+Model
MEDINE-1936; No. of Pages 11 ARTICLE IN PRESS
Medicina Intensiva xxx (xxxx) xxx---xxx
http://www.medintensiva.org/en/
REVIEW ARTICLE
Twelve controversial questions in aneurysmal
subarachnoid hemorrhage
Juan Antonio Llompart-Pou a,∗ , Jon Pérez-Bárcena b , Alfonso Lagares b ,
Daniel Agustín Godoy c
a
Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma,
Spain
b
Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid. Spain
c
Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
Received 6 July 2023; accepted 28 September 2023
KEYWORDS Abstract Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains
Aneurysmal a major challenge. Despite the recent publication of guidelines from the American Heart
subarachnoid Association/American Stroke Association and the Neurocritical Care Society, there are many
hemorrhage; controversial questions in the intensive care unit (ICU) management of this population. The
Acute brain injury; authors provide an analysis of common issues in the ICU and provide guidance on the daily
Neurocritical care; management of this specific population of neurocritical care patients.
Intensive care © 2023 Published by Elsevier Espa?a, S.L.U.
medicine
PALABRAS CLAVE Doce preguntas controvertidas en hemorragia subaracnoidea aneursmática
Hemorragia
subaracnoidea Resumen El manejo en la unidad de cuidados intensivos (UCI) de los pacientes con hemorragia
aneurismática; subaracnoidea aneurismática continua siendo un reto. A pesar de la publicación de las guías
Lesion cerebral de la American Heart Association/American Stroke Association y la Neurocritical Care Society
aguda; todavía existen muchos aspectos controvertidos en el manejo de esta población en la UCI. Los
Cuidados autores proporcionan un detenido análisis de los problemas habituales en la UCI y proporcionan
neurocríticos; recomendaciones en el manejo diario de esta población específica de pacientes neurocríticos.
Medicina intensiva © 2023 Publicado por Elsevier Espa?a, S.L.U.
∗ Corresponding author.
E-mail address: (J.A. Llompart-Pou).
https://doi.org/10.1016/j.medine.2023.09.003
2173-5727/© 2023 Published by Elsevier Espa?a, S.L.U.
Please cite this article as: J.A. Llompart-Pou, J. Pérez-Bárcena, A. Lagares et al., Twelve controversial questions in
aneurysmal subarachnoid hemorrhage, Medicina Intensiva, https://doi.org/10.1016/j.medine.2023.09.003
, +Model
MEDINE-1936; No. of Pages 11 ARTICLE IN PRESS
J.A. Llompart-Pou, J. Pérez-Bárcena, A. Lagares et al.
Introduction risks of BP lowering in the acute phase of SAH, since it could
be a promising strategy to improve outcomes and could be
Critical care management of aneurysmal subarachnoid hem- initiated during the transport of patients by ambulance to
orrhage (aSAH) remains a major challenge worldwide.1,2 an appropriate facility.13
The lack of class I recommendations and the evolving
knowledge of early brain injury3 and delayed cerebral
What is the optimal timming for coiling or
ischemia (DCI)4 faces neurointensivists with uncertainity,
despite recently published guidelines by the American Heart clipping?
Association/American Stroke Association (AHA/ASA)5 and
the Neurocritical Care Society (NCS).6 Whilst the AHA/ASA Due to the high risk of poor outcome and mortality after
guidelines cover a comprehensive approach from the nat- aneurism rebleeding, ruptured aneurysms should be secured
ural history and clinical presentation to prevention of as soon as possible.5 Timing of the ruptured aneurysm treat-
recurrence,5 the NCS guideline focused on the critical care ment was directly examined in one randomized trial on
management.6 However, they used an approach using the good-grade patients, which demonstrated that early surgery
Grading of Recommendations, Assessment, Development (up to 3 days after SAH) was related to lower death and
and Evaluation (GRADE) framework limited to 12 manage- dependence at three months.14 This data has been corrobo-
ment questions that could probably be most impacted by rated in other types of studies in which early securing of the
new evidence and evolving management paradigms in the aneurysm (<24 h) produced better outcomes,15---17 especially
last decade.6 Thus, NCS guidelines were developed around in the endovascular treatment group.17 However, these data
specific clinical questions in a population, intervention, are not unequivocal.18
comparison, and outcomes (PICO) format,6,7 resulting mostly Indeed, from a pathophysiological rationale and consid-
in non-conclusive recommendations in a daily basis for the ering that rebleeding is especially relevant in poor grade
neurointensivist. Thus, we provide a comprehensive review aSAH within 0---12 hours from stroke 19 , inmediate (<6 h) clip-
of controversial topics in the intensive care unit (ICU) mana- ping/coiling strategies appear reasonable but its benefit has
gement of aSAH (Fig. 1). to be proven yet.
