When to operate: ultra-early vs next-morning approach

Nazih Assaad provides his expertise on the treatment of subarachoid haemorrhage. Treatment for aneurysmal subarachnoid haemorrhage (SAH) is an area that has had extensive research but not a great deal of success. Promising animal studies have not turned out as hoped in clinical trials and many questions remain unanswered. Nazih guides the listener through his approach on how to address the complicated presentation of SAH.

Firstly, subarachnoid haemorrhages can be graded clinically and radiologically. Clinical grades provide useful prognostic information, with poorer grades less likely to do as well as more favourable grades, despite best medical and intervention management. Nazih mentions the Fisher Scale which is useful for predicting vasospasm and how he integrates both into practise.

Moreover, these are the four areas he believes every clinician working in this space should consider with every patient presenting with a SAH.

The first is the effect of the haemorrhage itself on the patient. The sudden rise of intracranial pressure secondary to aneurysm rupture leads to dramatic clinical signs. These includes loss of consciousness and seizure like activity. There are no known agents to reverse the effects of the initial insult.

Secondly, managing the degree of hydrocephalus that most, if not all, patients will have if critical. Clinical hydrocephalus is treated with CSF drainage.

Thirdly, the prevention of re-haemorrhage is important. In bygone eras, patients with aneurysmal SAH did not have immediate management of the bleed. This has changed.

Finally, delayed cerebral ischaemia (usually relating to vasospasm) should be addressed. Gold standard of diagnosis is digital subtraction angiography, and following this, Nazih describes his aggressive management approach.

Nazih takes the listener through what he considers the most critical aspects of managing a patient with an aneurysmal SAH. This talk explores diagnostic techniques, patient examination, surgical options, and other management considerations. He touches on the most recent guidelines and protocols around Australia and the world.

Please note this episode was recorded in November 2018 as part of Brain, a CICM Neuro Special Interest Group meeting click here for more info.

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