Management of aneurysmal subarachnoid hemorrhage: State of the art and future perspectives

Abstract

Background:Aneurysmal subarachnoid hemorrhage (SAH) accounts for 5% of strokes and carries a poor prognosis. It affects around 6 cases per 100,000 patient years occurring at a relatively young age.Methods:Common risk factors are the same as for stroke, and only in a minority of the cases, genetic factors can be found. The overall mortality ranges from 32% to 67%, with 10–20% of patients with long-term dependence due to brain damage. An explosive headache is the most common reported symptom, although a wide spectrum of clinical disturbances can be the presenting symptoms. Brain computed tomography (CT) allow the diagnosis of SAH. The subsequent CT angiography (CTA) or digital subtraction angiography (DSA) can detect vascular malformations such as aneurysms. Non-aneurysmal SAH is observed in 10% of the cases. In patients surviving the initial aneurysmal bleeding, re-hemorrhage and acute hydrocephalus can affect the prognosis.Results:Although occlusion of an aneurysm by surgical clipping or endovascular procedure effectively prevents rebleeding, cerebral vasospasm and the resulting cerebral ischemia occurring after SAH are still responsible for the considerable morbidity and mortality related to such a pathology. A significant amount of experimental and clinical research has been conducted to find ways in preventing these complications without sound results.Conclusions:Even though no single pharmacological agent or treatment protocol has been identified, the main therapeutic interventions remain ineffective and limited to the manipulation of systemic blood pressure, alteration of blood volume or viscosity, and control of arterial dioxide tension.

Introducing the concept of “CSF‐shift edema” in traumatic brain injury

“…Similarly to aneurysmal SAH (aSAH), following TBI SAH can produce direct brain damage and cerebral injury mediated by vasospasm. Acute brain injury after SAH is a multifactorial process characterized by ‘primary’ insults that involve acute ICP/CPP and CBF changes, vascular constriction, and ‘secondary’ ischemic processes that include anaerobic cellular respiration, energy depletion, impaired protein synthesis, excitotoxicity, free radical attack, neuronal stress, DNA damage, apoptosis, and necrosis (Grasso, ; Grasso, Alafaci, & Macdonald, ; Sehba & Bederson, ).…”

Cerebrospinal fluid cytology in nonmalignant aseptic meningeal disorders

“…84 Initially, the diagnosis of SAH depends upon a high index of clinical suspicion combined with radiologic confirmation, followed by a lumbar puncture or CT angiography of the brain. It may occur for several reasons, the most common being head trauma.…”

“…However, utilization of the term SAH usually refers to nontraumatic (or spontaneous) haemorrhage, which in the majority of cases occurs in the setting of a ruptured cerebral aneurysm or arteriovenous malformation. 84 Initially, the diagnosis of SAH depends upon a high index of clinical suspicion combined with radiologic confirmation, followed by a lumbar puncture or CT angiography of the brain. A bloody and/or xanthochromic CSF provides evidence of a SAH.…”

Role of serum biomarkers and transcranial Doppler in predicting cerebral vasospasm after aneurysmal subarachnoid hemorrhage

“…Aneurysmal subarachnoid hemorrhage (aSAH) is a neurologic emergency caused by a brain aneurysm burst, resulting in a bleeding into the subarachinoid space. Around 10.5 per 100,000 persons per year developed subarachnoid hemorrhage (SAH) [1]. Approximately 20 to 30% of patients with aSAH suffer from delayed cerebral ischemia (DCI) due to cerebral vasospasm (CV) [2].…”