LEEDS TEACHING HOSPITALS TRUST



LEEDS TEACHING HOSPITALS TRUST

eClinical Guidelines Template

|Guidelines for the Management of aneurysmal Subarachnoid Hemorrhage |

|(referring hospital and LTHT management) |

|Guideline Detail |

|These guidelines establish a standard of care for patients admitted with aneurysmal Subarachnoid Haemorrhage (aSAH). They provide a framework of |

|best practice to manage the presenting condition and prevent complications. |

|Recommendations are made for management of patient presenting at non-LTH hospitals as well as management within LTHT. |

|Ownership LTHT |

|Publication date |

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|Provenance: Author name (s) and address (es)- updated 2023 |

|Mr Ian Anderson- Consultant Neurosurgeon |

|Mr Asim Sheikh -Consultant Neurosurgeon |

|Dr Chris Day -Consultant Anaesthetist (reviewed only) |

|Dr Tony Goddard- Consultant Interventional Neuroradiologist |

|Elizabeth Drewe – Neurosurgical Specialist Pharmacist |

|Emily Cutts - Neurosurgical Specialist Pharmacist |

|Naomi Sherwin – Clinical Nurse Specialist (Neurovascular) |

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|Summary |

|Background |

|Diagnosis |

|Treatment/Management |

|Management at primary receiving hospital |

|Continued care at Regional Neuroscience Centre |

|Interventional management |

|Anti-platelet treatment |

|Pharmacological management |

|Blood pressure management |

|Management of seizures and prophylactic use |

|Management of specific complications |

|Thromboprophylaxis of DVT/PE |

|Analgesia |

|Infection Prevention and Control |

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|Appendix 1: Clinical and radiological scoring systems in aneurysmal subarachnoid haemorrhage |

|Appendix 2: Management of sodium disorders in aneurysmal subarachnoid haemorrhage |

|Appendix 3: Guidelines for the use of lumbar drains in patients with aneurysmal subarachnoid haemorrhage |

|Appendix 4: Phenytoin (monitoring and formula) |

|Appendix 5: Nimodipine (IV and oral)- under the instruction of the Consultant (ICU only) |

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|Aims |

|To standardise the diagnosis and management of aneurysmal Subarachnoid Haemorrhage |

|Objectives |

|To provide evidence-based recommendations for appropriate diagnosis, investigation and management of aneurysmal Subarachnoid Haemorrhage |

|Background |

|Aneurysmal (spontaneous) subarachnoid haemorrhage occurs with an incidence of approximately 10 cases per 100, 000 person years. It most commonly |

|affects people aged 40-60 years old. It is twice as common in women as men and is associated with a high mortality and morbidity, with over a |

|third of patients dying by the end of the first week from ictus. Risk factors include: cigarette smoking, hypertension, moderate to heavy alcohol |

|consumption, use of sympathomimetic drugs (e.g. cocaine), a familial history of aneurysms and (rarely) genetic disorders such as autosomal |

|dominant polycystic kidney disease, and type IV Ehlers-Danlos syndrome. Early diagnosis and treatment is critical to improve the survival from |

|this devastating medical condition. All cases should be discussed with the Regional Neuroscience Centre. |

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|Risk factors for and prevention of aSAH |

|Treatment of hypertension is recommended to prevent ischaemic stroke, ICH and cardiac, renal and other end-organ injury (Level 1/A evidence) |

|Hypertension should be treated and such treatment may reduce the risk of aSAH (Level 1/B evidence) |

|Tobacco use and alcohol misuse should be avoided, to reduce the risk of aSAH (Level 1/B evidence) |

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|Diagnosis |

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|If aneurysmal (spontaneous) subarachnoid haemorrhage (aSAH) is suspected, establish the diagnosis as soon as possible, following initial |

|resuscitation, when the patient is in a stable clinical condition. |

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|Typical presentations include: ‘thunderclap’ headache, collapse with- or without loss of consciousness, seizures and associated nausea, vomiting |

|and photophobia. Examination may reveal focal neurology including neck stiffness. |

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|Complications of aSAH, for example acute hydrocephalus, may require emergency neurosurgical intervention. |

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|[pic] |

|The World Federation of Neurological Surgeons grading scale should be recorded in the clinical notes |

