and a high grade on Hunt-Hess scale, the high World Federation of Neurological Surgeons grades, and Fisher grade (P < 0.01). Higher levels of plasma C-reactive protein in the blood were correlated with poor outcome. The areas under the receiver operating characteristic curves for the levels of inflammatory cytokines in CSF were 0.85, 0.84, and 0.95, respectively. Clinical features (age, Hunt-Hess grade, etc.) were positively correlated with poor outcomes (P < 0.05).

CONCLUSIONS

The levels of IL-1β, IL-18, and TNF-α in CSF were elevated in aSAH patients and were positively associated with cerebral edema and acute hydrocephalus. Our findings suggest that CSF inflammatory cytokines might be biomarkers to assess severity and predict outcomes.

Risks of Routinely Clamping External Ventricular Drains for Intrahospital Transport in Neurocritically Ill Cerebrovascular Patients

BACKGROUND

Current guidelines recommend routine clamping of external ventricular drains (EVD) for intrahospital transport (IHT). The aim of this project was to describe intracranial hemodynamic complications associated with routine EVD clamping for IHT in neurocritically ill cerebrovascular patients.

METHODS

We conducted a retrospective review of cerebrovascular adult patients with indwelling EVD admitted to the neurocritical care unit (NICU) during the months of September to December 2015 at a tertiary care center. All IHTs from the NICU of the included patients were examined. Main outcomes were incidence and risk factors for an alteration in intracranial pressure (ICP) and cerebral perfusion pressure after IHT.

RESULTS

Nineteen cerebrovascular patients underwent 178 IHTs (79.8 % diagnostic and 20.2 % therapeutic) with clamped EVD. Twenty-one IHTs (11.8 %) were associated with post-IHT ICP ≥ 20 mmHg, and 33 IHTs (18.5 %) were associated with escalation of ICP category. Forty IHTs (26.7 %) in patients with open EVD status in the NICU prior to IHT were associated with IHT complications, whereas no IHT complications occurred in IHTs with clamped EVD status in the NICU. Risk factors for post-IHT ICP ≥ 20 mmHg were IHT for therapeutic procedures (adjusted relative risk [aRR] 5.82; 95 % CI, 1.76-19.19), pre-IHT ICP 15-19 mmHg (aRR 3.40; 95 % CI, 1.08-10.76), pre-IHT ICP ≥ 20 mmHg (aRR 12.94; 95 % CI, 4.08-41.01), and each 1 mL of hourly cerebrospinal fluid (CSF) drained prior to IHT (aRR 1.11; 95 % CI, 1.01-1.23).

CONCLUSIONS

Routine clamping of EVD for IHT in cerebrovascular patients is associated with post-IHT ICP complications. Pre-IHT ICP ≥ 15 mmHg, increasing hourly CSF output, and IHT for therapeutic procedures are risk factors.

Aneurysm rebleeding after placement of external ventricular drainage: a systematic review and meta-analysis

BACKGROUND

The association between external ventricular drainage (EVD) and aneurysm rerupture is still a controversial issue. We performed a systematic review and meta-analysis of published series reporting data of EVD placement in aneurysmal subarachnoid hemorrhage (SAH) with the aim to evaluate the relationship between ventricular drainage and aneurysm rebleeding.

METHOD

PRISMA/MOOSE guidelines were followed. The Newcastle-Ottawa Scale was used to assess the quality of the studies. We conducted a comprehensive literature search of three databases (PubMed, Ovid MEDLINE, and Ovid EMBASE) on series reporting patients with EVD placement and aneurysmal SAH. The reported studies were analyzed with a primary aim to calculate the strength of the association (odds ratio) between rebleeding and EVD placement in patients with SAH.

