Management of aneurysmal subarachnoid hemorrhage patients in the first days after hemorrhage

Abstract

Patients with aneurysmal subarachnoid hemorrhage (aSAH) have a high risk to die or remain in a dependent state. The initial hemorrhage causes early brain inury (EBI) which subsequently initiates a cascade of secondary brain injuries. Above this, a recurrent hemorrhage can occur in the first few hours after the initial hemorrhage and leads to additional damage to the already vulnerable brain. These problems make this type of hemorrhage a medical emergency. The goal of physicians who are specialized in the treatment and management of aSAH patients is to prevent complications and treat the secondary brain injuries. The selection of the right patients for the right treatment is mandatory in this process and the majority of the decisionmaking is done in the first days after the initial hemorrhage. The articles presented below describe management and treatment options that can be applied to aSAH patients in the first days after hemorrhage. Article 1 investigates the risk for the development of one of the secondary brain injuries, being delayed cerebral ischemia (DCI) in a cohort of 6,713 patients. The results, existing of patient data from different continents and therefore generalizable, show that female sex is independently associated with a higher risk for DCI. The influence of sex hormones was investigated but plays probably no role in causing this difference. These results help physicians in the decision-making process regarding the risk calculation for secondary brain injuries. Article 2 shows an in-hospital mortality rate of 13.9% in 1,669 patients who were treated for a ruptured intracranial aneurysm. Independent predictors were recurrent hemorrhage, cerebral infarction attributed to DCI and aneurysm treatment, and intraventricular hemorrhage. Preventing a recurrent hemorrhage from the aneurysm at the earliest possible opportunity with the treatment option that results in the lowest risk of posttreatment infarction will have a relevant impact on the reduction of in-hospital mortality. Patients who are at highest risk to achieve an unfavorable outcome after hospital discharge, including those with a poor clinical condition at admission (World Federation of Neurosurgical Societies (WFNS) grade 4 and 5), are studied in Article 3. The results show that, despite an initial poor clinical condition, these patients are able to achieve a favorable outcome in 30-45%. Therefore, in patients with a poor neurological condition (Glasgow Coma Scale (GCS) ≤12) the treatment should not be delayed or postponed because these patients have an acceptable chance to survive without significant neurological deficits. Nevertheless, a substantial part of patients who are admitted in a poor clinical condition still die in the hospital. In Article 4 we found that 43% of patients in poor clinical condition die. The major cause of death was withdrawal of life support (WOLS; 71%) followed by brain death (15%). The data were collected from hospitals in Europe and North-America and showed differences in the major causes of death, probably due to cultural and referral differences. As WOLS is a decision of the team of physicians, future studies need to investigate the exact reason that lead to WOLS in order to improve the care of patients who are admitted in poor clinical condition. What if patients used antiplatelet agents before the hemorrhage? The management options of different hospitals are summarized in Article 5 and show a large variety regarding discontinuing the antiplatelet agent and transfusing thrombocytes. This emphasizes the importance of evidence-based guidelines for the management of prehemorrhage antiplatelet agent use. As mentioned previously, the prevention of recurrent hemorrhage might have a relevant impact on in-hospital mortality. This was proven by the results in Article 6, which compares patients who received the antifibrinolytic agent tranexamic acid (TXA) or not. Early administration of TXA resulted in a significant reduction of in-hospital mortality with an odds ratio of 0.42. Early pharmacological thromboprophylaxis (PTP) is known to reduce venous thromboembolisms. However, PTP could potentially be harmful in patients with recently treated aneurysms or absence of an aneurysm on the first digital subtraction angiography (DSA). In Article 7 we reviewed the safety profile of early administration of PTP and concluded that this can be done safely in treated aneurysms and non-aneurysmal hemorrhage.