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

Hoh, Brian L.; Ko, Nerissa; Amin‐Hanjani, Sepideh; Chou, Sherry Hsiang‐Yi; Cruz‐Flores, Salvador; Dangayach, Neha; Derdeyn, Colin P.; Du, Rose; Hänggi, Daniel; Hetts, Steven W.; Johnson, Regina Jones; Keigher, Kiffon M; Leslie‐Mazwi, Thabele M; Lucke‐Wold, Brandon; Rabinstein, Alejandro A.; Robicsek, Steven A.; Stapleton, Christopher J.; Suárez, José I.; Tjoumakaris, Stavropoula; Welch, Babu G.

doi:10.1161/str.0000000000000436

Cited by 261 publications

(259 citation statements)

References 471 publications

(1,028 reference statements)

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“…Relevant ist in diesem Zusammenhang, dass 10-15 % dieser Patienten bereits im präklinischen Setting versterben [5]. Eine adäquate Erstversorgung und die unmittelbare Einweisung in ein Zentrum der neurovaskulären Maximalversorgung sind somit entscheidend.…”

Section: Merkeunclassified

“…Die notfallmäßige Akutversorgung orientiert sich an internationalen Leitlinien, den BLS-/ALS-Leitlinien des "European Resuscitation Council 2021", den PHTLS-/ATLS-Konzepten sowie aus Teilen der aktuell gültigen S3-Leitlinie "Schlaganfall" [5,22,23,24]. Die vorhandene S1-Leitlinie "Subarachnoidalblutung" besitzt inzwischen keine Gültigkeit mehr, eine Aktualisierung mit S2 k-Klassen-Upgrade ist bereits angemeldet und steht vor der zeitnahen Veröffentlichung.…”

Section: Akutversorgungunclassified

“…Hieraus leitet sich die wichtigste therapeutische Maßnahme in der prähospitalen Versorgung der SAB ab: die Aufrechterhaltung einer adäquaten zerebralen Perfusion bei gleichzeitiger Vermeidung systolischer Blutdruckspitzen. Bei Diagnosestellung einer SAB wird empfohlen, den systolischen Blutdruck unter 160 mmHg zu halten, weitere Blutdrucksenkungen auf Werte unter 140 mmHg werden bei eingeschränkter Datenlage kontrovers diskutiert [3,5,26]. Dabei sollte auf kurzwirksame intravenöse Medikamente wie Urapidil, Dihydralazin oder Kalziumantagonisten (z.…”

Section: Blutdruckmanagementunclassified

“…Wichtig ist die vorsichtige Titration der genannten Substanzen, um große Fluktuationen sowie Hypotonien mit verminderter zerebraler Perfusion zu vermeiden. Der MAP sollte zwischen 70 und 110 mmHg gehalten werden [3,5].…”

Section: Blutdruckmanagementunclassified

“…Der Nutzen einer Antagonisierung gerinnungsbeeinflussender Medikation wurde im Rahmen der SAB bisher nicht hinreichend untersucht, wird jedoch vor dem Hintergrund der Studienlage zu anderen lebensbedrohlichen Blutungen wie z. B. der intrazerebralen Blutung empfohlen und sollte sich an den entsprechenden Leitlinien orientieren [5,28].…”

Section: Gerinnungunclassified

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Aneurysmatische Subarachnoidalblutungen

Teske,

Schichor

2023

Notfallmedizin up2date

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Section: Merkeunclassified

Section: Akutversorgungunclassified

Section: Blutdruckmanagementunclassified

Section: Gerinnungunclassified

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Aneurysmatische Subarachnoidalblutungen

Teske,

Schichor

2023

Notfallmedizin up2date

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Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Mark,

