Aneurysmal subarachnoid haemorrhage (SAH) is a devastating disease associated with high mortality and poor outcome in many survivors. Aggressive treatment by a comprehensive multidisciplinary team is associated with improved outcome, but the intensive care management of SAH presents significant challenges. Multimodal neuromonitoring may detect secondary insults before irreversible neuronal damage has occurred, and is increasingly being used to guide treatment. This article reviews current trends in the intensive care management of SAH from aspects of initial resuscitation to recent developments in the prevention and management of complications, including delayed cerebral ischaemia. Evidence from clinical trials and recent consensus guidance is reviewed.
FeiginVLLawesCMBennettDA. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol2009;8: 355–69.
2.
PassierPEVisser-MeilyJMvan ZandvoortMJ. Prevalence and determinants of cognitive complaints after aneurysmal subarachnoid hemorrhage. Cerebrovasc Dis2010;29: 557–63.
3.
HaugTSortebergAFinsetA. Cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients). Neurosurgery2010;66: 475–84.
4.
WartenbergKESchmidtJMClaassenJ. Impact of medical complications on outcome after subarachnoid hemorrhage. Crit Care Med2006;34: 617–23.
5.
RabinsteinAALanzinoGWijdicksEF. Multidisciplinary management and emerging therapeutic strategies in aneurysmal subarachnoid haemorrhage. Lancet Neurol2010;9: 504–19.
6.
DiringerMNBleckTPClaudeHJ. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society's Multidisciplinary Consensus Conference. Neurocrit Care2011;15: 211–40.
WartenbergKE. Critical care of poor-grade subarachnoid hemorrhage?Curr Opin Crit Care2011; 17: 85–93.
9.
SatoKShimizuHFujimuraM. Acute-stage diffusion-weighted magnetic resonance imaging for predicting outcome of poor-grade aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab2010;30: 1110–20.
10.
HelbokRKoSBSchmidtJM. Global cerebral edema and brain metabolism after subarachnoid hemorrhage. Stroke2011;42: 1534–39.
11.
ZetterlingMHallbergLHilleredL. Brain energy metabolism in patients with spontaneous subarachnoid hemorrhage and global cerebral edema. Neurosurgery2010;66: 1102–10.
12.
MarkDGPinesJM. The detection of nontraumatic subarachnoid hemorrhage: still a diagnostic challenge. Am J Emerg Med2006;24: 859–63.
WesterlaanHEvan DijkJMJansen-van der WeideMC. Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis—systematic review and meta-analysis. Radiology2011;258: 134–45.
15.
HuangAPAroraSWintermarkM. Perfusion computed tomographic imaging and surgical selection with patients after poor-grade aneurysmal subarachnoid hemorrhage. Neurosurgery2010;67: 964–74.
16.
KidwellCSWintermarkM. Imaging of intracranial haemorrhage. Lancet Neurol2008;7: 256–67.
17.
MolyneuxAJKerrRSYuLM. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet2005;366: 809–17.
18.
BritzGW. ISAT trial: coiling or clipping for intracranial aneurysms?Lancet2005;366: 783–85.
GaberelTMagheruCEmeryEDerlonJM. Antifibrinolytic therapy in the management of aneurismal subarachnoid hemorrhage revisited. A meta-analysis. Acta Neurochir (Wien)2012;154: 1–9.
21.
SmithM. Intensive care management of patients with subarachnoid haemorrhage. Curr Opin Anaesthesiol2007;20: 400–07.
22.
KomotarRJSchmidtJMStarkeRM. Resuscitation and critical care of poor-grade subarachnoid hemorrhage. Neurosurgery2009;64: 397–410.
23.
SpringborgJBFrederiksenHJEskesenVOlsenNV. Trends in monitoring patients with aneurysmal subarachnoid haemorrhage. Br J Anaesth2005;94: 259–70.
24.
TisdallMMSmithM. Multimodal monitoring in traumatic brain injury: current status and future directions. Br J Anaesth2007;99: 61–67.
25.
SpiottaAMProvencioJJRasmussenPAMannoE. Brain monitoring after subarachnoid hemorrhage: lessons learned. Neurosurgery2011;69: 755–66.
