Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients.
Materials and methods
We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients.
Results
Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension.
Conclusions
Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
KonczallaJSeifertVBeckJ, et al. Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980–1995) versus post-ISAT era (2005–2014). J Neurosurg2018; 128: 100–110.
2.
CahillWJCalvertJHZhangJH.Mechanisms of early brain injury after subarachnoid hemorrhage. J Cereb Blood Flow Metab2006; 26: 1341–1353.
3.
FronteraJAAhmedWZachV, et al. Acute ischaemia after subarachnoid haemorrhage, relationship with early brain injury and impact on outcome: a prospective quantitative MRI study. J Neurol Neurosurg Psychiatry2015; 86: 71–78.
4.
WilsonDANakajiPAlbuquerqueFC, et al. Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design. J Neurosurg2013; 119: 606–612.
5.
EriksenNRostrupEFabriciusM, et al. Early focal brain injury after subarachnoid hemorrhage correlates with spreading depolarizations. Neurology2019; 92: e326–e341.
6.
SuwatcharangkoonSMeyersEFaloC, et al. Loss of consciousness at onset of subarachnoid hemorrhage as an important marker of early brain injury. JAMA Neurol2016; 73: 28–35.
7.
HelbokRClaassenJ.Global cerebral edema and brain metabolism after subarachnoid hemorrhage. Crit Care2011; 15(Suppl 1): P327.
8.
Al-MuftiFRohDLahiriS, et al. Ultra-early angiographic vasospasm associated with delayed cerebral ischemia and infarction following aneurysmal subarachnoid hemorrhage. J Neurosurg2017; 126: 1545–1551.
9.
DreierJPWoitzikJFabriciusM, et al. Delayed ischaemic neurological deficits after subarachnoid haemorrhage are associated with clusters of spreading depolarizations. Brain2006; 129: 3224–3237.
10.
GonçalvesBTuronRMendesA, et al. Effect of early brain infarction after subarachnoid hemorrhage: a systematic review and meta-analysis. World Neurosurg2018; 115: e292–e298.
11.
StarkeRMKassellNF.The link between hyperoxia, delayed cerebral ischaemia and poor outcome after aneurysmal SAH: association or therapeutic endeavour. J Neurol Neurosurg Psychiatry2014; 85: 1292.
12.
WinklerMKLChassidimYLublinskyS, et al. Impaired neurovascular coupling to ictal epileptic activity and spreading depolarization in a patient with subarachnoid hemorrhage: possible link to blood–brain barrier dysfunction. Epilepsia2012; 53: 22–30.
13.
KimJARosenthalESBiswalS, et al. Epileptiform abnormalities predict delayed cerebral ischemia in subarachnoid hemorrhage. Clin Neurophysiol2017; 128: 1091–1099.
14.
SchmidtJMKoSBHelbokR, et al. Cerebral perfusion pressure thresholds for brain tissue hypoxia and metabolic crisis after poor-grade subarachnoid hemorrhage. Stroke2011; 42: 1351–1356.
15.
Von der BrelieCSeifertMRotS, et al. Sedation of patients with acute aneurysmal subarachnoid hemorrhage with ketamine is safe and might influence the occurrence of cerebral infarctions associated with delayed cerebral ischemia. World Neurosurg2017; 97: 374–382.
16.
DiedlerJSantosEPoliS, et al. Optimal cerebral perfusion pressure in patients with intracerebral hemorrhage: an observational case series. Crit Care2014; 18: R51.
17.
ChoiKSChunHJYiHJ, et al. Seizures and epilepsy following aneurysmal subarachnoid hemorrhage: incidence and risk factors. J Korean Neurosurg Soc2009; 46: 93–98.
18.
FungCBalmerMMurekM, et al. Impact of early-onset seizures on grading and outcome in patients with subarachnoid hemorrhage. J Neurosurg2015; 122: 408–413.
19.
De MarchisGMPuginDLantiguaH, et al. Tonic-clonic activity at subarachnoid hemorrhage onset: impact on complications and outcome. PLoS ONE2013; 8: e71405.
