Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1

Abstract

Background Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm. Methods A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. Results Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided. Conclusions This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.

Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)—part 2

“…The methodology of the consensus has been previously described in detail [8,9]. Briefly, the project was commissioned and approved by the Executive Committee of the SIAARTI which supported and supervised the development and the methodology of the consensus.…”

“…This paper, similarly to the first part [9], has several limitations. We deliberately did not base our statements on systematic literature reviews because of the lack of evidence (previously underlined) and in favor of simple, basic topics that are rarely subject to investigation.…”

“…8 With advanced hemodynamic monitoring. 9 If available, to utilize therapy personalization for DCI associated with cerebral vasospasm in poor-grade SAH patients where neurological assessment is not possible. Abbreviations: TCD transcranial doppler, TCCD transcranial color doppler, MAP mean arterial pressure, Mg magnesium, BCT body core temperature, Hb hemoglobin, ICP intracranial pressure, CPP cerebral perfusion pressure, DCI delayed cerebral ischemia, CTA computed tomography angiography, DSA digital subtraction angiography, IA intra-arterial, CT computed tomography, MMN multimodal neuromonitoring We recommend against the administration of oral/intravenous nimodipine in hemodynamically unstable SAH patients (i.e., under inotropes and/or vasopressors therapy) (agreement 77%, weak recommendation).…”

“…Over the years, numerous intra-arterial vasodilators have been evaluated such as papaverine, nicardipine, verapamil, nimodipine, and milrinone [7]. Possible advantages of intra-arterial vasodilators with respect to PTCA are a distal and more diffuse effect and a better safety profile [7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]. In some cases (distal + proximal vessels vasospasm), they can be used in conjunction with PTCA [21].…”

“…The treatment should be individualized after discussion with the interventional neuroradiologist 8. With advanced hemodynamic monitoring 9. If available, to utilize therapy personalization for DCI associated with cerebral vasospasm in poor-grade SAH patients where neurological assessment is not possible.…”