From one side it has been calculated that implement-
ing such an scheme of ultra-early management would
Which is the optimal blood pressure before only provide treatment for a very limited number of
coilling and clipping? possible rebleedings, making a modest reduction in the
rebleeding rates (around 0.3% of reduction of incidence of
The exact role of blood pressure (BP) management to pre- rebleeding).20 On the other hand, this would impose signifi-
vent early rebleeding before aneurysm securing remains to cant stress to the teams, determining that many procedures
be determined yet. The NCS guidelines state that there is would be performed by less experienced teams and with
insufficient evidence to recommend a BP reduction goal for worse equipment. Therefore, since experience is relevant
the treatment of hypertension before aneurysm treatment in final outcomes, most centers (and the authors) accept to
in aSAH patients, since the quality of available evidence perform the treatment as soon as possible by the team that
was too low to support the recommendation of a target for usually treats aneurysms by clipping or by coiling, prefer-
BP reduction vs no BP reduction.6 However, NCS guidelines ably in the first 24 h. Best results are obtained when both
specifically state that ‘‘Lack of evidence to recommend a treatments can be delivered. However when there is a
specific blood pressure reduction goal does not necessarily ruptured aneurysm producing a large cerebral hematoma,
imply that blood pressure reduction is not helpful before urgent surgery accompanied with surgical clipping of the
aneurysm treatment’’.6 On the other hand, the AHA/ASA aneurysm has demonstrated a large reduction in mortality
guidelines state that in patients with aSAH and unsecured and a higher rate of independent outcome.21 Although it is
aneurysm, frequent BP monitoring and BP control with feasible to first coil and then evacuating the hematoma, it
shortacting medications is recommended to avoid severe seems more logical not to delay hematoma evacuation and
hypotension, hypertension, and BP variability.5 perform concomitant aneurysm clipping.
The rationale behind these recommendations relies on
the low quality of studies in this setting. Retrospective
studies8 and meta-analysis9 addressed a higher risk of Which is the optimal blood pressure target
rebleeding in patients with systolic blood pressure (SBP) after securing the aneurysm?
>160 mmHg, but an aggressive approach has not been asso-
ciated with reduced reebleeding.10 Additionally, systemic There is a paucity of studies addressing this topic, making
hypotension is linked to compromised cerebral perfusion it an appealing area for planning multicenter studies and
and can be associated with DCI11 and BP variability could therefore, improve outcomes.22 In consequence, there is a
be also associated with rebleeding.12 Taking these data into huge variability in commonly used targets and indeed, there
consideration, it can only be recommended that extreme is no consensus even in using mean arterial pressure (MAP)
values and marked variability in BP must be avoided. In the or SBP targets.23
authors experience, in initially hypertensive aSAH patients, In the MANTRA survey, when the aneurysm was secured
a target of SBP 140−160 mmHg avoiding fluctuations seems 34.9% of the responders considered MAP targets (median
reasonable. (IQR) 90 (75---100) mmHg, 16.8% used SBP targets (median
Anyway, a RCT is clearly required to provide the neces- (IQR) 155 (140---180) mmHg, 33.2 % used both MAP and
sary evidence to define the balance of potential benefits and SBP (median (IQR) 90 (80---100) and median (IQR) 160
2
MEDINE-1936; No. of Pages 11 ARTICLE IN PRESS
Medicina Intensiva xxx (xxxx) xxx---xxx
http://www.medintensiva.org/en/
REVIEW ARTICLE
Twelve controversial questions in aneurysmal
subarachnoid hemorrhage
Juan Antonio Llompart-Pou a,∗ , Jon Pérez-Bárcena b , Alfonso Lagares b ,
Daniel Agustín Godoy c
a
Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d’Investigació Sanitària Illes Balears (IdISBa), Palma,
Spain
b
Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid. Spain
c
Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
Received 6 July 2023; accepted 28 September 2023
KEYWORDS Abstract Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains
Aneurysmal a major challenge. Despite the recent publication of guidelines from the American Heart
subarachnoid Association/American Stroke Association and the Neurocritical Care Society, there are many
hemorrhage; controversial questions in the intensive care unit (ICU) management of this population. The
Acute brain injury; authors provide an analysis of common issues in the ICU and provide guidance on the daily
Neurocritical care; management of this specific population of neurocritical care patients.
