Management of Subarachnoid Haemorrhage

Apr 22, 2022

Nazih Assaad, an experienced neurosurgeon adept in aneurysmal subarachnoid haemorrhage, shares his insights on this complex condition. He discusses the clinical and radiological grading of SAH and how they provide crucial prognostic information. Assaad emphasizes four critical management pillars: addressing the effects of the hemorrhage, managing hydrocephalus, preventing re-bleeding, and addressing delayed ischemia. He also explores surgical techniques, the evolving role of endovascular options, and the necessity of high-volume, multidisciplinary care for optimal patient outcomes.

Ask episode

AI Snips

Chapters

Transcript

Episode notes

INSIGHT

Presentation Grade Predicts Outcome

Clinical grade at presentation strongly predicts outcome after aneurysmal SAH.
Radiological Fisher grade correlates with vasospasm risk but is not identical to clinical prognosis.

ADVICE

Aggressively Drain Clinical Hydrocephalus

Treat clinical hydrocephalus aggressively with CSF drainage, usually via EVD for monitoring and drainage.
Consider lumbar drains or surgical techniques to improve CSF circulation to reduce subarachnoid blood load.

ADVICE

Secure Aneurysms Early (12–24h)

Secure ruptured aneurysms early, typically within 12–24 hours, to prevent re-bleeding.
Avoid ultra‑early night operations unless time-critical pathology demands immediate surgery.

Get the Snipd Podcast app to discover more snips from this episode

Get the app

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.

Nazih will guide you through the four elements in the management of established SAH.

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.

For more like this, head to our podcast page #CodaPodcast