26.
FugateJERabinsteinAA. Intensive care unit management of aneurysmal subarachnoid hemorrhage. Curr Neurol Neurosci Rep2012;12: 1–9.
27.
Skjoth-RasmussenJSchulzMKristensenSRBjerreP. Delayed neurological deficits detected by an ischemic pattern in the extracellular cerebral metabolites in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg2004;100: 8–15.
28.
SoehleMCzosnykaMPickardJDKirkpatrickPJ. Continuous assessment of cerebral autoregulation in subarachnoid hemorrhage. Anesth Analg2004;98: 1133–39.
29.
FriedmanDClaassenJHirschLJ. Continuous electroencephalogram monitoring in the intensive care unit. Anesth Analg2009;109: 506–23.
30.
DreierJP. The role of spreading depression, spreading depolarization and spreading ischemia in neurological disease. Nat Med2011;17: 439–47.
31.
AralasmakAAkyuzMOzkaynakC. CT angiography and perfusion imaging in patients with subarachnoid hemorrhage: correlation of vasospasm to perfusion abnormality. Neuroradiology2009;51: 85–93.
32.
LadSPGuzmanRKellyME. Cerebral perfusion imaging in vasospasm. Neurosurg Focus2006;21: E7.
33.
CarreraESchmidtJMOddoM. Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Neurosurgery2009;65: 316–23.
34.
JodickeAHubnerFBokerDK. Monitoring of brain tissue oxygenation during aneurysm surgery: prediction of procedure-related ischemic events. J Neurosurg2003;98: 515–23.
WolfS. Routine management of volume status after aneurysmal subarachnoid hemorrhage. Neurocrit Care2011;15: 275–80.
37.
TreggiariMM. Hemodynamic management of subarachnoid hemorrhage. Neurocrit Care2011;15: 329–35.
38.
DankbaarJWSlooterAJRinkelGJSchaafIC. Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care2010;14: R23.
39.
GressDR. Monitoring of volume status after subarachnoid hemorrhage. Neurocrit Care2011;15: 270–74.
40.
SantillanAKnopmanJZinkW. Transluminal balloon angioplasty for symptomatic distal vasospasm refractory to medical therapy in patients with aneurysmal subarachnoid hemorrhage. Neurosurgery2011;69: 95–101.
41.
PierotLAggourMMoretJ. Vasospasm after aneurysmal subarachnoid hemorrhage: recent advances in endovascular management. Curr Opin Crit Care2010;16: 110–16.
42.
Castanares-ZapateroDHantsonP. Pharmacological treatment of delayed cerebral ischemia and vasospasm in subarachnoid hemorrhage. Ann Intensive Care2011;1: 12.
43.
MuroiCSeuleMMishimaKKellerE. Novel treatments for vasospasm after subarachnoid hemorrhage. Curr Opin Crit Care2012;18: 119–26.
44.
VergouwenMDde HaanRJVermeulenMRoosYB. Effect of statin treatment on vasospasm, delayed cerebral ischemia, and functional outcome in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis update. Stroke2010;41: e47–e52.
45.
TsengMY. Summary of evidence on immediate statins therapy following aneurysmal subarachnoid hemorrhage. Neurocrit Care2011;15: 298–301.
46.
SuarezJI. Magnesium sulfate administration in subarachnoid hemorrhage. Neurocrit Care2011;15: 302–07.
47.
WongGKPoonWSChanMT. Plasma magnesium concentrations and clinical outcomes in aneurysmal subarachnoid hemorrhage patients: post hoc analysis of intravenous magnesium sulphate for aneurysmal subarachnoid hemorrhage trial. Stroke2010;41: 1841–44.
48.
MacdonaldRLHigashidaRTKellerE. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol2011;10: 618–25.
49.
MeesSM Dorhoutvan den BerghWMAlgraARinkelGJ. Antiplatelet therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev2007: CD006184.
50.
SiironenJJuvelaSVarisJ. No effect of enoxaparin on outcome of aneurysmal subarachnoid hemorrhage: a randomized, double-blind, placebo-controlled clinical trial. J Neurosurg2003;99: 953–9.
