Managing aneurysmal subarachnoid hemorrhage: It takes a team

Manoel, Airton Leonardo de Oliveira; Turkel‐Parrella, David; Duggal, Abhijit; Murphy, Amanda; McCredie, Victoria; Marotta, Thomas R.

doi:10.3949/ccjm.82a.14021

Cited by 22 publications

(30 citation statements)

References 108 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…Low risk patients (VASOGRADE-Green) may be monitored less aggressively, probably only with frequent neurological examination. 24,36 Patients predicted to have higher risk of DCI b. Decision on disposition and length of stay: Two thirds of the total direct medical costs generated during a 1-year followup in patients with aneurysmal SAH is because of hospital inpatient days.…”

Section: 11mentioning

confidence: 99%

“…17 Only decreasing the average length of stay, especially in the ICU, can reduce these costs. Because of high risk of DCI, VASOGRADE-Yellow and -Red patients should probably be admitted to a step-down or intensive care unit, respectively, for ≈14 days, 24,36 whereas VASOGRADEGreen patients, especially if older and without SAH-related medical complications, 16 may be discharged to a regular ward earlier, by the end of the first week. 24,36 c. Treatment aggressiveness: VASOGRADE-Red patients are at high risk of developing cardiac and pulmonary complications; therefore, they may benefit from invasive hemodynamic monitoring (eg, transpulmonary thermodilution).…”

Section: 11mentioning

confidence: 99%

“…Because of high risk of DCI, VASOGRADE-Yellow and -Red patients should probably be admitted to a step-down or intensive care unit, respectively, for ≈14 days, 24,36 whereas VASOGRADEGreen patients, especially if older and without SAH-related medical complications, 16 may be discharged to a regular ward earlier, by the end of the first week. 24,36 c. Treatment aggressiveness: VASOGRADE-Red patients are at high risk of developing cardiac and pulmonary complications; therefore, they may benefit from invasive hemodynamic monitoring (eg, transpulmonary thermodilution). 37 Additionally, aggressive strategies to avoid hypovolemia should be implemented (eg, goal-directed therapy, daily sodium balance, daily weight, prophylactic use of fludrocortisone) in this patient population because hypovolemia increases even further the risk of DCI.…”

Section: 11mentioning

confidence: 99%

See 2 more Smart Citations

The VASOGRADE

Manoel¹,

Jaja

Germans³

et al. 2015

Stroke

Self Cite

107

View full text Add to dashboard Cite

Background and Purpose— Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale—the VASOGRADE—for prediction of DCI. Methods— We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1–3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots. Results— In a cohort of 746 patients, the VASOGRADE significantly predicted DCI ( P <0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77–2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07–4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration. Conclusions— The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.

show abstract

Section: 11mentioning

confidence: 99%

Section: 11mentioning

confidence: 99%

Section: 11mentioning

confidence: 99%

See 1 more Smart Citation

The VASOGRADE

Manoel¹,

Jaja

Germans³

et al. 2015

Stroke

Self Cite

107

View full text Add to dashboard Cite

show abstract

“…Management algorithms are largely based on admission clinical status and the volume of SAH. 1,2 The World Federation of Neurosurgical Societies (WFNS) has a commonly used scale to assess presentation clinical status. 3 Higher WFNS grades (IV-V) are associated with a higher risk of DCI and death, [3][4] while a good grade (WFNS I-III) at admission indicates lower risk.…”

mentioning

confidence: 99%

Prospective Multicenter Study of Changes in MTT after Aneurysmal SAH and Relationship to Delayed Cerebral Ischemia in Patients with Good- and Poor-Grade Admission Status

