Aneurysmal Subarachnoid Hemorrhage Guidelines
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3. PubMed PMID: 22556195 1).
Hospital Characteristics and Systems of Care
According to current Aneurysmal Subarachnoid Hemorrhage Guidelines (aSAH) patients are mostly managed in intensive care units (ICU) regardless of baseline severity.
Low-volume hospitals (eg, <10 aSAH cases per year) should consider early transfer of patients with aSAH to high-volume centers (eg, >35 aSAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neuro-intensive care services (Class I; Level of Evidence B). (Revised recommendation from previous guidelines)
Annual monitoring of complication rates for surgical and interventional procedures is reasonable (Class IIa; Level of Evidence C). (New recommendation)
A hospital credentialing process to ensure that proper training standards have been met by individual physicians treating brain aneurysms is reasonable (Class IIa; Level of Evidence C). (New recommendation) 2).
The adjusted odds of definitive repair were significantly higher in urban teaching hospitals than in urban nonteaching hospitals (odds ratio, 1.62) or rural hospitals (odds ratio, 3.08).7 In another study from 1993 to 2003, teaching status and larger hospital size were associated with higher charges and longer stay but also with better outcomes (P<0.05) and lower mortality rates (P<0.05), especially in patients who underwent aneurysm clipping (P<0.01). Endovascular treatment, which was more often used in the elderly, was also associated with significantly higher mortality rates in smaller hospitals (P<0.001) and steadily increasing morbidity rates (45%). Large academic centers were associated with better results, particularly for surgical clip placement 3).
Llull et al. from a Comprehensive Stroke Center in Barcelona assessed the prognostic and economic implications of initial admission of low-grade aSAH patients into a Stroke Unit (SU) compared to initial ICU admission.
They reviewed prospectively registered data from consecutive aSAH patients with a WFNS grade lower than 3 admitted at a Comprehensive Stroke Center between April-2013 and September-2018. Clinical and radiological baseline traits, in-hospital complications, length of hospital stay (LOS) and poor outcome at 90 days (modified Rankin Scale >2) were compared between the ICU and SU groups in the whole population and in a propensity score matched cohort.
From 131 patients, 74 (56%) were initially admitted in the ICU and 57 (44%) in the SU. In-hospital complication rates were similar in the ICU and SU groups and included rebleeding (10% vs 7%, p=0.757), angiographic vasospasm (61% vs 60%, p=0.893), delayed cerebral ischemia (12% vs 12%, p=0.984), pneumonia (6% vs 4%, p=0.697) and death (10% vs 5%, p=0.512). LOS did not differ across both groups [median (IQR) 22 (16-30) vs 19 (14-26) days, p=0.160]. In adjusted multivariate models, the location of initial admission was not associated with long-term poor outcome either in the whole population (OR=1.16, 95%CI=0.32-4.19, p=0.825) or in the matched cohort (OR=0.98, 95%CI=0.24-4.06, p=0.974).
A dedicated SU cared by a multidisciplinary team might be an optimal alternative to ICU to initially admit patients with low-risk aSAH 4).
Bederson JB, Connolly ES Jr, Batjer HH, Dacey RG, Dion JE, Diringer MN, Duldner JE Jr, Harbaugh RE, Patel AB, Rosenwasser RH; American Heart Association. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Mar;40(3):994-1025. doi: 10.1161/STROKEAHA.108.191395. Epub 2009 Jan 22. Review. Erratum in: Stroke. 2009 Jul;40(7):e518. PubMed PMID: 19164800. 5).