Guidelines for the Management of Aneurysmal SAH Danny Aghion, MD PGY-4 CV conference 6/4/12

Guidelines from the AHA/ASA Purpose: current and comprehensive recommendations for the dx and tx of aSAH Methods: MEDLINE lit search (11/1/06-5/1/10). Evidence tables and data derived rec’s were graded. Intended to be fully updated every 3 years Results: Evidence based guidelines are presented for aSAH. Risk factors, prevention, natural hx, outcome, dx, prevention of re-bleeding, surgical and endov. repair systems of care, anesthesia care, mgmt of vasospasm and delayed cerebral ischemia, mgmt of HCP, seizures and medical complications Conclusions: aSAH outcome can be dramatically impacted by early, aggressive, expert care. These guidelines offer a framework for goal-directed tx of the aSAH patient.

Introduction aSAH is a significant cause of M+M throughout the world At least ¼ of pt’s with aSAH will die ½ of survivors are left with some persistent neuro deficit That said, fatality rates are dropping Early aneurysm repair and aggressive mgmt of complications (HCP, DCI) is leading to improved functional outcomes

Incidence and prevalence Overall spontaneous SAH: 2-16 /100,000 USA: 2-14/10,000 Japan and Finland: 22.5/10,000 Lower in Central America 12-15% die pre-hospital Incidence increases with age (>50), women (1.24), Blacks, Hispanics

Etiology of SAH Pathological condition – bleeding into the subarachnoid space Spontaneous SAH – aneurysm, vascular malformations, idiopathic, secondary extension of ICH or IVH (hypertensive ICH), venous thrombosis, pituitary apoplexy, coagulopathies 20% of spontaneous SAH are idiopathic, about 2/3 of these are benign perimesencephalic SAH

Re-bleeding Most common in first hours after SAH and declines thereafter 4% in first 24 hours, 1% per day for 14 days =15% cumulative in first 2 weeks 50% re-bleed within first year, > 80% of those die After 6 months, rebleed rate: 2-3% per year Death: initial bleed 25-43%, within 1 year 2/3 die

Risk Factors and Prevention Age (increased with advancing age) Gender (females > males) Smoking (3-5 fold) Recent heavy alcohol intake Hypertension Cocaine Arterial occlusions, stenosis Presence of an unruptured aneurysm (large, pcomm, or VB) History of prior aSAH History of familial aneurysms (at least 1, and especially >2) Other genetic syndromes…

Diseases associated with aneurysms Fibromuscular dysplasia: up to 20% of patients may have aneurysms Autosomal dominant polycystic kidney disease: 0-40% have aneurysms Others: Ehlers Danlos type 4 Marfans syndrome coarctation of aorta sickle cell anemia

Avoidance of adverse effects Avoid Hypovolemia/Hypotension Avoid Hyponatremia Avoid Antifibrinolytics Avoid Hypomagnesemia Avoid Hypocarbia/Hypoxia Avoid Hyperthermia Avoid Hyper or hypoglycemia Avoid ↑ ICP Avoid Anti-hypertensives

Table 3. Applying Classification of Recommendations and Level of Evidence *Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial inf... Bederson J B et al. Stroke 2009;40:

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Risk Factors and prevention of aSAH: Recommendations Tx of HTN w/ anti-HTN meds to prevent ischemic stroke, ICH, other end- organ injury (Class I; Level of Evidence A) HTN should be treated, and such tx may reduce risk of aSAH (Class I; Level of Evidence B) Tobacco use and Alcohol misuse should be avoided to reduce the risk of aSAH (Class I; Level of Evidence B) Size, location, age, health status, morphology and hemodynamic ch of aneurysm when discussing risk of rupture (NEW; Class IIb,; LoE B) Diet rich in vegetables may lower aSAH risk (NEW; Class IIb, LOE B) Offer non-invasive screening (familial or at least 1 imm) (Class IIb; LOE B) After any repair, immediate CV imaging (NEW; Class I; Level of Evidence B)

What we do at RIH Tx HTN w/ anti-HTN meds HTN should be treated, and may reduce risk of aSAH Size, location, age, health status, morphology of aneurysm when discussing risk of rupture

Proposed changes: risk factors and prevention Continue to treat HTN Tobacco/Alcohol counseling Include discussion on hemodynamic characteristics of aneurysm when discussing risk of rupture Promote diet rich in vegetables on d/c paper work Discuss screening and offer MRA’s for familial SAH or at least 1 immediate family member with aneurysm/SAH Immediate CV imaging after any aneurysm repair

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Natural history and Outcome of aSAH: Recommendations Initial clinical severity should be rapidly determined, Hunt/Hess or World Federation of NS, b/c it is the most useful indicator of outcome after aSAH (Class I; Level of Evidence B) The risk of early re-bleeding is high and is associated with poor outcomes, therefore, URGENT eval and treatment is recommended (Class I; Level of Evidence B) After d/c, it is reasonable to refer pt to cognitive, behavioral, and psychosocial assessments (NEW; Class IIa; LOE B)

What we do at RIH Use Hunt/Hess scale (just be sure to document in chart for comp stroke ctr status) URGENT evaluation in ED and prompt treatment in VIR, 6INC, OR, etc.