RESULTS

Our systematic review included 16 articles with a total of 6804 patients with SAH of which 595 (8.7%) had aneurysmal rebleeding. Ventricular drainage was inserted in 19% of patients. Rebleeding occurred in 18.8% (95% CI = 16.4-20.6%) of patients requiring EVD and in 6.4% (95% CI = 5.8-7.1%) of patients who did not require EVD (OR = 3.92, p < 0.0001). The mean time between EVD placement and rebleeding was 1 h (range, 0-8 h). The maximal aneurysm diameter of patients with rerupture was larger when compared with patients without rerupture (9.9 mm vs. 7.5 mm; p < 0.04). High Fisher grades (III-IV) were present in 75% of patients with rerupture and in 60% of patients without aneurysmal rerupture (p < 0.0001).

CONCLUSIONS

Our study conclusively defined an association between EVD and rebleeding. However, the effective role of EVD in aneurysm rebleeding is insufficiently investigated in the literature. Other significant factors of rebleeding are usually observed in patients requiring ventricular drainage. According to our findings, a causal relationship between EVD and aneurysm rebleeding could be a plausible hypothesis, at least in certain cases.

Intracranial Multimodality Monitoring for Delayed Cerebral Ischemia

Management of patients with aneurysmal subarachnoid hemorrhage focuses on prevention of rebleeding by early treatment of the aneurysm, as well as detection and management of neurologic and medical complications. Early detection of delayed cerebral ischemia and management of modifiable contributing causes such as vasospasm take a central role, with the goal of preventing irreversible cerebral injury. In efforts to prevent delayed cerebral ischemia, multimodality monitoring has emerged as a promising tool in detecting subclinical physiologic changes before infarction occurs. However, there has been much variability in the utilization of this technology. Recent consensus guidelines discuss the role of multimodality monitoring in acute brain injury. In this review, we evaluate these guidelines and the utility of each modality of multimodality monitoring in aneurysmal subarachnoid hemorrhage.

The critical care management of poor-grade subarachnoid haemorrhage

Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.

Hybrid Operating Room for Combined Neuroendovascular and Endoscopic Treatment of Ruptured Cerebral Aneurysms with Intraventricular Hemorrhage

BACKGROUND

Intraventricular hemorrhages (IVHs) caused by ruptured cerebral aneurysms often have poor outcomes. Treatment challenges include comorbidities, increased intracranial pressure caused by IVH, and risk of rebleeding.

CASE DESCRIPTION

Two cases of severe IVH accompanied by acute hydrocephalus caused by ruptured aneurysm were treated with coil embolization followed by endoscopic hematoma evacuation as a single treatment session in a hybrid operating room (OR) equipped with a multipurpose angio biplane system. The first case was an 84-year-old woman with a ruptured basilar top aneurysm, who presented with Hunt and Hess (H&H) grade 5 subarachnoid hemorrhage (SAH) with packed IVH. The second case was a 43-year-old man with a ruptured anterior communicating artery aneurysm who presented with H&H grade 5 SAH with packed IVH. In both cases, endovascular coil embolization was performed first to prevent intraoperative bleeding. The coiled aneurysms suddenly appeared on the screen of the endoscope during the hematoma removal, which could have led to massive rebleeding if not treated previously. Neither patient needed a reinsertion of the ventricular drainage or developed chronic hydrocephalus during hospitalization. The hybrid OR enabled the 2 treatment approaches to be performed without the need to transfer the patient, thereby minimizing the transition time between the modalities. Intraoperative cone-beam computed tomography contributed to the evaluation of residual clots.

CONCLUSIONS

A hybrid OR may contribute to a combined neuroendoscopic and endovascular treatment for ruptured cerebral aneurysms with severe intraventricular hemorrhage.

Managing subarachnoid hemorrhage in the neurocritical care unit

Patients with aneurysmal subarachnoid hemorrhage who survive the initial hemorrhage require complex interventions to occlude the aneurysm, typically followed by a prolonged intensive care unit and hospital course to manage the complications that follow. Much of the morbidity and mortality from this disease happens in delayed fashion in the neurocritical care unit. Despite progress made in the last decades, much remains to be understood about this disease and how to best manage these patients. This article provides a review of current evidence and the authors' experience, aimed at providing practical aid to those caring for patients with this disease.