Intensive care © 2023 Published by Elsevier Espa?a, S.L.U.
medicine
PALABRAS CLAVE Doce preguntas controvertidas en hemorragia subaracnoidea aneursmática
Hemorragia
subaracnoidea Resumen El manejo en la unidad de cuidados intensivos (UCI) de los pacientes con hemorragia
aneurismática; subaracnoidea aneurismática continua siendo un reto. A pesar de la publicación de las guías
Lesion cerebral de la American Heart Association/American Stroke Association y la Neurocritical Care Society
aguda; todavía existen muchos aspectos controvertidos en el manejo de esta población en la UCI. Los
Cuidados autores proporcionan un detenido análisis de los problemas habituales en la UCI y proporcionan
neurocríticos; recomendaciones en el manejo diario de esta población específica de pacientes neurocríticos.
Medicina intensiva © 2023 Publicado por Elsevier Espa?a, S.L.U.
∗ Corresponding author.
E-mail address: (J.A. Llompart-Pou).
https://doi.org/10.1016/j.medine.2023.09.003
2173-5727/© 2023 Published by Elsevier Espa?a, S.L.U.
Please cite this article as: J.A. Llompart-Pou, J. Pérez-Bárcena, A. Lagares et al., Twelve controversial questions in
aneurysmal subarachnoid hemorrhage, Medicina Intensiva, https://doi.org/10.1016/j.medine.2023.09.003
, +Model
MEDINE-1936; No. of Pages 11 ARTICLE IN PRESS
J.A. Llompart-Pou, J. Pérez-Bárcena, A. Lagares et al.
Introduction risks of BP lowering in the acute phase of SAH, since it could
be a promising strategy to improve outcomes and could be
Critical care management of aneurysmal subarachnoid hem- initiated during the transport of patients by ambulance to
orrhage (aSAH) remains a major challenge worldwide.1,2 an appropriate facility.13
The lack of class I recommendations and the evolving
knowledge of early brain injury3 and delayed cerebral
What is the optimal timming for coiling or
ischemia (DCI)4 faces neurointensivists with uncertainity,
despite recently published guidelines by the American Heart clipping?
Association/American Stroke Association (AHA/ASA)5 and
the Neurocritical Care Society (NCS).6 Whilst the AHA/ASA Due to the high risk of poor outcome and mortality after
guidelines cover a comprehensive approach from the nat- aneurism rebleeding, ruptured aneurysms should be secured
ural history and clinical presentation to prevention of as soon as possible.5 Timing of the ruptured aneurysm treat-
recurrence,5 the NCS guideline focused on the critical care ment was directly examined in one randomized trial on
management.6 However, they used an approach using the good-grade patients, which demonstrated that early surgery
Grading of Recommendations, Assessment, Development (up to 3 days after SAH) was related to lower death and
and Evaluation (GRADE) framework limited to 12 manage- dependence at three months.14 This data has been corrobo-
ment questions that could probably be most impacted by rated in other types of studies in which early securing of the
new evidence and evolving management paradigms in the aneurysm (<24 h) produced better outcomes,15---17 especially
last decade.6 Thus, NCS guidelines were developed around in the endovascular treatment group.17 However, these data
specific clinical questions in a population, intervention, are not unequivocal.18
comparison, and outcomes (PICO) format,6,7 resulting mostly Indeed, from a pathophysiological rationale and consid-
in non-conclusive recommendations in a daily basis for the ering that rebleeding is especially relevant in poor grade
neurointensivist. Thus, we provide a comprehensive review aSAH within 0---12 hours from stroke 19 , inmediate (<6 h) clip-
of controversial topics in the intensive care unit (ICU) mana- ping/coiling strategies appear reasonable but its benefit has
gement of aSAH (Fig. 1). to be proven yet.
