AHA/ASA Issues Guidelines for aSAH Management

May 25, 2012—The American Heart Association/American Stroke Association guidelines for the management of aneurysmal subarachnoid hemorrhage (aSAH) have been published by E. Sander Connolly Jr, MD, et al in Stroke (2012;43;1711–1737). The guidelines aim to present current and comprehensive recommendations for the diagnosis and treatment of aSAH.

As summarized in Stroke, the guideline authors performed a formal literature search of MEDLINE from November 1, 2006 through May 1, 2010. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by seven expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

The guidelines advise that aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care.

The evidence-based guidelines for the goal-directed care of patients presenting with aSAH are subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

Guidelines regarding surgical and endovascular methods of treatment of ruptured cerebral aneurysms include:

• Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Class I; Level of Evidence B).

• Complete obliteration of the aneurysm is recommended whenever possible (Class I; Level of Evidence B).

• Determination of aneurysm treatment, as judged by both experienced cerebrovascular surgeons and endovascular specialists, should be a multidisciplinary decision based on characteristics of the patient and the aneurysm (Class I; Level of Evidence C; Revised recommendation from previous guidelines).

• For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of Evidence B; Revised recommendation from previous guidelines).

• In the absence of a compelling contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and strong consideration should be given to retreatment, either by repeat coiling or microsurgical clipping, if there is a clinically significant (eg, growing) remnant (Class I; Level of Evidence B; New recommendation).

• Microsurgical clipping may receive increased consideration in patients presenting with large (> 50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms. Endovascular coiling may receive increased consideration in the elderly (> 70 years of age), in those presenting with poor-grade (World Federation of Neurological Surgeons classification IV/V) aSAH, and in those with aneurysms of the basilar apex (Class IIb; Level of Evidence C; New recommendation).

• Stenting of a ruptured aneurysm is associated with increased morbidity and mortality, and should only be considered when less risky options have been excluded (Class III; Level of Evidence C; New recommendation).