[Aneurysmal subarachnoid hemorrhage]

Acute subarachnoid hemorrhage (SAH) is a severe and acute life-threatening cerebrovascular disease. Approximately 80% of all acute non-traumatic SAHs are the result of a ruptured cerebrovascular aneurysm. Despite advances in diagnosis and treatment a high morbidity and mortality still exists. Apart from the primary cerebral damage there are also secondary complications, such as vasospasm, rebleeding, hydrocephalus, cerebral edema or hydrocephalus. For an appropriate therapy an understanding of the extensive pathophysiology, the options in diagnostics and therapy and the complications of the disease are essential. Anesthesiologists are decisively involved in the therapy of the primary and secondary damages and subsequently in the outcome as well. This article provides an overview of the perioperative and intensive care management of patients with SAH.

Aggressive CSF diversion reverses delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a case report

BACKGROUND

External ventricular drain (EVD) placement temporarily provides cerebrospinal fluid (CSF) diversion and is indicated in patients with aneurysmal subarachnoid hemorrhage (aSAH) to relieve hydrocephalus.

METHODS

Case report.

RESULTS

A 56-year-old woman was admitted to our hospital with aSAH complicated by acute hydrocephalus. An EVD was placed and set to 15 mmHg. After nearly 72 h, she clinically deteriorated. A computed tomography (CT) perfusion scan showed hypoperfusion in the watershed regions in both hemispheres and CT angiogram showed mild segmental arterial narrowings. After the EVD was lowered to 5 mmHg, the radiologic perfusion abnormalities and clinical symptoms resolved.

CONCLUSIONS

We postulate a mechanism by which CSF diversion could decrease the risk of delayed cerebral ischemia after aSAH: CSF drainage at low levels of intracranial pressure (e.g., 5 mmHg) could improve blood flow in the microcirculation, and thus improve tissue perfusion.

Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

PURPOSE

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

RESULTS

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

CONCLUSIONS

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

External ventricular drainage for intraventricular hemorrhage

Hemorrhagic stroke accounts for only 10% to 15% of all strokes; however, it is associated with devastating outcomes. Extension of intracranial hemorrhage (ICH) into the ventricles or intraventricular hemorrhage (IVH) has been consistently demonstrated as an independent predictor of poor outcome. In most circumstances the increased intracranial pressure and acute hydrocephalus caused by ICH is managed by placement of an external ventricular drain (EVD). We present a systematic review of the literature on the topic of EVD in the setting of IVH hemorrhage, articulating the scope of the problem and prognostic factors, clinical indications, surgical adjuncts, and other management issues.

Hydrocephalus after aneurysmal subarachnoid hemorrhage

Hydrocephalus is a common and potentially devastating complication of aneurysmal subarachnoid hemorrhage (SAH). Its incidence is approximately 20% to 30%, and its onset can be acute, within 48 hours after SAH, or rarely chronic, occurring in a delayed fashion weeks and even months after the hemorrhage. Early recognition of its signs and symptoms and accurate interpretation of computed tomography (CT) studies are important for the management of patients with SAH. Clinically, a poor neurologic grade has the highest correlation with an increased incidence of hydrocephalus. Radiographically, the bicaudate index on CT studies has emerged as the best marker of this condition. Although further studies are needed to understand the complex pathophysiology of this condition, hydrocephalus after SAH can be treated effectively using current technology.

Acute hydrocephalus and cerebral perfusion after aneurysmal subarachnoid hemorrhage

BACKGROUND AND PURPOSE

Acute hydrocephalus after aneurysmal subarachnoid hemorrhage (SAH) may decrease cerebral perfusion by increasing intracranial pressure. We studied cerebral perfusion in patients with and without acute hydrocephalus after SAH.

MATERIALS AND METHODS

We performed noncontrast CT scans, CT perfusion (CTP), and CT angiography on admission in all patients with aneurysmal SAH. Patients were dichotomized at a relative bicaudate index of 1 for the presence or absence of hydrocephalus. Cerebral perfusion was measured in the cortex, basal ganglia, and periventricular white matter. Mean CTP parameters were compared between patients with and without acute hydrocephalus (ie, within 3 days after SAH).