20.
HelbokRSchiefeckerAJBeerR, et al. Early brain injury after aneurysmal subarachnoid hemorrhage: a multimodal neuromonitoring study. Crit Care2015; 19: 75.
21.
ZetterlingMHallbergLHilleredL, et al. Brain energy metabolism in patients with spontaneous subarachnoid hemorrhage and global cerebral edema. Neurosurgery2010; 66: 1102–1110.
22.
BaradaranHFoderaVMirD, et al. Evaluating CT perfusion deficits in global cerebral edema after aneurysmal subarachnoid hemorrhage. Am J Neuroradiol2015; 36: 1431–1435.
23.
HaymanEGWessellAGerzanichV, et al. Mechanisms of global cerebral edema formation in aneurysmal subarachnoid hemorrhage. Neurocrit Care2017; 26: 301–310.
24.
RostamiEEngquistHHowellsT, et al. Early low cerebral blood flow and high cerebral lactate: prediction of delayed cerebral ischemia in subarachnoid hemorrhage. J Neurosurg2018; 128: 1762–1770.
25.
HopJWRinkelGJEAlgraA, et al. Initial loss of consciousness and risk of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke1999; 30: 2268–2271.
26.
MagniFPozziMRotaM, et al. High-resolution intracranial pressure burden and outcome in subarachnoid hemorrhage. Stroke2015; 46: 2464–2469.
27.
RavishankarNNuomanRAmuluruK, et al. Management strategies for intracranial pressure crises in subarachnoid hemorrhage. J Intensive Care Med2020; 35: 211–218.
28.
ShapiroHMWyteSRLoeserJ.Barbiturate-augmented hypothermia for reduction of persistent intracranial hypertension. J Neurosurg1974; 40: 90–100.
JamesMLOlsonDMGraffagninoC.A pilot study of cerebral and haemodynamic physiological changes during sedation with dexmedetomidine or propofol in patients with acute brain injury. Anaesth Intensive Care2012; 40: 949–957.
31.
PurruckerJCRenzlandJUhlmannL, et al. Volatile sedation with sevoflurane in intensive care patients with acute stroke or subarachnoid haemorrhage using AnaConDa®: an observational study. Br J Anaesth2015; 114: 934–943.
32.
BöselJPurruckerJCNowakF, et al. Volatile isoflurane sedation in cerebrovascular intensive care patients using AnaConDa(®): effects on cerebral oxygenation, circulation, and pressure. Intensive Care Med2012; 38: 1955–1964.
33.
Al-RawiPGTsengMYRichardsHK, et al. Hypertonic saline in patients with poor-grade subarachnoid hemorrhage improves cerebral blood flow, brain tissue oxygen, and pH. Stroke2010; 41: 122–128.
34.
CarneyNTottenAMO’ReillyC, et al. Guidelines for the management of severe traumatic brain injury, Fourth Edition. Neurosurgery2017; 80: 6–15.
35.
CuiJBChenQQLiuTT, et al. Risk factors for early-onset ventilator-associated pneumonia in aneurysmal subarachnoid hemorrhage patients. Braz J Med Biol Res2018; 51: e6830.
36.
GodoyDASeifiAGarzaD, et al. Hyperventilation therapy for control of posttraumatic intracranial hypertension. Front Neurol2017; 8: 250.
37.
CurleyGKavanaghBPLaffeyJG.Hypocapnia and the injured brain: more harm than benefit. Crit Care Med2010; 38: 1348–1359.
38.
BrattonSLBullockRCarneyN, et al. Guidelines for the management of severe traumatic brain injury, Third Edition. J Neurotrama2007; 24(Suppl 1): S1–106.
SugimotoKInamasuJKatoY, et al. Association between elevated plasma norepinephrine levels and cardiac wall motion abnormality in poor-grade subarachnoid hemorrhage patients. Neurosurg Rev2013; 36: 259–266.
42.