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|The Fisher CT score (see appendix 1) should be recorded in the clinical notes. Fisher score of 3-4 is associated with an increased risk of delayed|

|ischaemic neurological deficits (vasospasm). |

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|The presence of an intra-cerebral haematoma causing mass effect is a contraindication to lumbar puncture (LP), as is the presence of obstructive |

|hydrocephalus. A lumbar puncture should not be performed in the absence of a prior CT scan in these patients. A positive CT scan result |

|precludes the need for a lumbar puncture. |

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|Level of evidence B |

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|Lumbar Puncture |

|The 2022 NICE guidelines for Subarachnoid Haemorrhage state that, in the context of a negative CT scan result, lumbar puncture should be |

|considered in patients whose CT scan was performed >6 hours after symptom onset. |

|The NICE guidelines also state that, in the context of a negative CT scan result (as reported by a radiologist), lumbar puncture needs not to be |

|routinely be undertaken for patients whose CT scan was performed 10 g/dL) may be appropriate in patients with associated co-morbidities and|

|those at highest risk of DCI. Haemodilution in an attempt to improve blood rheology should not be undertaken except in the case of polycythaemia.|

|Reduction in the oxygen-carrying capacity of blood can have deleterious effects. |

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|Management of groin Haematoma |

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|For patients undergoing endovascular procedure via femoral artery puncture, the puncture site should be inspected for any underlying haematoma. |

|Unexplained drop in Hb, groin/leg or back pain should prompt a review to rule out haematoma at puncture site. An urgent ultrasound examination |

|should be requested for further investigations. Early involvement of endovascular and vascular surgery teams is recommended. |

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|Risk factors for groin haematoma include multiple punctures, difficult access, use of large bore sheaths and catheters and patient factors |

|predisposing them to formation of haematoma, antiplatelet and anticoagulation medication. Consideration for a pelvic CT scan is indicated in |

|patients at increased risk of haematoma with severe back pain and/or unexplained hypotension/post procedural persistent tachycardia/anaemia (an |

|ultrasound may have difficulty in detecting a retroperitoneal haematoma and there may be NO outward sign of bleeding at the puncture site). |

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|Management of Sodium Balance |

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|Aim for plasma sodium ≥140mmol/l and 65years)

= 0.45 x body weight (women>65years)

Example A

Estimates effect of 1 litre of 1.8% sodium chloride (308 mmol/L).

Dividing the desired change in serum Na by the formula result determines the volume of infusate required and the rate of administration.

60 year old man, 100 kg. serum Na 114. Desired Na 130 mmol/L.

1 litre of 1.8% sodium chloride (308 mmol/L) would change serum Na by

(308-114) / [(100 x 0.6) + 1] = 3.2 mmol

If desired correction is 130-114 = 16 mmol

Then volume of fluid is 16 / 3.2 = 5 litres of 1.8 litres of 1.8% sodium chloride (5000ml)

Correction over 32 hours (0.5 mmol/hr) then rate of correction is 5000 / 32 = 156 ml/hr

Without hydrocephalus

Class II evidence for the use of early lumbar drain insertion in order to reduce the prevalence of delayed ischaemic neurological deficit (DIND) and improve early clinical outcome in World Federation of Neurological Surgeons (WFNS) grade I-III patients with aneurysmal subarachnoid haemorrhage (aSAH).

Insertion should be aimed for as early as possible following aneurysmal diagnosis and treatment (or placed during general anaesthetic for aneurysmal treatment). Insertion should not be performed later than four days post haemorrhagic ictus. There is no evidence to suggest that insertion of a lumbar drain will reverse established DIND unless there is an element of hydrocephalus thought to be contributing to the neurological deficit (in which case DIND should not be diagnosed until hydrocephalus has been excluded).

LUMBAR DRAINAGE IS CONTRAINDICATED WITH COAGULATION ABNORMALTIES, INTRACEREBRAL HAEMATOMAS AND/OR SUBDURAL HAEMATOMAS.

Insertion should be performed in an aseptic manner with gown and gloves and a complete sterile field created in the appropriate lumbar interspace (L3-5). Local anaesthetic should be applied to the skin and subcutaneous tissue and allowed to work (3 minutes) prior to attempted insertion of the drain.

Once inserted, the drain should be secured with suture and dressed. This dressing should not be removed unless there are concerns over the function of the drain or the integrity of the exit site. The Becker collecting system should be placed on level with the drain exit site and adjusted hourly in order to aim for 5-10 ml of CSF drainage per hour.

The drain is to remain in situ until the cerebrospinal fluid (CSF) is visibly clear or xanthochromic or until the drain has been in situ for eight days. CSF sampling is not routinely required if the drain is less than 4 days old and should be performed every 48 hours thereafter (using aseptic technique). When the drain is to be removed, it should be removed immediately without prior clamping and a non-silk suture placed over the exit site.

With hydrocephalus

Any patient with aSAH and an altered consciousness (GCS 95 |2000mg (40mL) max dose |

Take a level 6-24 hours after loading dose

Therapeutic drug monitoring:

PPM reported level does NOT correct the phenytoin level if patients albumin is ................
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