Aneurysmal Subarachnoid Hemorrhage Edited version of AHA presentation

Aneurysmal Subarachnoid Hemorrhage Edited version of AHA presentation (2009). Editing by WCR. Full version at www. americanheart. org/presenter. jhtml? identifier=3063278. Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 2009: published online before print January 22, 2009, 10. 1161/STROKEAHA. 108. 191395.

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (SAH) A Statement for Healthcare Professionals from a Special Writing Group of the Stroke Council, American Heart Association Joshua B. Bederson, MD, Chair; E. Sander Connolly, Jr. , MD, Vice. Chair; H. Hunt Batjer, MD; Ralph G. Dacey, MD; Jacques E. Dion, MD; Michael N. Diringer, MD; John E. Duldner, Jr. , MD; Robert E. Harbaugh, MD; Aman B. Patel; Robert H. Rosenwasser, MD This slide presentation was developed by members of the Stroke Council Professional Education committee. Opeolu Adeoye MD; Dawn Kleindorfer MD 3/19/2018© 2009, American Heart Association. All rights reserved.

Introduction • SAH is a common and devastating condition • SAH affects up to 30, 000 persons annually in the United States (US) • Mortality rates are as high as 45% with significant morbidity among survivors • These recommendations summarize the best available evidence for treatment of patients with aneurysmal SAH 3/19/2018© 2009, American Heart Association. All rights reserved.

Stroke 3/19/2018© 2009, American Heart Association. All rights reserved.

Aneurysm 3/19/2018© 2009, American Heart Association. All rights reserved.

Epidemiology • SAH incidence varies greatly between countries, from 2 cases/ 100, 000 in China to 22. 5/100, 000 in Finland • Many cases of SAH are misdiagnosed • Thus, the annual incidence of aneurysmal SAH in the US may exceed 30, 000 • Incidence increases with age, occurring most commonly between 40 and 60 years of age (mean age > 50 years) 3/19/2018© 2009, American Heart Association. All rights reserved.

Epidemiology • SAH is ~1. 6 times higher in women than men • Risk factors for SAH include hypertension, smoking, female gender and heavy alcohol use • Cocaine-related SAH occurs in younger patients • Familial intracranial aneurysm (FIA) syndrome occurs when two firstthrough third-degree relatives have intracranial aneurysms 3/19/2018© 2009, American Heart Association. All rights reserved.

CT Scan non-contrast showing blood in basal cisterns (SAH) – so called “Star-Sign” CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery 3/19/2018© 2009, American Heart Association. All rights reserved.

CT Scan of a 65 yo woman, Subarachnoid Hemorrhage Arrow: Hyperintense signal. Blood in the subarachnoid space CT Scan courtesy: University of Texas Health Science Center at San Antonio, Department of Neurosurgery 3/19/2018© 2009, American Heart Association. All rights reserved.

Angiogram - Giant ICA Aneurysm Angio image courtsey: University of Texas Health Science Center at San Antonio - Department of Neurosurgery 3/19/2018© 2009, American Heart Association. All rights reserved.

Natural History and Outcome of an Aneurysmal SAH • 30 -day mortality rate after SAH ranges from 3350% • Severity of initial hemorrhage, sex, time to treatment, and medical comorbidities impact SAH outcome • Aneurysm size, location in the posterior circulation, and morphology may also impact outcome • Endovascular services at a given institution, the volume of SAH patients treated, and the facility where the patient is first evaluated may also impact outcome 3/19/2018© 2009, American Heart Association. All rights reserved.

Acute Evaluation - Diagnosis • “The worst headache of my life” is described by ~80% of patients • “Sentinel” headache is described by ~20% • Nausea/vomiting, stiff neck, loss of consciousness, or focal neurological deficits may occur • Misdiagnosis of SAH occurred in as many as 64% of cases prior to 1985 • Recent data suggest an SAH misdiagnosis rate of approximately 12% 3/19/2018© 2009, American Heart Association. All rights reserved.

Acute Evaluation - Diagnosis • Importance of recognition of a warning or sentinel leak cannot be overemphasized • A high index of suspicion is warranted in the ED • The diagnostic sensitivity of CT scanning is not 100%, thus diagnostic lumbar puncture should be performed if the initial CT scan is negative 3/19/2018© 2009, American Heart Association. All rights reserved.

Acute Evaluation – Emergency Evaluation • Emergency medical services (EMS) is first medical contact in about 2/3 of SAH patients • EMS personnel should receive continuing education regarding signs and symptoms and the importance of rapid neurological assessment in cases of possible SAH • On-scene delays should be avoided • Rapid transport and advanced notification of the ED should occur 3/19/2018© 2009, American Heart Association. All rights reserved.

Acute Evaluation – Preventing Re -bleeding • Up to 14% of SAH patients may experience re-bleeding within 2 hours of the initial hemorrhage • Re-bleeding was more common in those with a systolic blood pressure >160 mm Hg • Anti-fibrinolytic therapy may reduce rebleeding but has not been shown to improve outcomes 3/19/2018© 2009, American Heart Association. All rights reserved.

Surgical and Endovascular Management of SAH • Occluding aneurysms using endovascular coils was described in 1991 • Improved outcomes have been linked to hospitals that provide endovascular services • Use of endovascular versus surgical techniques varies greatly across centers • Coil embolization is associated with a 2. 4% risk of aneurysmal perforation and an 8. 5% risk of ischemic complications 3/19/2018© 2009, American Heart Association. All rights reserved.

Surgical and Endovascular Management of SAH • Combined morbidity and mortality was significantly greater in surgically treated patients than in those treated with endovascular techniques (30. 9% vs. 23. 5%; absolute risk reduction 7. 4%, P = 0. 0001) • During the short follow-up period in ISAT the re -bleeding rate for coiling was 2. 9% versus 0. 9% for surgery • There have been no randomized comparisons of coiling versus clipping for unruptured aneurysms 3/19/2018© 2009, American Heart Association. All rights reserved.

Clipping 3/19/2018© 2009, American Heart Association. All rights reserved.

Left image arrow -Angio with Large aneurysm Right image arrow – Angio showing aneurysm post clipping Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery 3/19/2018© 2009, American Heart Association. All rights reserved.

Coiling 3/19/2018© 2009, American Heart Association. All rights reserved.

Coil system embolization: immediate result Angio showing large ICA aneurysm Same aneurysm - Post GDC Coiling Angio Image Courtsey: The University of Texas Health Science Center at San Antonio – Department of Neurosurgery 3/19/2018© 2009, American Heart Association. All rights reserved.

Summary and Conclusions • The current standard of practice calls for microsurgical clipping or endovascular coiling of the aneurysm neck whenever possible • Treatment morbidity is determined by numerous factors, including patient, aneurysm, and institutional factors 3/19/2018© 2009, American Heart Association. All rights reserved.

Summary and Conclusions • Favorable outcomes are more likely in institutions that treat high volumes of patients with SAH, in institutions that offer endovascular services, and in selected patients whose aneurysms are coiled rather than clipped • Optimal treatment requires availability of both experienced cerebrovascular surgeons and endovascular surgeons working in a collaborative effort to evaluate each case of SAH 3/19/2018© 2009, American Heart Association. All rights reserved.