SugimotoKYamadaAInamasuJ, et al. Electrocardiographic scoring helps predict left ventricular wall motion abnormality commonly observed after subarachnoid hemorrhage. J Stroke Cerebrovasc Dis2018; 27: 3148–3154.
43.
OrasJGrivansCBartleyA, et al. Elevated high-sensitive troponin T on admission is an indicator of poor long-term outcome in patients with subarachnoid haemorrhage: a prospective observational study. Crit Care2016; 20: 11.
44.
ZhangLWangZQiS.Cardiac troponin elevation and outcome after subarachnoid hemorrhage: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis2015; 24: 2375–2384.
45.
NaidechAMKreiterKTJanjuaN, et al. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation2005; 112: 2851–2856.
46.
NaidechAMBendokBRTamulP, et al. Medical complications drive length of stay after brain hemorrhage: a cohort study. Neurocrit Care2009; 10: 11–19.
47.
DoerflerSFaerberJMcKhannGM, et al. The incidence and impact of secondary cerebral insults on outcome after aneurysmal subarachnoid hemorrhage. World Neurosurg2018; 114: e483–e494.
48.
CaiKZhangYShenL, et al. Characteristics of blood pressure profiles after endovascular coiling as predictors of clinical outcome in poor-grade aneurysmal subarachnoid hemorrhage. World Neurosurg2017; 104: 459–466.
49.
Ortega-GutierrezSThomasJRecciusA, et al. Effectiveness and safety of nicardipine and labetalol infusion for blood pressure management in patients with intracerebral and subarachnoid hemorrhage. Neurocrit Care2013; 18: 13–19.
50.
RoseJCMayerSA.Optimizing blood pressure in neurological emergencies. Neurocrit Care2004; 1: 287–299.
51.
DarkwahOppong MGümüsMPierscianekD, et al. Aneurysm rebleeding before therapy: a predictable disaster?J Neurosurg2018; 1: 1–8.
52.
LarsenCCAstrupJ.Rebleeding after aneurysmal subarachnoid hemorrhage: a literature review. World Neurosurg2013; 79: 307–312.
53.
LinQSPing-ChenLinYX, et al. Systolic blood pressure variability is a novel risk factor for rebleeding in acute subarachnoid hemorrhage: a case-control study. Medicine (Baltimore)2016; 95: e3028.
54.
ParkJWooHKangDH, et al. Formal protocol for emergency treatment of ruptured intracranial aneurysms to reduce in-hospital rebleeding and improve clinical outcomes. J Neurosurg2015; 122: 383–391.
55.
FrancoeurCLRohDSchmidtJM, et al. Desmopressin administration and rebleeding in subarachnoid hemorrhage: analysis of an observational prospective database. J Neurosurg2018; 1: 1–7.
56.
HarriganMRRajneeshKFArdeltAA, et al. Short-term antifibrinolytic therapy before early aneurysm treatment in subarachnoid hemorrhage: effects on rehemorrhage, cerebral ischemia, and hydrocephalus. Neurosurgery2010; 67: 935–939; discussion 939–940.
57.
HillmanJFridrikssonSNilssonO, et al. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg2002; 97: 771–778.
58.
ConnollyESRabinsteinAACarhuapomaJR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2012; 43: 1711–1737.
59.
Murphy-HumanTWelchEZipfelG, et al. Comparison of short-duration levetiracetam with extended-course phenytoin for seizure prophylaxis after subarachnoid hemorrhage. World Neurosurg2011; 75: 269–274.
60.
MahmoudSHBuxtonJ.Seizures and choice of antiepileptic drugs following subarachnoid hemorrhage: a review. Can J Neurol Sci2017; 44: 643–653.
61.
De MarchisGMPuginDMeyersE, et al. Seizure burden in subarachnoid hemorrhage associated with functional and cognitive outcome. Neurology2016; 86: 253–260.
62.
DankbaarJWRijsdijkMvan der SchaafIC, et al. Relationship between vasospasm, cerebral perfusion, and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neuroradiol2009; 51: 813–819.