Horton,

Reed

2024

JAMA Netw Open

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ImportanceSubarachnoid hemorrhage is typically diagnosed by noncontrast head computed tomography (CT); lumbar puncture is recommended if computed tomography is nondiagnostic, although CT cerebral angiography has been promoted as an alternative to lumbar puncture in this diagnostic pathway. The outcomes of this debate in practice have not been studied.ObjectiveTo determine whether CT cerebral angiography use has increased in lieu of lumbar puncture among emergency department (ED) patients with headache, with an increase in unruptured intracranial aneurysm detection.Design, Setting, and ParticipantsThis retrospective cohort study took place in 21 community EDs of an integrated health care system in Northern California between 2015 and 2021. Participants were adult (aged &gt;17 years) health plan members with a chief concern of headache. Exclusions were prior diagnoses of subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral arteriovenous malformation, or cerebrospinal fluid shunt. Data were analyzed from October to November 2023.ExposuresCT cerebral angiography and/or lumbar puncture during the ED encounter.Main Outcomes and MeasuresPrimary and secondary outcomes were 14-day and 90-day unruptured intracranial aneurysm detection, respectively. Safety outcomes were missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. The annual incidence of unruptured intracranial aneurysm detection was normalized to the incidence of subarachnoid hemorrhage (UIA:SAH ratio). Average annualized percentage changes were quantified using joinpoint regression analysis.ResultsAmong 198 109 included ED encounters, the mean (SD) age was 47.5 (18.4) years; 140 001 patients (70.7%) were female; 29 035 (14.7%) were Black or African American, 59 896 (30.2%) were Hispanic or Latino, and 75 602 (38.2%) were White. Per year, CT cerebral angiography use increased (18.8%; 95% CI, 17.7% to 20.3%) and lumbar punctures decreased (−11.1%; 95% CI, −12.0% to −10.4%), with a corresponding increase in the 14-day UIA:SAH ratio (3.5%; 95% CI, 0.9% to 7.4%). Overall, computed tomography cerebral angiography use increased 6-fold relative to lumbar puncture, with a 33% increase in the detection of UIA. Results were similar at 90 days and robust to sensitivity analyses. Subarachnoid hemorrhage (1004 cases) and bacterial meningitis (118 cases) were misdiagnosed in 5% and 18% of cases, respectively, with no annual trends (P = .34; z1003 = .95 and P = .74; z117 = −.34, respectively).Conclusions and RelevanceIn this cohort study of ED patients with headache, increases in CT cerebral angiography use were associated with fewer lumbar punctures and higher detection of unruptured intracranial aneurysms, with no significant change in missed diagnoses of subarachnoid hemorrhage or bacterial meningitis. While this shift in diagnostic strategy appeared safe in the short-term, the long-term consequences remain unclear.

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Localized Nicardipine Release Implants for Prevention of Vasospasm After Aneurysmal Subarachnoid Hemorrhage

Wessels,

Wolf,

Adage

et al. 2024

JAMA Neurol

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ImportanceCerebral vasospasm largely contributes to a devastating outcome after aneurysmal subarachnoid hemorrhage (aSAH), with limited therapeutic options.ObjectiveTo investigate the safety and efficacy of localized nicardipine release implants positioned around the basal cerebral vasculature at risk for developing proximal vasospasm after aSAH.Design, Setting, and ParticipantsThis single-masked randomized clinical trial with a 52-week follow-up was performed between April 5, 2020, and January 23, 2023, at 6 academic neurovascular centers in Germany and Austria. Consecutive patients with World Federation of Neurological Surgeons grade 3 or 4 aSAH due to a ruptured anterior circulation aneurysm requiring microsurgical aneurysm repair participated.InterventionDuring aneurysm repair, patients were randomized 1:1 to intraoperatively receive 10 implants at 4 mg of nicardipine each plus standard of care (implant group) or aneurysm repair alone plus standard of care (control group).Main Outcome and MeasuresThe primary end point was the incidence of moderate to severe cerebral angiographic vasospasm (aVS) between days 7 and 9 after aneurysm rupture as determined by digital subtraction angiography.ResultsOf 41 patients, 20 were randomized to the control group (mean [SD] age, 54.9 [9.1] years; 17 female [85%]) and 21 to the implant group (mean [SD] age, 53.6 [11.9] years; 14 female [67%]). A total of 39 patients were included in the primary efficacy analysis. In the control group, 11 of 19 patients (58%) developed moderate or severe aVS compared with 4 of 20 patients (20%) in the implant group (P = .02). This outcome was paralleled by a lower clinical need for vasospasm rescue therapy in the implant group (2 of 20 patients [10%]) compared with the control group (11 of 19 patients [58%]; P = .002). Between days 13 and 15 after aneurysm rupture, new cerebral infarcts were noted in 6 of 19 patients (32%) in the control group and in 2 of 20 patients (10%) in the implant group (P = .13). At 52 weeks, favorable outcomes were noted in 12 of 18 patients (67%) in the control group and 16 of 19 patients (84%) in the implant group (P = .27). The adverse event rate did not differ between groups.Conclusions and RelevanceThese findings show that placing nicardipine release implants during microsurgical aneurysm repair can provide safe and effective prevention of moderate to severe aVS after aSAH. A phase 3 clinical trial to investigate the effect of nicardipine implants on clinical outcome may be warranted.Trial RegistrationClinicalTrials.gov Identifier: NCT04269408

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

Cited by 261 publications

References 471 publications

Aneurysmatische Subarachnoidalblutungen

Aneurysmatische Subarachnoidalblutungen

Shifts in Diagnostic Testing for Headache in the Emergency Department, 2015 to 2021

Localized Nicardipine Release Implants for Prevention of Vasospasm After Aneurysmal Subarachnoid Hemorrhage

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