Management of Subarachnoid Hemorrhage

Preface
Preface
Preface
Contents
Abbreviations
1: Aneurysmal Subarachnoid Haemorrhage: Epidemiology, Aetiology, and Pathophysiology
	1.1	 Introduction and Epidemiology
	1.2	 Aetiology and Risk Factors for aSAH
		1.2.1	 Modifiable Risk Factors for Aneurysmal Subarachnoid Haemorrhage (aSAH)
			1.2.1.1	 Cigarette Smoking
			1.2.1.2	 Hypertension
			1.2.1.3	 Alcohol Consumption
			1.2.1.4	 Recreational Drug Abuse
				Cocaine and Amphetamine Abuse
				Marijuana
			1.2.1.5	 Oral Contraceptives and Hormonal Replacement Therapy
			1.2.1.6	 Hypocholesterolemia
			1.2.1.7	 Atherosclerosis
			1.2.1.8	 Diabetes Mellitus
			1.2.1.9	 Low and High Body Mass Index (BMI)
			1.2.1.10	 Socioeconomic Status and Occupational Stress
		1.2.2	 Non-modifiable Risk Factors for Increased aSAH
			1.2.2.1	 Gender
			1.2.2.2	 Familial or Connective Tissue Disorders
	1.3	 Pathophysiology of Cerebral Aneurysms
		1.3.1	 Catecholamine Induced Injury
		1.3.2	 The Systemic Inflammatory Response Syndrome (SIRS) and Metabolic Derangements
	1.4	 Conclusion
	References
2: Cerebral Circulation and Its Clinical Impact
	2.1	 Background
	2.2	 Blood Supply of the Brain
		2.2.1	 Internal Carotid Arteries
		2.2.2	 The Bouthillier Classification
	2.3	 Posterior Circulation
	2.4	 Circle of Willis (COW)
	2.5	 Venous Drainage from Brain
	2.6	 Cerebrospinal Fluid (CSF)
	2.7	 Blood–Brain Barrier (BB)
	2.8	 Conclusion
	References
3: Central Nervous System Neurophysiology
	3.1	 Introduction
	3.2	 Electrophysiology
		3.2.1	 Neuron Structure
		3.2.2	 The Resting Membrane Potential
		3.2.3	 Depolarisation
		3.2.4	 Repolarisation
		3.2.5	 Nerve Impulse
		3.2.6	 Synaptic Transmission
	3.3	 Cerebral Metabolism
		3.3.1	 Oxygen
		3.3.2	 Energy Substrates
		3.3.3	 Neurometabolic Coupling
	3.4	 Cerebral Blood Flow (CBF)
		3.4.1	 Cerebral Metabolic Rate of Oxygen Consumption
		3.4.2	 Cerebral Perfusion Pressure
		3.4.3	 Autoregulation
		3.4.4	 Extrinsic Regulatory Mechanisms
			3.4.4.1	 Respiratory Gas Tensions
			3.4.4.2	 Temperature
			3.4.4.3	 Viscosity
			3.4.4.4	 Autonomic Influences
	3.5	 Blood–Brain Barrier
		3.5.1	 Structure and Function
		3.5.2	 Transport of Glucose and Amino Acids
		3.5.3	 Transport of Ions
		3.5.4	 Transport of Macromolecules
	3.6	 Cerebrospinal Fluid
		3.6.1	 Production and Secretion
		3.6.2	 Composition
		3.6.3	 Circulation
		3.6.4	 Absorption
		3.6.5	 Pathophysiology Related to Cerebrospinal Fluid
	3.7	 Intracranial Pressure
		3.7.1	 Volume/Pressure Relationship
		3.7.2	 ICP Waves
		3.7.3	 Increased ICP
		3.7.4	 Intracranial Pressure Monitors
			3.7.4.1	 Invasive Techniques
				External Ventricular Drainage (EVD)
				Implantable Microtransducer ICP Monitoring Devices
				Other Devices
			3.7.4.2	 Non-Invasive Techniques
	3.8	 Conclusion
	References
4: Neuroprotection in Subarachnoid Hemorrhage
	4.1	 Introduction
	4.2	 Primary and Secondary Brain Injury
	4.3	 Neuroprotective Strategies
		4.3.1	 General Measures
			4.3.1.1	 Cerebral Perfusion
			4.3.1.2	 Normoxia and Normocapnia
			4.3.1.3	 Therapeutic Hypothermia
			4.3.1.4	 Prevention of Fever
			4.3.1.5	 Glycemic Management
			4.3.1.6	 Dysnatremia and Sodium Management
			4.3.1.7	 Seizure Prophylaxis
			4.3.1.8	 Anemia
			4.3.1.9	 Nutrition
	4.4	 Specific Pharmacological Measures