Proposed changes: Natural history and Outcome of aSAH Continue to use Hunt/Hess Get down to the ED, VIR, ICU fast, early Utilize CM for referral or outpatient cognitive, behavioral, and psychosocial assessments

Add 1 for severe systemic disease or severe vasospasm

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Clinical Manifestations and Diagnosis: Recommendations aSAH is an emergency, often misdiagnosed, have high level of suspicion (Class I; Level of Evidence B) CT followed by LP if negative (Class I; Level of Evidence B) Consider CTA (?aid in repair) but Angio is gold standard (except in BPM SAH). (Class IIb; Level of Evidence C) MRI may be helpful in Dx in neg CT, but if neg still need LP (NEW; Class IIb; Level of Evidence C) Angio with 3D is indicated for aneurysm detection in patients with SAH and for planning treatment (NEW; Class I; LOE B)

What we do at RIH aSAH is an emergency, often misdiagnosed by ED, have high level of suspicion CT followed by LP if negative We tend to consider CTA (if allowed by ED rads attending) MRI (FLAIR, DWI, Gradiant Echo) may be helpful in Dx if neg CT, but we/ED still get LP Angio is our test of choice in patients with SAH

Proposed changes: Clinical Manifestations and Diagnosis aSAH is an emergency, get down to ED fast, have high level of suspicion in acute onset worst HA CT followed by LP if negative-we already do this CTA in aneurysmal vs trauma cases (chicken or egg) No use for MRI if pt getting admitted or if Angio will be performed anyway Always get 3D rotational images for surgical purposes and for educational purposes

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Medical Measures to prevent rebleeding: Recommendations b/w time of symptoms and securing aneurysm, BP should be controlled with titrateable agent to balance risk of stroke, HTN related re-bleeding, and maint of CPP (NEW; Class I; LOE B) Magnitude of BP control to reduce risk of re-bleeding has not been established, but keep SBP<160 (NEW; Class IIa; LOE C) For patients w/ unavoidable delay in securing aneurysm, a significant re-bleeding risk, and no contraindications, short term (<72hrs) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce risk of early re-bleeding (Revised; Class IIa, Level of Evidence B)

What we do at RIH Control BP b/w symptoms onset and aneurysm securing. We tend to use Cardene gtt Maintain SBP <140 until aneurysm is secured Have never used tranexamic acid and have only heard of using aminocaproic acid

Proposed changes: Medical Measures to prevent rebleeding Use Cardene gtt as titrateable agent to balance risk of stroke, HTN related re-bleeding, and maintenance of CPP Maintain SBP <160 until aneurysm is secured. No evidence to support our SBP<140 Rare but for patients w/ unavoidable delay in securing aneurysm, a significant re-bleeding risk, and no contraindications, short term (<72hrs) therapy with aminocaproic acid is reasonable and can be considered

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Surgical and endovascular methods for treatment of ruptured aneurysms: Recommendations Clipping or coiling should be done ASAP (Class I; LOE B) Complete obliteration whenever possible (Class I; LOE B) Determination of tx should be multidisciplinary decision based on patient and aneurysm (Revised; Class I; LOE C) Ruptured aneurysms amenable to both Clip or Coil, Coiling should be considered (Revised; Class I; Level of Evidence B) Pt’s who undergo coil or clip or ruptured aneurysm should have f/u imaging and re-treatment if significant remnant (NEW; I; B) Consider clipping large MCA aneurysms with large IPH (>50cc) Consider coiling in elderly (>70), poor grade, basilar apex (IIb; C)

What we do at RIH Clipping or coiling done ASAP (no night cases) Complete obliteration whenever possible multidisciplinary decision VIR + NSGY Ruptured aneurysms amenable to both Clip or Coil, we usually favor coiling Pt’s who undergo coil or clip or ruptured aneurysm DO have f/u imaging and re-treatment if significant remnant Usually clip large MCA aneurysms with large IPH (clot evac) and usually coil elderly and poor grade

Proposed changes: Surgical and endovascular methods for treatment of ruptured aneurysms Continue to clip or coil ASAP. Continue with NO night cases Continue with complete obliteration whenever possible Continue multidisciplinary decision and CV conference Consider coiling ruptured aneurysms amenable to both Clip or Coil Continue to provide f/u imaging (Angio vs MRA) and treatment for Pt’s who undergo coil or clip or ruptured aneurysm Continue to clip large MCA aneurysms with clot and coil elderly (>70), poor grade, basilar apex

