New AHA/ASA Guideline on Aneurysmal Subarachnoid Hemorrhage

Megan Brooks

May 03, 2012

May 3, 2012 — Patients diagnosed with aneurysmal subarachnoid hemorrhage (aSAH) in hospitals that manage fewer than 10 cases per year should be considered for immediate transfer to a hospital that treats at least 35 cases a year, according to updated guidelines on management of aSAH from the American Heart Association/American Stroke Association (AHA/ASA).

Research has shown that 30-day death rates are significantly higher in low-volume facilities (39% in hospitals treating fewer than 10 patients compared with 27% in hospitals treating more than 35 patients each year), the AHA/ASA notes in a statement.

The new guideline, published online May 3 in Stroke, updates guidelines issued in 2009 and reported by Medscape Medical News at that time.

Rapidly Developing Field

"These guidelines are released every 2 to 3 years; nothing prompted them, they were a planned update," E. Sander Connolly Jr, MD, chair of the statement writing group, noted in an email to Medscape Medical News.

"The biggest take home message is that the field is changing fast. There are lots of new guidelines; staying on top of these is critical to patient care," added Dr. Connolly, vice-chairman of neurological surgery at Columbia University in New York City and the co-director of the neurosciences intensive care unit at New York-Presbyterian Hospital.

The writing group notes that the new update, "which is based on a mere 42 months of publications," contains 21 new recommendations (outlined in Table 4 in the paper), 5 of which are Class I recommendations. There are also 9 changes in prior recommendations. In total, there are now 22 Class I recommendations (outlined in Table 3).

Although it's not completely clear why outcomes are better at high-volume centers, "patients admitted to high-volume facilities have increased access to experienced cerebrovascular surgeons and endovascular specialists, as well as multidisciplinary neuro-intensive care services, such as EEG [electroencephalography] monitoring to rule out non-convulsive status seizures," Dr. Connolly noted in a statement.

Larry B. Goldstein, MD, professor of medicine (neurology) and director of the Duke Stroke Center in Durham, North Carolina, told Medscape Medical News that transfer to high-volume centers when possible "makes sense [as] there is an association between center volume and outcomes, and has been seen for some other conditions."

He noted, however, that "decisions regarding transfer of unstable patients with recent SAH is a bit more complicated, and would likely need to be determined regionally and depending on individual patient issues."

In these patients, "a multidisciplinary approach afforded in larger centers might also contribute to better outcomes. Studies have shown better outcomes for patients with hemorrhagic strokes cared for in Primary Stroke Centers, even though the focus of these centers is on non-hemorrhagic strokes. This may reflect institutional commitment to stroke care in general, and better care organization."

aSAH is responsible for about 5% of all strokes and affects more than 30,000 Americans each year, most of them aged 40 to 60 years. Prevention recommendations still center on controlling hypertension and avoiding cigarette smoking and excessive alcohol use.

The 5 new class I (level B) recommendations are as follows:

  • After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment.

  • Digital subtraction angiography with 3-dimensional rotational angiography is indicated for detection of aneurysm in patients with aSAH (except when the aneurysm was previously diagnosed by noninvasive angiography) and for planning treatment (to determine whether an aneurysm is amenable to coiling or to expedite microsurgery).

  • Between the time of aSAH symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk for stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure.

  • In the absence of a "compelling" contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and re-treatment, by repeat coiling or clipping, should be strongly considered if there is a clinically significant (eg, growing) remnant.

  • Heparin-induced thrombocytopenia and deep venous thrombosis are both infrequent but not uncommon occurrences after aSAH. Early identification and targeted treatment are recommended, but further research is needed to identify the ideal screening paradigms.

The 9 revised recommendations are as follows:

  • For patients with an unfavorable delay in obliteration of aneurysm, a significant risk for rebleeding, and no compelling medical contraindications, short-term ( < 72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk for early aneurysm rebleeding. (Class IIa, Level B)

  • Experienced cerebrovascular surgeons and endovascular specialists should determine a multidisciplinary treatment approach based on characteristics of the patient and the aneurysm. (Class I, Level C)

  • For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered. (Class I, Level B)

  • Low-volume hospitals should consider early transfer of patients with aSAH to high-volume centers. (Class I, Level B)

  • Maintaining euvolemia and normal circulating blood volume is recommended to prevent delayed cerebral ischemia (DCI). (Revised, Class I, Level B)

  • Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it. (Class I, Level B)

  • Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is "reasonable" in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy. (Class IIa, Level B)

  • aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario). (Class I, Level B)

  • aSAH-associated chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion. (Class I, Level B)

In this "fast-developing field," frequent revision of these guidelines is "clearly needed [and] the data presented here only begin to scratch the surface of the burgeoning knowledge," the writing group concludes. "Those faced with managing these patients will thus do well to use these guidelines as merely a starting point for doing everything possible to improve the outcomes of patients with aSAH."

Dr. Connolly has disclosed no relevant financial relationships. A complete list of disclosures for members of the guideline writing group is published with the original article. Dr. Goldstein has disclosed no relevant financial relationships.

Stroke. Published online May 3, 2012. Abstract


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