Murphy¹,

Lee

Marotta

et al. 2018

AJNR Am J Neuroradiol

View full text Add to dashboard Cite

BACKGROUND AND PURPOSE: Patients with aneurysmal SAH and good clinical status at admission are considered at a lower risk for delayed cerebral ischemia. Prolonged MTT may be associated with an increased risk. It is unclear whether this is dependent on clinical status. Our purpose was to determine whether increased MTT within 3 days of aneurysmal SAH compared with baseline is associated with a higher risk of delayed cerebral ischemia in patients with good (World Federation of Neurosurgical Societies I-III) versus poor (World Federation of Neurosurgical Societies IV-V) admission status. MATERIALS AND METHODS: This prolonged MTT was a multicenter, prospective cohort investigation of 87 patients with aneurysmal SAH. MTT was measured at admission before aneurysm treatment (MTT1) and following repair (MTT2) within 3 days of admission; MTT diff was calculated as the difference between MTT2 and MTT1. Changes in MTT across time were assessed with repeated measures analyses. Risk of delayed cerebral ischemia or death was determined with multivariate logistic regression analysis. RESULTS: In patients with a good grade (n ϭ 49), MTT was prolonged in patients who developed delayed cerebral ischemia, with MTT diff significantly greater (0.82 Ϯ 1.5) compared with those who did not develop delayed cerebral ischemia (Ϫ0.14 Ϯ 0.98) (P ϭ .03). Prolonged MTT was associated with a significantly higher risk of delayed cerebral ischemia or death (OR ϭ 3.1; 95% CI, 1.3-7.4; P ϭ .014) on multivariate analysis. In patients with poor grades (n ϭ 38), MTT diff was not greater in patients who developed delayed cerebral ischemia; MTT1 was significantly prolonged compared with patients with a good grade. CONCLUSIONS: Patients in good clinical condition following aneurysmal SAH but with increasing MTT in the first few days after aneurysmal SAH are at high risk of delayed cerebral ischemia and warrant close clinical monitoring. ABBREVIATIONS: aSAH ϭ aneurysmal SAH; DCI ϭ delayed cerebral ischemia; GCS ϭ Glasgow Coma Scale; ICP ϭ intracranial pressure; MTT1 ϭ MTT before aneurysm treatment; MTT2 ϭ MTT after repair; MTT diff ϭ the difference between MTT before aneurysm treatment and after repair; WFNS ϭ World Federation of Neurosurgical Societies

show abstract

“…The main purpose of fluid treatment in SAH is to maintain euvolemia and normal circulating blood volume. It should be noted that uncontrolled hypervolemia and hemodilution do not improve cerebral oxygen formation and may cause adverse events [73][74][75][76][77].…”

Section: Complications and Current Treatment Approachesmentioning

confidence: 99%

Intensive Care Management in Cerebral Aneurysm and Arteriovenous Malformations

Ozkan¹

2020

Vascular Malformations of the Central Nervous System

View full text Add to dashboard Cite

Aneurysmal subarachnoid hemorrhage is an important group of intracranial hemorrhage with a high risk of disability and mortality. The initial amount of bleeding, rebleeding, and delayed cerebral ischemia are considered as the most important factors in determining the prognosis of aneurysm-induced bleeding. In arteriovenous malformations, its location and deep venous drainage play a role in the prognosis. Cardiac complications, neurogenic pulmonary edema, hypertension, hyperglycemia, infections, and prolonged mechanical ventilation in aneurysmal subarachnoid hemorrhage lead to morbidity and mortality. Aneurysm bleeding control, appropriate fluid replacement to ensure euvolemia, when necessary external ventricular drainage and/or decompressive craniectomy, mannitol or hypertonic saline application, and infection control are the main principles of treatment.

show abstract

Managing aneurysmal subarachnoid hemorrhage: It takes a team

Abstract: Patients with aneurysmal subarachnoid hemorrhage are at high risk of complications, including rebleeding, delayed cerebral ischemia, cerebral infarction, and death. This review presents a practical approach for managing this condition and its complications.

Cited by 22 publications

References 108 publications

The VASOGRADE

The VASOGRADE

Prospective Multicenter Study of Changes in MTT after Aneurysmal SAH and Relationship to Delayed Cerebral Ischemia in Patients with Good- and Poor-Grade Admission Status

Intensive Care Management in Cerebral Aneurysm and Arteriovenous Malformations

Contact Info

Product

Resources

About