Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50 % to 35 % in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
Highlights
Aneurysmal subarachnoid haemorrhage (SAH) is a complex neurovascular syndrome with profound systemic effects and is associated with high disability and mortality [1]
We could not identify any study addressing the role of mannitol in the management of raised intracranial pressure (ICP) in the SAH population; for hypertonic saline, we found only case series [43,44,45,46] and a small placebo-controlled trial in patients with raised but stable ICP [47]
Aneurysmal SAH is a complex neurovascular disease associated with multiple neurological and systemic complications and requires multidisciplinary specialised care, best provided in high-volume centres
Summary
Aneurysmal subarachnoid haemorrhage (SAH) is a complex neurovascular syndrome with profound systemic effects and is associated with high disability and mortality [1]. Despite a 17 % decrease in case fatality in the last three decades associated with improved management strategies, 30-day mortality and before-admission death rate are still high, around 35 % and 15 %, respectively [2]. Outcomes after SAH can vary significantly, from full recovery to severe disability or death, depending on the severity of the initial bleed and potential complications typically happening in the first 2 weeks after the haemorrhage [3]. The level of consciousness is considered the most important early predictor of outcome [4,5,6]. Patients with a normal level of consciousness have a low risk of mortality.
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