RESULTS

We included 138 consecutive patients with successful CTP measurements, of whom 49 (36%) had acute hydrocephalus. Mean cerebral blood flow (CBF) was lower in patients with hydrocephalus than in those without in the basal ganglia (difference of means, 6.8; 95% CI, 1.6-11.0 mL/100 g/min) and periventricular white matter (difference of means, 3.8; 95% CI, 0.9-6.8 mL/100 g/min) but not in the cortex (difference of means, 1.8; 95% CI, -2.8 to 6.4 mL/100 g/min). In all regions studied, mean transit time (MTT) and time-to-peak (TTP) were statistically significantly longer in patients with hydrocephalus, but cerebral blood volume (CBV) values were similar.

CONCLUSIONS

Acute hydrocephalus after SAH reduces CBF in the deep gray matter and periventricular white matter and delays MTT and TTP in all investigated brain areas. The negative effect of acute hydrocephalus on cerebral perfusion in patients with SAH seems more pronounced in the vicinity of the ventricles than in remote sites.

[General management in intensive care of patient with spontaneous subarachnoid hemorrhage]

Aneurysmal subarachnoid hemorrhage (SAH) is a neurologic emergency and often a neurologic catastrophe. Nontraumatic subarachnoid hemorrhage is characterized by the extravasation of blood into the spaces covering the central nervous system. The leading cause of SAH is rupture of an intracranial aneurysm, which accounts for about 80-85% of cases. Mortality and morbidity can be reduced if SAH is treated urgently. Sudden, explosive headache is a cardinal but nonspecific feature in the diagnosis of SAH; computered tomography (CT) scanning is mandatory in all the patients with symp toms that are suggestive of SAH. Catheter angiography for detecting aneurysms is gradually being replaced by CT angiography. Diagnosing SAH can be challenging and treatment is complex, sophisticated and multidisciplinary. Reble eding is the most imminent danger, which must be prevented by endovascular occlusion with detachable coils (coiling) or by surgical clipping of the aneurysm; the risk of delayed cerebral ischemia is reduced with nimodipine and avoiding hypovolemia; hydrocephalus can be treated by ventricular drainage. Intensive care plays a more important role in the management of SAH than in any other neurological disorder. Excellence in neurologic diagnosis, in operative neurosurgery or neuroradiologic procedures must be accompanied by excellence in Intensive Care. This review emphasizes treatment in the Intensive Care Unit, surgical and endovascular therapeutic options and the current state of treatment of major complications such as rebleeding, cerebral vasospasm and acute hydrocephalus.

Intraventricular hemorrhage caused by peripheral anterior choroidal artery aneurysm rupture. A case report

Intraventricular hemorrhage is a severe ictal event secondary to several pathological conditions (anticoagulation therapies, hypertension, post-surgical, traumatic, neoplastic, vascular malformations), leading to blockage of CSF flow and possible hydrocephalus, often justifying surgical intervention. We describe an uncommon source of intraventricular hemorrhage in a 54-year-old woman caused by a peripheral anterior choroidal artery aneurysm rupture.

Subarachnoid haemorrhage

Subarachnoid haemorrhage accounts for only 5% of strokes, but occurs at a fairly young age. Sudden headache is the cardinal feature, but patients might not report the mode of onset. CT brain scanning is normal in most patients with sudden headache, but to exclude subarachnoid haemorrhage or other serious disorders, a carefully planned lumbar puncture is also needed. Aneurysms are the cause of subarachnoid haemorrhage in 85% of cases. The case fatality after aneurysmal haemorrhage is 50%; one in eight patients with subarachnoid haemorrhage dies outside hospital. Rebleeding is the most imminent danger; a first aim is therefore occlusion of the aneurysm. Endovascular obliteration by means of platinum spirals (coiling) is the preferred mode of treatment, but some patients require a direct neurosurgical approach (clipping). Another complication is delayed cerebral ischaemia; the risk is reduced with oral nimodipine and probably by maintaining circulatory volume. Hydrocephalus might cause gradual obtundation in the first few hours or days; it can be treated by lumbar puncture or ventricular drainage, dependent on the site of obstruction.