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Hospital Characteristics and Systems of care: Recommendations Low volume hospitals ( 35 aSAH cases/yr) with VIR, NSGY, NCC (Revised; Class I; Level of Evidence B) Annual monitoring of complication rates for OR and VIR procedures is reasonable (NEW; Class IIa; Level of Evidence C) Hospital credentialing process to ensure that proper training standards have been met by treating physicians is reasonable (NEW; Class IIa; Level of Evidence C)

What we do at RIH We get all the transfers. We treat >35 aSAH cases/yr We have M+M and other measures to monitor complication rates for OR and VIR procedures There is a hospital credentialing process for the attendings

Proposed changes: Hospital Characteristics and Systems of care Continue to get all SAH cases transferred to RIH Ensure we log all VIR and operative cases for ACGME/RRC credit Set up annual monitoring of complication rates Develop, thr hospital credentialing process to ensure that only attendings capable of performing Vascular related procedures are doing them

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Anesthetic management during surgical and endovascular treatment of ruptured aneurysm: Recommendations Minimize degree and duration of intra-op hypotension (IIa; B) Insufficient data on induced hypertension during temporary vessel occlusion to make a recommendation but may be reasonable (Class IIb; Level of Evidene C) Induced hypothermia is not routinely recommended, but may be a reasonable option in select cases (Class III; LOE B) Prevention of intra-op hyperglycemia is probably indicated (Class IIa; Level of Evidence B) The use of general anesthesia in endovascular tx of ruptured aneurysms can be beneficial in select patients (Class IIa; LOE C)

What we do at RIH Attempt to keep normotensive Keep normotensive during temporary vessel occlusion (SBP 110) Never induce hypothermia (32-35 deg) Prevention of intra-op hyperglycemia PaO2 >130 is neuro-protective Now, ALWAYS general anesthesia in VIR (but not in strokes to avoid hypotension)

Proposed changes: Anesthetic management during surgical and endovascular treatment of ruptured aneurysm Minimize degree and duration of intra-op hypotension and temp fluctuations Continue with normotension to hypertensive during temporary clipping (avoid hypotension) Avoid hypothermia, goal is euthermia Continue with intra-op glucose and Sodium checks Continue GETA in emergent (and elective) endovascular tx of ruptured aneurysms

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Management of Vasospasm and DCI after aSAH: Recommendations Oral Nimodipine should be given to all aSAH (improves OUTCOME, not vasospasm) (Class I; Level of Evidence A) Maintenance of Euvolemia is recommended to prevent DCI (Revised, Class I; Level of Evidence B) Prophylactic hypervolemia or balloon angioplasty before development of angiographic spasm is NOT recommended (NEW; Class III, Level of Evidence B) TCD’s reasonable to monitor for VS (NEW; Class IIa; LOE B) CT or MR perfusion can be useful to id regions of potential brain ischemia (NEW; Class IIa; Level of Evidence B) Induced HTN is recommended for pt’s w/ DCI unless baseline elevated BP or cardiac status precludes it (Revised; Class I; Level of Evidence B) Angioplasty or IA dilator is reasonable in symptomatic vasospasm, particularly those not responding to HTN therapy (Revised; Class IIa; Level of Evidence B)

What we do at RIH Oral Nimodipine is given to all aSAH x 21 days Maintain Euvolemia in 6INC Usually do not prophylactically use hypervolemia or balloon angioplasty Daily TCD’s x days to monitor for Vasospasm Rarely utilize CT or MR perfusion to identify regions of potential brain ischemia Induce HTN for pt’s w/ DCI unless cardiac status precludes it Send patient to VIR for Angioplasty or IA cardene for symptomatic vasospasm if not responsive to induced hypertension

Proposed changes: Management of Vasospasm and DCI after aSAH Continue oral Nimodipine to all aSAH x 21 days Continue to maintane Euvolemic status to prevent DCI Do NOT prophylactically send pt’s to VIR for balloon angioplasty Continue TCD’s to monitor for vasospasm Can consider CT or MR perfusion to identify regions of potential brain ischemia compared to other regions Continue to induce HTN for pt’s w/ DCI unless cardiac status precludes it Continue to send pt’s to VIR for Angioplasty or IA dilator in symptomatic vasospasm, particularly those not responding to HTN therapy

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Management of Hydrocephalus after aSAH: Recommendations aSAH associated symptomatic HCP should be managed by CSF diversion (EVD or LD) (Revised; Class I; Level of Evidence B) aSAH associated chronic symptomatic HCP should be managed by permanent CSF diversion (Revised; Class I; LOE C) Weaning EVD over >24 hrs does NOT appear to be effective in reducing need for shunt (NEW; Class III, Level of Evidence B) Routine fenestration of Lamina Terminalis is NOT useful for reducing the rate of shunt dependent HCP, and, therefore, should not be performed (NEW; Class III; Level of Evidence B)