		4.4.1	 Corticosteroids
		4.4.2	 Calcium Channel Antagonists
		4.4.3	 Statins
		4.4.4	 Magnesium
		4.4.5	 Erythropoietin (EPO)
		4.4.6	 Anti-platelet Therapy
		4.4.7	 Endothelin A Antagonist
		4.4.8	 Beta Blockers/Dexmedetomidine
		4.4.9	 Heparin
		4.4.10	 Hydrogen Rich Saline
		4.4.11	 Ghrelin
		4.4.12	 ADAMTS13
		4.4.13	 Fasudil
		4.4.14	 Deferoxamine
	4.5	 Conclusions
	References
5: Systematic Approach for Diagnosis of Aneurysmal Subarachnoid Hemorrhage
	5.1	 Introduction
	5.2	 History
	5.3	 Physical Examination
	5.4	 Diagnostic Investigations
		5.4.1	 Non-contrast Head CT Scan
		5.4.2	 Lumbar Puncture (LP)
		5.4.3	 Computed Tomography Angiography (CTA)
		5.4.4	 Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA)
		5.4.5	 Digital Subtraction Angiography (DSA)
	5.5	 Conclusion
	References
6: Grading of Aneurysmal Subarachnoid Hemorrhage
	6.1	 Introduction
		6.1.1	 Definition of Grading Scale
		6.1.2	 The Hunt and Hess Grading Scale
		6.1.3	 Fisher Scale
		6.1.4	 Fisher Revised Scale
		6.1.5	 Hijdra Scale
		6.1.6	 The Glasgow Coma Scale
		6.1.7	 Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH)
		6.1.8	 World Federation of Neurosurgeons SAH Scale (WFNS)
		6.1.9	 VASOGRADE
	6.2	 Conclusion
	References
7: Anesthetic Management of Aneurysmal Subarachnoid Hemorrhage (aSAH)
	7.1	 Introduction
	7.2	 General Principles of Anesthesia
		7.2.1	 The Primary Goals of Anesthetic Management Are
	7.3	 Preoperative Evaluation and Optimization
	7.4	 Premedication
	7.5	 Anesthesia for Surgical Clipping of Cerebral Aneurysm
		7.5.1	 Monitoring
			7.5.1.1	 Standard Monitoring
			7.5.1.2	 Hemodynamic Monitoring
			7.5.1.3	 Neuromonitoring
				ICP Monitoring
				Jugular Venous Bulb Monitoring
				Near-Infrared Spectroscopy
			7.5.1.4	 Neurophysiology Monitoring
		7.5.2	 Induction
		7.5.3	 Maintenance
		7.5.4	 Brain Relaxation
			7.5.4.1	 Positioning
			7.5.4.2	 Mannitol
			7.5.4.3	 Furosemide
			7.5.4.4	 Hypertonic Saline
			7.5.4.5	 CSF Drainage
			7.5.4.6	 Hyperventilation
		7.5.5	 Fluids and Electrolytes
		7.5.6	 Temporary Clipping
		7.5.7	 Intraoperative Aneurysmal Rupture
		7.5.8	 Emergence
	7.6	 Anesthesia for Interventional Neuroradiology (INR)
		7.6.1	 Anesthetic Concerns Include
			7.6.1.1	 Remote Site Anesthesia
			7.6.1.2	 Radiation Safety
			7.6.1.3	 Anticoagulation
		7.6.2	 Pre-Intervention Assessment
		7.6.3	 Monitoring
		7.6.4	 Anesthetic Technique
			7.6.4.1	 Sedation for Only Diagnostic Procedure
			7.6.4.2	 General Anesthesia
		7.6.5	 Complications of INR Procedures
			7.6.5.1	 Hemorrhagic Complications
			7.6.5.2	 Occlusive Complications
			7.6.5.3	 Contrast Reactions
			7.6.5.4	 Contrast Induced Nephropathy (CIN)
				Pre-Procedural Management for High-Risk Patients
					Volume Repletion
					Patient Medication
				Intraoperative Management for High-Risk Patients
				Postoperative Management
		7.6.6	 Postoperative Care
	7.7	 Conclusion
	References
8: Subarachnoid Hemorrhage Coiling and Intervention
	8.1	 Introduction
	8.2	 Concept of Treatment
	8.3	 Equipment and Materials
		8.3.1	 The Angio Suite
		8.3.2	 Introducers (Sheaths)
		8.3.3	 Catheters
		8.3.4	 Microcatheters
		8.3.5	 Micro-Guide Wires
		8.3.6	 Torque Device
		8.3.7	 Balloons
		8.3.8	 Stents
		8.3.9	 Flow Diverting Stents
		8.3.10	 Coils
