Managing a suspected aneurysm can be a daunting process for clinciains—even the seasoned ones! In this video, we take an in-depth approach to the initial management of aneurysmal hemorrhage, controversial medications sometimes used in the process, and what to do if your patient deteriorates further.
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As noted previously, initial management of the aneurysmal subarachnoid hemorrhage patient involves assessing and addressing the ABCs, resuscitation, stabilization, rapid assessment and initiation of imaging. Once subarachnoid hemorrhage has been confirmed, there are several interventions and management schemes that should be initiated.
Start by contacting your neurosurgery team and or your endovascular surgery team. They may want to address the aneurysm itself nearly immediately. Also, don't hesitate to contact your neurosurgery team if the patient's history is strongly suggestive of a subarachnoid hemorrhage, even if the original CT scans of the head show no evidence of hemorrhage.
In initial care of the patient elevate their head to 30 degrees, this will help lower intracranial pressure. Make sure that the patient consumes nothing by mouth ntil next steps have been determined by your neurosurgical team. Keep the patient well oxygenated, monitor oxygenation and vital signs closely. Obtain an electrocardiogram. Subarachnoid hemorrhage can be associated with significant cardiac strain.
Rehemorrhage from a ruptured aneurysm is very common with devastating consequences. Elevation of blood pressure strongly increases the risk of re rupture of the aneurysm. Blood pressure control is therefore paramount. Titrate the patient's systolic blood pressure to less than 140 millimeters of mercury. Nicardipine and labetalol are currently popular agents for blood pressure control in aneurysm patients.
Run IV fluids generously, they help maintain perfusion, run them at around 120 to 140 milliliters per hour in a standard sized patient. Avoid hypotonic fluids as a worsened cerebral edema and can contribute to hyponatremia. It turns out the patients experiencing subarachnoid hemorrhage are prone to profound hyponatremia. Generally use normal sailne for maintenance fluids.
Start naimodipine, a calcium channel blocker, 60 milligrams by mouth every four hours. This is a medication that limits cerebral blood vessel spasm, a potential deadly threat to aneurysmal rupture patients over the ensuing week or two. In vasospasm cerebral blood vessels spontaneously clamped down, they do so so much that they can cause widespread ischemic strokes.
Reverse any anticoagulation or antiplatelet medications the patient may be on in accordance with your pharmacist recommendations. Also manage coagulopathies as effectively as possible. You are trying to prevent re hemorrhage from the aneurysm. Although not strongly supported by the literature, we tend to use levetiracetam 500 to 1000 milligrams twice a day as prophylaxis against seizures. Seizures could cloud the all important neurological exam and could cause aneurysmal rebleeding.
Steroids are controversial. We initially give dexamethasone four milligrams intravenously every six hours to diminish cerebral irritation and headache for the first two to four days of hospitalization. Although they have not been demonstrated to help with overall outcomes, they certainly seem to help patients feel better. We use it for all patients unless contraindicated, for example, patients with brittle diabetes, ulcers, etc.
Severe headaches should be treated with acetaminophen. Narcotics should be avoided, unless approved by your neurosurgical team as they may obscure the neurological exam, they may also result in straining and bowel movements, such straining may precipitate aneurysm or re rupture. Keep a close eye on the patient.
Watch for declining level of consciousness, this often is due to developing hydrocephalus and or increased intracranial pressure from brain swelling. Notify the neurosurgical team immediately if the patient deteriorates and prepare for an emergent repeat noncontrast CT scan of the head. Now after the initial evaluation, the patient may be taken directly to the angiography suites.
Otherwise prepare the patient for admission to an intensive care unit for continuous monitoring and frequent neurological assessment. Note, in patients where definitive treatment of the aneurysm, that is endovascular or surgical obliteration of the aneurysm is delayed, treatment with an antifibrinolytic may be initiate.
Such medications include aminocaproic acid, this therapy is oriented to reducing the risk of aneurysmal rebleeding. As we've noted several times aneurisms, frequently re hemorrhage after rupture, with devastating consequences. 20% will re hemorrhage within the first two weeks after the original rupture, 50% within six months, thus, the sooner they can be eliminated, the better.
A critical step in the care of ruptured aneurysms is there for physical obliteration of the aneurysm through endovascular or surgical techniques, taking away its ability to re rupture. Endovascular method methods are less invasive, and have less associated morbidity than brain surgery through craniotomy, and thus have become the principal resource for the treatment of cerebral aneurysms.
Endovascular treatment of an aneurysm involves passing a catheter from an artery in the groin, all the way to the cerebral circulation and into the region of the aneurysm. There the aneurysm can be packed with tiny platinum coils to help clot off the aneurysm. Alternatively, a stent can be placed in the adjacent artery to divert blood flow away from the aneurysm and encourage the aneurysm to clot off.
When aneurysms cannot be successfully treated by endovascular methods. Patients will undergo surgical clipping of their aneurysms via craniotomy. During a surgical clipping, the surgeon will place a spring loaded titanium clip around the opening of the aneurysm to stop blood flow into the aneurysm. If blood cannot flow into it, it cannot rupture and bleed. Now please understand obliteration of an aneurysm by surgery or endovascular techniques removes the risk of re hemorrhage, but unfortunately, the patient is far from being out of the woods. a whole series of complications are still very possible.