From one side it has been calculated that implement-
ing such an scheme of ultra-early management would
Which is the optimal blood pressure before only provide treatment for a very limited number of
coilling and clipping? possible rebleedings, making a modest reduction in the
rebleeding rates (around 0.3% of reduction of incidence of
The exact role of blood pressure (BP) management to pre- rebleeding).20 On the other hand, this would impose signifi-
vent early rebleeding before aneurysm securing remains to cant stress to the teams, determining that many procedures
be determined yet. The NCS guidelines state that there is would be performed by less experienced teams and with
insufficient evidence to recommend a BP reduction goal for worse equipment. Therefore, since experience is relevant
the treatment of hypertension before aneurysm treatment in final outcomes, most centers (and the authors) accept to
in aSAH patients, since the quality of available evidence perform the treatment as soon as possible by the team that
was too low to support the recommendation of a target for usually treats aneurysms by clipping or by coiling, prefer-
BP reduction vs no BP reduction.6 However, NCS guidelines ably in the first 24 h. Best results are obtained when both
specifically state that ‘‘Lack of evidence to recommend a treatments can be delivered. However when there is a
specific blood pressure reduction goal does not necessarily ruptured aneurysm producing a large cerebral hematoma,
imply that blood pressure reduction is not helpful before urgent surgery accompanied with surgical clipping of the
aneurysm treatment’’.6 On the other hand, the AHA/ASA aneurysm has demonstrated a large reduction in mortality
guidelines state that in patients with aSAH and unsecured and a higher rate of independent outcome.21 Although it is
aneurysm, frequent BP monitoring and BP control with feasible to first coil and then evacuating the hematoma, it
shortacting medications is recommended to avoid severe seems more logical not to delay hematoma evacuation and
hypotension, hypertension, and BP variability.5 perform concomitant aneurysm clipping.
The rationale behind these recommendations relies on
the low quality of studies in this setting. Retrospective
studies8 and meta-analysis9 addressed a higher risk of Which is the optimal blood pressure target
rebleeding in patients with systolic blood pressure (SBP) after securing the aneurysm?
>160 mmHg, but an aggressive approach has not been asso-
ciated with reduced reebleeding.10 Additionally, systemic There is a paucity of studies addressing this topic, making
hypotension is linked to compromised cerebral perfusion it an appealing area for planning multicenter studies and
and can be associated with DCI11 and BP variability could therefore, improve outcomes.22 In consequence, there is a
be also associated with rebleeding.12 Taking these data into huge variability in commonly used targets and indeed, there
consideration, it can only be recommended that extreme is no consensus even in using mean arterial pressure (MAP)
values and marked variability in BP must be avoided. In the or SBP targets.23
authors experience, in initially hypertensive aSAH patients, In the MANTRA survey, when the aneurysm was secured
a target of SBP 140−160 mmHg avoiding fluctuations seems 34.9% of the responders considered MAP targets (median
reasonable. (IQR) 90 (75---100) mmHg, 16.8% used SBP targets (median
Anyway, a RCT is clearly required to provide the neces- (IQR) 155 (140---180) mmHg, 33.2 % used both MAP and
sary evidence to define the balance of potential benefits and SBP (median (IQR) 90 (80---100) and median (IQR) 160
2