			8.3.10.1	 Helical Coils
			8.3.10.2	 3D Coils/360 Coils
			8.3.10.3	 Hydrogel Coils
		8.3.11	 Intra-Saccular Diversion Devices
	8.4	 Procedures and Techniques
		8.4.1	 Anesthesia
		8.4.2	 Access
		8.4.3	 Simple Coiling
		8.4.4	 Treatment of Wide Neck Aneurysms
			8.4.4.1	 Balloon Assisted Coiling (BAC)
			8.4.4.2	 Stent Assisted Coiling (SAC)
			8.4.4.3	 Three-Dimensional Coils (3D Coils)
			8.4.4.4	 Simultaneous Coil Deposition
			8.4.4.5	 Liquid Embolic Agents
			8.4.4.6	 Partial Embolization
			8.4.4.7	 Deconstructive Treatment
		8.4.5	 Flow Diverters
		8.4.6	 Antiplatelets
	8.5	 Complications
		8.5.1	 Thromboembolism
		8.5.2	 Aneurysm Rupture
		8.5.3	 Vascular Injury
			8.5.3.1	 Pseudoaneurysm
			8.5.3.2	 Retroperitoneal Hematoma
			8.5.3.3	 Dissection or Rupture
		8.5.4	 Vasospasm
			8.5.4.1	 Diagnosis of Vasospasm
			8.5.4.2	 Endovascular Management of Vasospasm
	8.6	 Conclusion
	References
9: Surgical Management of Aneurysmal Subarachnoid Hemorrhage
	9.1	 Historical Background
	9.2	 Perianeurysmal Environment and Subarachnoid Spaces
	9.3	 Preoperative Assessment and Preparation
		9.3.1	 Timing of Surgery
		9.3.2	 Preoperative Imaging
		9.3.3	 Operating Microscope
		9.3.4	 Aneurysm Clips
	9.4	 Surgical Positioning and Approaches
		9.4.1	 Surgical Positions
		9.4.2	 Surgical Approaches
			9.4.2.1	 Perianal Approach
			9.4.2.2	 Sub-Temporal Approach
			9.4.2.3	 Far Lateral Retrosigmoid Approach
	9.5	 Proximal Vascular Control and Temporary Clipping
	9.6	 Retractorless Tachnique
	9.7	 Microsurgical Dissection and Clip Application
		9.7.1	 Aneurysm of Anterior Communicating Artery
		9.7.2	 Middle Cerebral Artery Aneurysm
		9.7.3	 Posterior Communication and Anterior Choroidal Artery Aneurysm
		9.7.4	 Aneurysms of the Pericallosal Artery
		9.7.5	 Aneurysms of Basilar Quadrification
	9.8	 Confirmation of Aneurysm Obliteration
		9.8.1	 Intraoperative Doppler Ultrasound
		9.8.2	 Indocyanine Green Video Angiography (ICG-VA)
		9.8.3	 Cerebral Angiography
	9.9	 Intraoperative Aneurysm Rupture
	9.10	 Postoperative Complications
		9.10.1	 Vasospasm
		9.10.2	 Hydrocephalus
		9.10.3	 Seizures
		9.10.4	 Postoperative Pain
		9.10.5	 Mortality
	9.11	 Post-Clipping Remnants, Growth, and Recurrences
	9.12	 Future Prospects, Advances, and Innovations
	9.13	 Conclusions
	References
10: Complications and Critical Care Management of Aneurysmal Subarachnoid Hemorrhage
	10.1	 Introduction
	10.2	 Complications Associated with SAH
		10.2.1	 Neurological Complications
			10.2.1.1 Re-bleeding
				Risk Factors of Re-bleeding
					Amount of Subarachnoid Blood on Initial Non-contrast CT Head
					Poor Neurological Status on Admission
					Aneurysmal Factors (Size, Location, Total Number)
					High Blood Pressure (More than 160 mmHg)
					Patient Age
					Angiography within 6 h After Initial SAH
					Sentinel Headache Preceding SAH
					Longer Interval from Ictus to Admission
					Ventriculostomy Before Aneurysmal Treatment
					Coagulopathy
				Pathophysiology of Re-bleeding
				Diagnosis
				Prevention of Re-bleeding
					Early Obliteration of the Aneurysm
					Blood Pressure Control
					Short Course of Antifibrinolytic Medications
			10.2.1.2 Vasospasm, Delayed Cerebral Ischemia (DCI)
				Risk Factors
					Age
					Gender
					Cigarette Smoking
