Subarachnoid Hemorrhage

Susanne Muehlschlegel, MD, MPH, FNCS, FCCM p. 1623-1657 December 2018, Vol.24, No.6 doi: 10.1212/CON.0000000000000679
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PURPOSE OF REVIEW: This article reviews the epidemiology, clinical presentation, diagnosis, and management of patients with aneurysmal subarachnoid hemorrhage (SAH). SAH is a type of hemorrhagic stroke and is a neurologic emergency with substantial morbidity and mortality. This article reviews the most common and potentially life-threatening neurologic and medical complications to promote their early recognition and prevent secondary brain injury.

RECENT FINDINGS: Over the past 30 years, the incidence of SAH has remained stable; yet, likely because of improved care in specialized neurocritical care units, discharge mortality has considerably decreased. Two consensus guidelines by the American Heart Association/American Stroke Association and the Neurocritical Care Society have outlined best practices for the management of patients with SAH. The most important recommendations include admission of patients to high-volume centers (defined as more than 35 SAH admissions per year) under the management of a multidisciplinary, specialized team; expeditious identification and treatment of the bleeding source with evaluation by a multidisciplinary team consisting of cerebrovascular neurosurgeons, neuroendovascular specialists, and neurointensivists; management of patients in a neurocritical care unit with enteral nimodipine, blood pressure control, euvolemia, and close monitoring for neurologic and medical complications; and treatment of symptomatic cerebral vasospasm/delayed cerebral ischemia with induced hypertension and endovascular therapies. This article also highlights new insights of SAH pathophysiology and provides updates in the management approach.

SUMMARY: SAH remains a neurologic emergency. Management of patients with SAH includes adherence to published guidelines, but some areas of SAH management remain understudied. Clinical trials are required to elucidate the role of these controversial management approaches in improving patient outcomes.

Address correspondence to Dr Susanne Muehlschlegel, Departments of Neurology, Anesthesia/Critical Care & Surgery, University of Massachusetts Medical School, University Campus, S-5, 55 Lake Ave N, Worcester, MA 01655, susanne.muehlschlegel@umassmemorial.org.

RELATIONSHIP DISCLOSURE: Dr Muehlschlegel has received research/grant support from the National Institutes of Health/National Institute of Child Health and Human Development and the Prize for Academic Collaboration and Excellence (PACE) from the University of Massachusetts Memorial Medical Group. Dr Muehlschlegel receives partial research salary support as the site principal investigator for the INTREPID (Impact of Fever Prevention Continued on page 1657in Brain Injured Patients) trial sponsored by C. R. Bard Inc. Dr Muehlschlegel has received compensation for serving as a course director for the American Academy of Neurology.

UNLABELED USE OF PRODUCTS/INVESTIGATIONAL USE DISCLOSURE: Dr Muehlschlegel discusses the unlabeled/investigational short-term use of antifibrinolytics (ε-aminocaproic acid and tranexamic acid) for the treatment of early aneurysm bleeding, the use of fludrocortisone for the treatment of cerebral salt wasting syndrome after subarachnoid hemorrhage, the use of levetiracetam for seizure prophylaxis, and the use of milrinone, nicardipine, and verapamil as endovascular therapy using intraarterial vasodilators for the treatment of subarachnoid hemorrhage.

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© 2018 American Academy of Neurology