63.
WuHTRuanJZhangXD, et al. Association of promoter polymorphism of apolipoprotein E gene with cerebral vasospasm after spontaneous SAH. Brain Res2010; 1362: 112–116.
64.
Pulcrano-NicolasASProustCClarençonF, et al. Whole-blood miRNA sequencing profiling for vasospasm in patients with aneurysmal subarachnoid hemorrhage. Stroke2018; 49: 2220–2223.
65.
Al-MuftiFAmuluruKSmithB, et al. Emerging markers of early brain injury and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. World Neurosurg2017; 107: 148–159.
66.
DodsonVMajmundarNEl-GhanemM, et al. Intracranial administration of nicardipine after aneurysmal subarachnoid hemorrhage: a review of the literature. World Neurosurg2019; 125: 511–518.
67.
KomotarRJSchmidtJMStarkeRM, et al. Resuscitation and critical care of poor-grade subarachnoid hemorrhage. Neurosurg2009; 64: 397–410.
68.
PaľaASchneiderMBrandC, et al. The evolution of invasive cerebral vasospasm treatment in patients with spontaneous subarachnoid hemorrhage and delayed cerebral ischemia—continuous selective intracarotid nimodipine therapy in awake patients without sedation. Neurosurg Rev2019; 42: 463–469.
69.
Dorhout MeesSMRinkelGJEFeiginVL, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev2007; 2007: CD000277.
70.
DiringerMNZazuliaAR.Aneurysmal subarachnoid hemorrhage: strategies for preventing vasospasm in the intensive care unit. Semin Respir Crit Care Med2017; 38: 760–767.
71.
KramerAHRobertsDJHolodinskyJ, et al. Intraventricular tissue plasminogen activator in subarachnoid hemorrhage patients: a prospective, randomized, placebo-controlled pilot trial. Neurocrit Care2014; 21: 275–284.
72.
LoanJJMWigginsANBrennanPM.Medically induced hypertension, hypervolaemia and haemodilution for the treatment and prophylaxis of vasospasm following aneurysmal subarachnoid haemorrhage: systematic review. Br J Neurosurg2018; 32: 157–164.
73.
FronteraJAFernandezASchmidtJM, et al. Clinical response to hypertensive hypervolemic therapy and outcome after subarachnoid hemorrhage. Neurosurgery2010; 66: 35–41.
74.
PasarikovskiCRAlotaibiNMAl-MuftiF, et al. Hypertonic saline for increased intracranial pressure after aneurysmal subarachnoid hemorrhage: a systematic review. World Neurosurg2017; 105: 1–6.
75.
Al-MuftiFKamalNDamodaraN, et al. Updates in the management of cerebral infarctions and subarachnoid hemorrhage secondary to intracranial arterial dissection: a systematic review. World Neurosurg2019; 121: 51–58.
76.
Dorhout MeesSMAlgraAVandertopWP, et al. Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomised placebo-controlled trial. Lancet2012; 380: 44–49.
77.
DucruetAFAlbuquerqueFCCrowleyRW, et al. Balloon-pump counterpulsation for management of severe cardiac dysfunction after aneurysmal subarachnoid hemorrhage. World Neurosurg2013; 80: e347–e352.
78.
VenkatramanAKhawajaAMGuptaS, et al. Intra-arterial vasodilators for vasospasm following aneurysmal subarachnoid hemorrhage: a meta-analysis. J Neurointerv Surg2018; 10: 380–387.
79.
SchmidtJMWartenbergKEFernandezA, et al. Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage. J Neurosurg2008; 109: 1052–1059.
80.
HemphillJCAndrewsPDe GeorgiaM.Multimodal monitoring and neurocritical care bioinformatics. Nat Rev Neurol2011; 7: 451–460.
81.
Al-MuftiFLanderMSmithB, et al. Multimodality monitoring in neurocritical care: decision-making utilizing direct and indirect surrogate markers. J Intensive Care Med2019; 34: 449–463.