					Diabetes Mellitus
					Initial Loss of Consciousness
					Hypertension
					Severity of aSAH Clot on CT Scan
					Electrolyte Disturbance
					Myocardial Dysfunction
				Diagnosis of DCI
					Clinical Monitoring
					Radiological Monitoring
						Digital Subtraction Angiography (DSA)
						Computed Tomogram Angiography (CTA)
						Computed Tomogram Perfusion (CTP)
					Physiological Monitoring
						Transcranial Doppler (TCD)
				Prevention of Delayed Cerebral Ischemia
					Nimodipine
					Avoidance Hyponatremia and Hypovolemia
					Induced Hypertension
					Rescue Therapy for Medically-Refractory DCI (Tier One Interventions)
						Haemoglobin Optimization
						Endovascular Therapy
						Mechanical Dilatation
						Intra-arterial Vasodilators
			10.2.1.3 Hydrocephalus
				Pathophysiology
					Communicating Hydrocephalus
					Noncommunicating Hydrocephalus
				Diagnosis
					CT Scan
					Magnatic Resonance Imaging (MRI)
				Clinical Predictor of Shunt-Dependent Hydrocephalus
				Management of Hydrocephalus
					External Ventricular Drain (EVD)
					Lumbar Drain
					Ventriculoperitoneal Shunt (VPS)
			10.2.1.4 Seizures
				Management
		10.2.2	 Non-neurological Complications Associated with SAH
			10.2.2.1 Cardiac Complications
				Pathophysiology
					Mild Myocardial Injury
					Cardiomyopathy
					Arrhythmia
			10.2.2.2 Electrolyte Disturbances
			10.2.2.3 Hyponatremia
				Treatment of Hyponatremia
			10.2.2.4 Hyperglycemia
			10.2.2.5 Fever
			10.2.2.6 Anemia
			10.2.2.7 Deep Venous Thrombosis (DVT)
			10.2.2.8 Heparin-Induced Thrombocytopenia (HIT)
	10.3	 Conclusion
	References
11: Headache in Subarachnoid Hemorrhage
	11.1	 Introduction
	11.2	 Pathophysiology of Headache in Aneurysmal SAH
	11.3	 Pain Severity Evaluation in SAH
	11.4	 Management of Headache in SAH
		11.4.1	 Pharmacological
			11.4.1.1	 Opioids
			11.4.1.2	 Non-opioids Therapy
				Paracetamol
				Non-steroidal Anti-inflammatory Drugs (NSAIDs)
				Dexmedetomidine
				Pregabalin
				Gabapentin
				Ketamine
				Magnesium
				Corticosteroids
		11.4.2	 Non-pharmacological Options
			11.4.2.1	 Scalp Block
	11.5	 Conclusion and Recommendations
	11.6	 Research Gaps and Future Directions
	References
12: Traumatic Subarachnoid Hemorrhage
	12.1	 Introduction
	12.2	 Incidence
	12.3	 Pathophysiology
	12.4	 Clinical Features and Presentations
	12.5	 Diagnosis
		12.5.1	 CT Scan
			12.5.1.1	 Advantages
			12.5.1.2	 Limitations
		12.5.2	 Magnetic Resonance Imaging and Others
			12.5.2.1	 Advantages
			12.5.2.2	 Limitations
	12.6	 Grading of tSAH
		12.6.1	 Fisher Grade Classification
		12.6.2	 Modified Fisher’s Scale [7]
		12.6.3	 Morris-Marshall Grading [7]
		12.6.4	 Greene et al. Grading [7]
	12.7	 Complications of tSAH
		12.7.1	 Post-traumatic Vasospasm (PTV)
		12.7.2	 Hydrocephalus
		12.7.3	 Pseudoaneurysm
		12.7.4	 Cognitive Dysfunction
	12.8	 Management of tSAH
	12.9	 Management of Specific Complications
		12.9.1	 Dyslectrolytemia
		12.9.2	 Post-traumatic Vasospasm
		12.9.3	 Hydrocephalus
		12.9.4	 Ruptured Pseudoaneurysm
			12.9.4.1	 Surgical Clipping
			12.9.4.2	 Trapping
				Surgical “Complete Trapping”
			12.9.4.3	 Artery Occlusion and Bypass
			12.9.4.4	 Wrapping
			12.9.4.5	 Non-surgical Management
				Endovascular Coiling
			12.9.4.6	 Follow-Up
