Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome

Abstract

BackgroundAneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients.Main body of the abstractDelayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined.Short conclusionAlthough we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.

Association of abnormal carbon dioxide levels with poor neurological outcomes in aneurysmal subarachnoid hemorrhage: a retrospective observational study

“…All the patients with SAH were managed in accordance with the Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage by the American Heart Association/American Stroke Association [8, 18]. In addition to general intensive care, all the patients were monitored for clinical deterioration or for the development of cerebral infarction owing to DCI.…”

“…The overall mortality in patients with SAH is over 30%, and approximately 10–20% of survivors show functional dependence despite intensive neurological care [1, 2]. Several extensive studies have been conducted to improve intensive neurological care in patients with SAH [3–8].…”

Contemporary Management of Aneurysmal Subarachnoid Hemorrhage: A Literature Review

“…29,46,47 Of the components, hypertensive therapy has the most supporting evidence. 27,39,48,49 A recent retrospective observational study of 300 patients with DCI found that hypertensive therapy was associated with a reduction in both cerebral infarcts and poor clinical outcomes. 39 In the induced hypertension group, 20% of patients developed infarcts compared with 33% in the group who did not receive therapy.…”

“…29,77,78 Hypernatremia Hypernatremia is much less common than hyponatremia in aSAH and usually occurs due to inadequate free water replacement, volume loss, or excess sodium administration. 36,49 Central diabetes insipidus (DI) can occur from hypothalamic dysfunction but is very infrequent in SAH. 36,49 Maintaining fluid balance can be a challenge in managing patients with DI, as significant prolonged polyuria is often a key feature.…”

“…36,49 Central diabetes insipidus (DI) can occur from hypothalamic dysfunction but is very infrequent in SAH. 36,49 Maintaining fluid balance can be a challenge in managing patients with DI, as significant prolonged polyuria is often a key feature.…”