What we do at RIH aSAH associated symptomatic HCP is managed by EVD. LD has been used after EVD infection. aSAH associated chronic symptomatic HCP is managed by VPS Usually wean EVD over >24 hrs Usually do NOT intentionally fenestrate the Lamina Terminalis

Proposed changes: Management of Hydrocephalus after aSAH aSAH associated symptomatic HCP should be managed by CSF diversion (EVD or LD). LD- less vasospasm. Do not use in obstructed HCP or if large IP clot present b/c can cause herniation aSAH associated chronic symptomatic HCP should be managed by VPS/VAS Continue to wean EVD over >24 hrs unless ventriculitis present (NEW; Class III, Level of Evidence B) (4 or 5 saves!) Do NOT routinely fenestrate Lamina Terminalis

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Management of Seizures associated with aSAH: Recommendations The use of prophylactic anticonvulsants may be considered in the immediate post-hemorrhagic period (Class IIb; LOE B) Routine long term use of AED is not recommended (Class III; LOE B) but may be considered for pt’s with known risk factors for delayed seizure d/o such as prior seizure, Intracerebral hematoma, intractable HTN, Infarction, or MCA aneurysm (Class IIb; Level of Evidence B)

What we do at RIH We use Dialntin in the immediate post-hemorrhagic period and d/c it once aneurysm is secured Routine long term use of AED is not used unless patient has +EEG, clinically suspicious seizure, or known seizure d/o.

Proposed changes: Management of Seizures associated with aSAH Continue the use of prophylactic Dilantin in the immediate post-hemorrhagic period, but d/c it once aneurysm is coiled, or 7 days post clipping. (? Supported by ISAT data) Do NOT use routine long term AED’s unless pt has seizure, +EEG, or Large intracerebral hematoma/MCA aneurysm (23% negative side effects from Long term AED use)

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Management of Medical complications associated with aSAH : Recommendations Hypotonic IVF and volume contraction is NOT recommended (Class III; Level of Evidence B) Monitoring volume status (CVP, PCWP, I/O) is reasonable as is tx of volume contraction w/ crystalloid/colloid ( Class IIa; LOE B) Aggressive control of fever to a target of normothermia (NEW; Class IIa; Level of Evidence B) Careful Glucose mgmt, avoiding hypoglycemia (Class IIb; LOE B) Use of PRBC’s to treat anemia in pt’s at risk for developing cerebral ischemia is reasonable (NEW; Class IIb; LOE B) Florinef and hypertonic saline is reasonable to correct and prevent hyponatremia (Class IIa; Level of Evidence B) HIT and DVT’s are frequent complications of aSAH. Early identification and tx is recommended (NEW; Class I; Level of Evidence B)

What we do at RIH Always use 0.9NS c 20mEq K Monitor volume status by CVP, I/O through CVL. Have seen 1 SWAN. Routiney use crystalloid/colloid IVF- Euvolemia We aggressively control fever to a target of normothermia Use ICU RISS to avoid hypoglycemia, ICU target 150 Routinely transfuse pt’s PRBC’s to treat anemia in those at risk for cerebral ischemia and elevated TCD’s Everyone and their grandmother is on Florinef and 3% NaCl TED/SCD, Lovenox/HSQ routinely used POD #2

Proposed changes: Management of Medical complications associated with aSAH Continue to always use 0.9 NS Place CVL and foley in H/H II-III or worse to monitor volume status Continue to aggressively treat fever to a target of normothermia ICU Glucose target 150. Allow some relative hyperglycemia and loosen those tight ISS’s. Avoid hypoglycemia Use of PRBC’s to transfuse for Hgb <7 in pt’s with elevated TCD’s, and possibly Hgb<10 is cardiac cripples Continue use of Florinef and 3% NaCl to correct and prevent hyponatremia Check HIT if PLT persistently <100 and check U/S on swollen extremity to dx and tx DVT’s

Risk factors and prevention Natural History and Outcome Clinical Manifestations and Diagnosis Medical Measures to prevent re-bleeding Surgical and endovascular methods for treatment of ruptured aneurysms Hospital characteristics and systems of care Anesthetic management during surgery and endovascular tx Management of Vasospasm and DCI after aSAH Management of HCP associated with aSAH Management of Seizures associated with aSAH Management of Medical complications associated with aSAH

Summary and Conclusions Rapidly evolving topic Have already come a long way and improved survival This update was based on only 42 months of publications 22 NEW recommendations identified, 5 of which were Class I Frequent revision in necessary Use these guidelines as a starting point for doing everything possible to improve the outcomes of patients with aSAH

THANK YOU!