	12.10	 Prognostic Factors
	12.11	 Conclusion
	References
13: Prognosis of Aneurysmal Subarachnoid Haemorrhage: Facts and Figures
	13.1	 Introduction
	13.2	 Mortality in aSAH
	13.3	 Morbidity in aSAH
		13.3.1	 Neurophysical Dysfunction
		13.3.2	 Neuropsychological Dysfunction
		13.3.3	 Neuropsychiatric Manifestation in Post aSAH
	13.4	 Prediction and Monitoring the Prognosis in aSAH
		13.4.1	 Severity of aSAH
		13.4.2	 Re-bleeding
		13.4.3	 Degree of Cerebral Vasospasm and Cerebral Ischaemia
		13.4.4	 Role of Nimodipine
		13.4.5	 Recreational Drug Abuse
		13.4.6	 Intraventricular Haemorrhage (IVH)
		13.4.7	 Seizures
		13.4.8	 Hydrocephalus
		13.4.9	 Cerebral Aneurysmal Diameter
		13.4.10 Patient Age
		13.4.11 Medical Complications or Organ Dysfunction and Association with Morbidity and Mortality
			13.4.11.1	 Electrolyte Disturbance
			13.4.11.2	 Fever
			13.4.11.3	 Anaemia
			13.4.11.4	 Hyperglycaemia
			13.4.11.5	 Pulmonary Complications
			13.4.11.6	 Cardiac Complications
			13.4.11.7	 Renal Dysfunctions
			13.4.11.8	 Coagulation Disorders
			13.4.11.9	 Gastrointestinal Bleeding
			13.4.11.10	 Aneurysm Recurrence and Late Re-bleeding
	13.5	 Conclusion
	References
14: Brain Death
	14.1	 Introduction
	14.2	 Historical Perspective
	14.3	 Preconditions for Diagnosis
		14.3.1	 Aetiology
		14.3.2	 Exclusion of Reversible Causes of Coma
			14.3.2.1	 Drugs
			14.3.2.2	 Primary Hypothermia
			14.3.2.3	 Metabolic and Endocrine Disturbance
				Endocrine Disorders
				Electrolyte Disorders
				Exclusion of Reversible Causes of Apnoea
	14.4	 Clinical Tests
		14.4.1	 Unresponsive Coma
		14.4.2	 Brain Stem Reflexes
			14.4.2.1	 Pupils
			14.4.2.2	 Pitfalls
			14.4.2.3	 Ocular Movements
			14.4.2.4	 Pitfalls
			14.4.2.5	 Corneal Reflex
			14.4.2.6	 Pitfalls
			14.4.2.7	 Motor and Sensory Response
			14.4.2.8	 Pitfalls
			14.4.2.9	 Pharyngeal and Tracheal Reflex
			14.4.2.10	 Pitfalls
		14.4.3	 Apnoea Test
			14.4.3.1	 Pitfalls
	14.5	 Ancillary Tests
	14.6	 Techniques to Confirm Cerebral Circulatory Arrest
		14.6.1	 Cerebral Digital Subtraction Angiography (DSA)
		14.6.2	 Cerebral Computerized Tomographic Angiography (CTA)
		14.6.3	 MRI and MR Angiography (MRA)
		14.6.4	 Transcranial Doppler Ultra sonography (TCD)
		14.6.5	 Cerebral Scintigraphy
	14.7	 Neurophysiological Methods: EEG and Evoked Potentials
	14.8	 Diagnosis of Brain Death in Infants and Children
		14.8.1	 Children Older Than 2 Months
		14.8.2	 37 Weeks Gestation to 2 Months of Age
		14.8.3	 Infants Below 37 Weeks Gestation
	14.9	 Diagnosis of Brain Death in Patients with Extra-Corporeal Membrane Oxygenation (ECMO)
	14.10	 Ethical, Legal, and Religious Aspects of Brain Death
	14.11	 Donor Management
		14.11.1 Pathophysiology of Organ Failure After Brain Death
			14.11.1.1	 Cardiovascular Effects of Brain Death
			14.11.1.2	 Pulmonary Changes
			14.11.1.3	 Endocrine Changes
				Thyroid Hormones
				Cortisol
				Pituitary Hormones
			14.11.1.4	 Inflammatory and Immunological Aspect of Brain Death
		14.11.2	 Clinical Management
			14.11.2.1	 Haemodynamic Management
			14.11.2.2	 Haemodynamic Monitoring
			14.11.2.3	 Thyroxine Supplementation
			14.11.2.4	 Pulmonary Care
			14.11.2.5	 Immunosuppressive Strategies
				Therapeutic Hypothermia
		14.11.3 Conclusion
	References