82.
ForemanBAlbersDSchmidtJM, et al. Intracortical electrophysiological correlates of blood flow after severe SAH: a multimodality monitoring study. J Cereb Blood Flow Metab2018; 38: 506–517.
83.
StuartRMWaziriAWeintraubD, et al. Intracortical EEG for the detection of vasospasm in patients with poor-grade subarachnoid hemorrhage. Neurocrit Care2010; 13: 355–358.
84.
ClaassenJVelazquezAMeyersE, et al. Bedside quantitative electroencephalography improves assessment of consciousness in comatose subarachnoid hemorrhage patients. Ann Neurol2016; 80: 541–553.
85.
AmantiniAFossiSGrippoA, et al. Continuous EEG-SEP monitoring in severe brain injury. Neurophysiol Clin2009; 39: 85–93.
86.
GerberLMChiuYLCarneyN, et al. Marked reduction in mortality in patients with severe traumatic brain injury. J Neurosurg2013; 119: 1583–1590.
87.
BudohoskiKPCzosnykaMSmielewskiP, et al. Impairment of cerebral autoregulation predicts delayed cerebral ischemia after subarachnoid hemorrhage. Stroke2012; 43: 3230–3237.
RosenthalGHemphillJCSoraniM, et al. Brain tissue oxygen tension is more indicative of oxygen diffusion than oxygen delivery and metabolism in patients with traumatic brain injury. Crit Care Med2008; 36: 1917–1924.
90.
SchmidtJMClaassenJKoSB, et al. Nutritional support and brain tissue glucose metabolism in poor-grade SAH: a retrospective observational study. Crit Care2012; 16: R15.
91.
SamuelssonCHilleredLEnbladP, et al. Microdialysis patterns in subarachnoid hemorrhage patients with focus on ischemic events and brain interstitial glutamine levels. Acta Neurochir (Wien)2009; 151: 437–446.
92.
TholanceYBarcelosGKDaillerF, et al. Biochemical neuromonitoring of poor-grade aneurysmal subarachnoid hemorrhage: comparative analysis of metabolic events detected by cerebral microdialysis and by retrograde jugular vein catheterization. Neurol Res2015; 37: 578–587.
93.
HanafyKAStuartRMKhandjiAG, et al. Relationship between brain interstitial fluid tumor necrosis factor-α and cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Clin Neurosci2010; 17: 853–856.
94.
WartenbergKEMayerSA.Medical complications after subarachnoid hemorrhage. Neurosurg Clin N Am2010; 21: 325–338.
95.
FugateJERabinsteinAA.Intensive care unit management of aneurysmal subarachnoid hemorrhage. Curr Neurol Neurosci Rep2012; 12: 1–9.
96.
OkazakiTHifumiTKawakitaK, et al. Target serum sodium levels during intensive care unit management of aneurysmal subarachnoid hemorrhage. Shock2017; 48: 558–563.
97.
LaiPMRSeeAPSilvaMA, et al. Noninfectious fever in aneurysmal subarachnoid hemorrhage: association with cerebral vasospasm and clinical outcome. World Neurosurg2019; 122: e1014–e1019.
98.
Al-MuftiFAmuluruKDamodaraN, et al. Novel management strategies for medically-refractory vasospasm following aneurysmal subarachnoid hemorrhage. J Neurol Sci2018; 390: 44–51.
99.
DharRDiringerMN.The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage. Neurocrit Care2008; 8: 404–412.
100.
TakiWSakaiNSuzukiH, et al. Determinants of poor outcome after aneurysmal subarachnoid hemorrhage when both clipping and coiling are available: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan. World Neurosurg2011; 76: 437–445.
101.
BeckerKJBaxterABCohenWA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology2001; 56: 766–772.
102.
Le RouxPDElliottJPNewellDW, et al. Predicting outcome in poor-grade patients with subarachnoid hemorrhage: a retrospective review of 159 aggressively managed cases. J Neurosurg1996; 85: 39–49.
