Treatment Guidelines Updated for Aneurysmal Subarachnoid Hemorrhage

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May 3, 2012 —The American Stroke Association (ASA) announced that updated guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) have been published online ahead of print in Stroke. E. Sander Connolly, Jr, MD, served as Chair of the statement writing group, which updated guidelines that were issued in 2009.

According to the ASA, aSAH is the cause of approximately 5% of all strokes and affects more than 30,000 Americans each year, most of them between 40 and 60 years old. Treatment of aSAH by clipping or coiling has been shown to prevent rebleeding of the aneurysm in most cases.

The guidelines recommended that patients who are diagnosed in the emergency room with aSAH should be considered for immediate transfer to a hospital that treats at least 35 cases a year. Research indicates 30-day death rates were significantly higher in low-volume facilities: 39% in hospitals admitting less than 10 patients compared to 27% in hospitals treating more than 35 patients each year.

Some of the other 21 new recommendations are:

• Between onset of aSAH symptoms and treatment of the aneurysm, blood pressure should be controlled with an agent to balance the risk of stroke and hypertension-related rebleeding, and to maintain cerebral perfusion pressure.

• Unless there is a compelling contraindication, follow-up imaging after coiling or microsurgical clipping of an aneurysm should be delayed, and strong consideration should be given to retreatment if the remnant is growing.

• Experienced cerebrovascular surgeons and endovascular specialists should determine a multidisciplinary treatment approach based on characteristics of the patient and the aneurysm.

Additionally, prevention recommendations continue to focus on controlling hypertension and avoiding cigarette smoking and excessive alcohol consumption. Patients experiencing aSAH symptoms (a sudden, severe “thunderclap” headache with vomiting, confusion, loss of consciousness, and seizures) are urged to immediately get to an emergency room.

“Admission to high-volume centers has been associated with lower disability and death,” Dr. Connolly commented in a press release. “While the reasons for this association are not completely clear, patients admitted to high-volume facilities have increased access to experienced cerebrovascular surgeons and endovascular specialists, as well as multidisciplinary neurointensive care services, such as electroencephalography monitoring to rule out nonconvulsive-status seizures.”

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