51.
WurmGTomancokBNussbaumerK. Reduction of ischemic sequelae following spontaneous subarachnoid hemorrhage: a double-blind, randomized comparison of enoxaparin versus placebo. Clin Neurol Neurosurg2004;106: 97–103.
52.
LanzinoGD'UrsoPISuarezJ. Seizures and anticonvulsants after aneurysmal subarachnoid hemorrhage. Neurocrit Care2011;15: 247–56.
53.
NaidechAMKreiterKTJanjuaN. Phenytoin exposure is associated with functional and cognitive disability after subarachnoid hemorrhage. Stroke2005;36: 583–87.
SolenskiNJHaleyECJr.KassellNF. Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med1995;23: 1007–17.
56.
BruderNRabinsteinA. Cardiovascular and pulmonary complications of aneurysmal subarachnoid hemorrhage. Neurocrit Care2011;15: 257–69.
57.
van der BilJHasanDVandertopWP. Impact of cardiac complications on outcome after aneurysmal subarachnoid hemorrhage: a meta-analysis. Neurology2009;72: 635–42.
58.
WartenbergKEMayerSA. Medical complications after subarachnoid hemorrhage: new strategies for prevention and management. Curr Opin Crit Care2006;12: 78–84.
BankiNMKopelnikADaeMW. Acute neurocardiogenic injury after subarachnoid hemorrhage. Circulation2005;112: 3314–19.
61.
TungPKopelnikABankiN. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke2004;35: 548–51.
62.
RiveraAM CastilloRuiz-BailenMRucabadoAL. Takotsubo cardiomyopathy – a clinical review. Med Sci Monit2011;17: RA135–47.
63.
TemesRETessitoreESchmidtJM. Left ventricular dysfunction and cerebral infarction from vasospasm after subarachnoid hemorrhage. Neurocrit Care2010;13: 359–65.
64.
NaidechADuYKreiterKT. Dobutamine versus milrinone after subarachnoid hemorrhage. Neurosurgery2005;56: 21–27.
65.
KahnJMCaldwellECDeemS. Acute lung injury in patients with subarachnoid hemorrhage: incidence, risk factors, and outcome. Crit Care Med2006;34: 196–202.
66.
MuroiCKellerMPangaluA. Neurogenic pulmonary edema in patients with subarachnoid hemorrhage. J Neurosurg Anesthesiol2008;20: 188–92.
67.
MasciaL. Acute lung injury in patients with severe brain injury: a double hit model. Neurocrit Care2009;11: 417–26.
68.
YoungNRhodesJKMasciaLAndrewsPJ. Ventilatory strategies for patients with acute brain injury. Curr Opin Crit Care2010;16: 45–52.
69.
RabinsteinAABruderN. Management of hyponatremia and volume contraction. Neurocrit Care2011;15: 354–60.
70.
TisdallMCrockerMWatkissJSmithM. Disturbances of sodium in critically ill adult neurologic patients: a clinical review. J Neurosurg Anesthesiol2006;18: 57–63.
71.
FisherLAKoNMissJ. Hypernatremia predicts adverse cardiovascular and neurological outcomes after SAH. Neurocrit Care2006;5: 180–85.
72.
FernandezASchmidtJMClaassenJ. Fever after subarachnoid hemorrhage: risk factors and impact on outcome. Neurology2007;68: 1013–19.
73.
ScaravilliVTincheroGCiterioG. Fever management in SAH. Neurocrit Care2011;15: 287–94.
74.
KruytNDBiesselsGJde HaanRJ. Hyperglycemia and clinical outcome in aneurysmal subarachnoid hemorrhage: a meta-analysis. Stroke2009;40: e424–30.
75.
OddoMSchmidtJMCarreraE. Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: a microdialysis study. Crit Care Med2008;36: 3233–38.
76.
SchmutzhardERabinsteinAA. Spontaneous subarachnoid hemorrhage and glucose management. Neurocrit Care2011;15: 281–86.
77.
KramerAHGurkaMJNathanB. Complications associated with anemia and blood transfusion in patients with aneurysmal subarachnoid hemorrhage. Crit Care Med2008;36: 2070–75.
