2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Three-Dimensional Virtual Reality Simulation to Safe Planning Neurosurgical Procedure in Brain Aneurysms, Latin American Single-Center Experience: Advantages and Limitations

Background The neurosurgical approach to clipping cerebral aneurysms has been a complex challenge for all neurosurgeon experts in cerebrovascular surgery. The three-dimensional computed tomography angiography (3D-CTA) allows identifying bone and vascular structures close to an aneurysm to simulate in virtual 3D images, the appropriate and safest approach to cerebral aneurysm clipping.

Objectives This study aims to share our experience using 3D simulation as a support to the safe planning for cerebrovascular disease surgery.

Materials and Methods We reviewed the surgical outcomes from a cerebrovascular neurosurgeon using the 3D-CTA images in 360-degree reconstruction in the planning of the preoperative surgical procedure for the treatment of brain aneurysm. In all patients, the virtual surgical approach was replicated in real-time surgery.

Results We analyzed 34 patients around 51 ± 8 years of age. Of these, 76.5% (n = 26) and 23.5% (n = 8) were males and females, respectively. Saccular aneurysms were the most frequent (85%), the Arteries affected by aneurysms were middle cerebral artery (n = 6), basilar tip (n = 6), vertebral artery in V3 and V4 (n = 6), and posterior cerebral artery (n = 5). The virtual surgical pterional approach was the most frequently used (50%), followed by fronto-orbito-zigomático (29%) and far lateral (15%) approaches. There were no intraoperative complications in any patient.

Conclusion Preoperative 3D virtual reality simulation is a great support tool to perform a safe surgical procedure in real-time for the treatment of simple and complex brain aneurysms.

Microsurgical clipping of multiple cerebral aneurysms in the acute phase of aneurysmal subarachnoid hemorrhage through a minipterional approach: The Chilean experience

OBJECTIVE

The minipterional craniotomy (MPTc) has been widely accepted as a minimally invasive alternative to the pterional approach for the treatment of certain small non-ruptured anterior circulation aneurysms. The aim of this study was to determine the effectiveness and safety of the MPTc in the context of a complex and potentially harmful scenario: acute onset of subarachnoid hemorrhage (SAH) in patients harboring multiple intracranial aneurysms (MIA).

METHODS

Patients harboring MIA clipped through a unilateral MPTc were selected from four retrospective databases of four high-volume neurosurgical centers. Patients with a Hunt & Hess score 4 or 5 were not considered candidates for clipping through a MPTc. Medical records and radiological images were retrospectively reviewed. Epidemiological, clinical and radiological data, as well as short-term outcome (modified Rankin scale at 6 month-follow-up) were analyzed.

RESULTS

16 patients harboring 33 aneurysms (16 ruptured, 17 non ruptured) met the inclusion criteria. Each aneurysm size was 5.7 ± 2.1 mm (range 3-11). 12 out of 33 aneurysms were located in the middle cerebral artery (MCA). Anterior communicating (ACom) and MCA aneurysms were the aneurysm locations most commonly ruptured (5 each, 62 %). Complete occlusion was achieved in 32 aneurysms (97 %) and near-complete occlusion in 1 (3%). 13 patients (93 %) were independent at 6 month-follow-up. Mortality rate was 0%. Complications included 1 cerebrospinal-fluid leakage.

CONCLUSION

When indicated (Hunt Hess < 4), performing a MPTc is safe and effective in aSAH cases with multiple aneurysms.

Fabrication of cerebral aneurysm simulator with a desktop 3D printer

Now, more and more patients are suffering cerebral aneurysm. However, long training time limits the rapid growth of cerebrovascular neurosurgeons. Here we developed a novel cerebral aneurysm simulator which can be better represented the dynamic bulging process of cerebral aneurysm The proposed simulator features the integration of a hollow elastic vascular model, a skull model and a brain model, which can be affordably fabricated at the clinic (Fab@Clinic), under $25.00 each with the help of a low-cost desktop 3D printer. Moreover, the clinical blood flow and pulsation pressure similar to the human can be well simulated, which can be used to train the neurosurgical residents how to clip aneurysms more effectively.

Recent advances in diagnostic approaches for sub-arachnoid hemorrhage

Sub-arachnoid hemorrhage (SAH) has been easily one of the most debilitating neurosurgical entities as far as stroke related case mortality and morbidity rates are concerned. To date, it has case fatality rates ranging from 32-67%. Advances in the diagnostic accuracy of the available imaging methods have contributed significantly in reducing morbidity associated with this deadly disease. We currently have computed tomography angiography (CTA), magnetic resonance angiography (MRA) and the digital subtraction angiography (DSA) including three dimensional DSA as the mainstay diagnostic techniques. The non-invasive angiography in the form of CTA and MRA has evolved in the last decade as rapid, easily available, and economical means of diagnosing the cause of SAH. The role of three dimensional computed tomography angiography (3D-CTA) in management of aneurysms has been fairly acknowledged in the past. There have been numerous articles in the literature regarding its potential threat to the conventional “gold standard” DSA. The most recent addition has been the introduction of the fourth dimension to the established 3D-CT angiography (4D-CTA). At many centers, DSA is still treated as the first choice of investigation. Although, CT angiography still has some limitations, it can provide an unmatched multi-directional view of the aneurysmal morphology and its surroundings including relations with the skull base and blood vessels. We study the recent advances in the diagnostic approaches to SAH with special emphasis on 3D-CTA and 4D-CTA as the upcoming technologies.

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.