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Guideline Summary
Guideline Title
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.
Bibliographic Source(s)
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. [509 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Aneurysmal subarachnoid hemorrhage

Guideline Category
Diagnosis
Evaluation
Management
Prevention
Treatment
Clinical Specialty
Cardiology
Emergency Medicine
Family Practice
Internal Medicine
Neurological Surgery
Neurology
Preventive Medicine
Intended Users
Physicians
Guideline Objective(s)
  • To update the recommendations for management of aneurysmal subarachnoid hemorrhage
  • To summarize the best available evidence for treatment of patients with aneurysmal subarachnoid hemorrhage and to identify areas of future research
Target Population

Patients with or at risk for aneurysmal subarachnoid hemorrhage

Interventions and Practices Considered

Prevention

  1. Antihypertensive medication
  2. Smoking cessation
  3. Screening with noninvasive imaging and catheter angiography, when indicated

Diagnosis/Evaluation

  1. Assessment of severity of headache and of initial bleed
  2. Urgent evaluation and treatment
  3. Assessment of risk of rebleed
  4. Computed tomography (CT) scan
  5. Lumbar puncture for analysis of cerebrospinal fluid (CSF)
  6. Cerebral angiography
  7. Magnetic resonance angiography (MRA) and computed tomography angiography (CTA)
  8. Assessment of neurological impairment with grading system
  9. Development of standardized emergency department (ED) management protocol

Treatment/Management

  1. Surgical clipping or endovascular coiling
  2. Complete obliteration of aneurysm whenever possible
  3. Early versus delayed surgery
  4. Early referral to specialist
  5. Minimization of hypotension during surgery
  6. Pharmacological strategies and induced hypertension
  7. Induced hypothermia during surgery
  8. Bedrest to prevent rebleeding

Cerebral Vasospasm

  1. Oral nimodipine
  2. Early management including maintaining normal circulating blood volume and avoiding hypovolemia
  3. Volume expansion, induction of hypertension, and hemodilution (triple-H therapy)
  4. Cerebral angiography and/or selective intraarterial vasodilator therapy

Hydrocephalus

  1. Temporary or permanent cerebrospinal fluid diversion
  2. Ventriculostomy

Seizures

Prophylactic anticonvulsants (not recommended for routine long-term use without specific risk factors)

Hyponatremia

  1. Avoidance of large volumes of hypotonic fluids and intravascular volume contraction
  2. Monitoring of volume status
  3. Fludrocortisone acetate and hypertonic saline
  4. Reduction of fluid administration in some instances
Major Outcomes Considered
  • Morbidity and mortality associated with aneurysmal subarachnoid hemorrhage (SAH)
  • Sensitivity and specificity of diagnostic procedures
  • Rate and severity of aneurysmal SAH
  • Rate of rebleeding/recurrence
  • Treatment complications
  • Changes in neurological status tests
  • Duration of hospitalization and intensive care unit stays
  • Destination at discharge
  • Cause and time to death
  • Rate of detection of second aneurysm

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

In an effort to update recommendations (prepared in 1994), a systematic literature review was conducted based on a search of MEDLINE to identify all relevant randomized clinical trials published between June 30, 1994, and November 1, 2006 (search terms: subarachnoid hemorrhage, cerebral aneurysm, trial; see Table 1 the original guideline document). Each identified article was reviewed by at least 2 members of the writing group. Selected articles had to meet one of the following criteria to be included: randomized trial or nonrandomized concurrent cohort study. Case series and nonrandomized historical cohort studies were reviewed if no studies with a higher level of evidence were available for a particular topic covered in the initial guidelines. These were chosen on the basis of sample size and the relevance of the particular studies to subjects that were covered in the initial guidelines.

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

Therapeutic Recommendations

Level of Evidence A: Data derived from multiple randomized clinical trials

Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies

Level of Evidence C: Consensus opinion of experts

Diagnostic/Prognostic Recommendations

Level of Evidence A: Data derived from multiple prospective cohort studies using a reference standard applied by a masked evaluator

Level of Evidence B: Data derived from a single grade A study or ≥1 case-control studies or studies using a reference standard applied by an unmasked evaluator

Level of Evidence C: Consensus opinion of experts

Applying Classification of Recommendations and Level of Evidence

  SIZE OF TREATMENT EFFECT
  CLASS I

Benefit >>> Risk

Procedure/Treatment

SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit > Risk
Additional studies with broad objectives needed; additional registry data would be helpful

Procedure/Treatment
MAY BE CONSIDERED
CLASS III

Risk > Benefit

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple population evaluated*

Data derived from multiple randomized clinical trials or meta-analysis
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited population evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited population evaluated*

Only consensus opinion of experts, case studies or standard of care.
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard-of-care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 3 in the original guideline document for a list of suggested phrases for writing recommendations.)

Methods Used to Analyze the Evidence
Review of Published Meta-Analyses
Systematic Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

The Stroke Council of the American Heart Association (AHA) formed a writing group to reevaluate the recommendations for management of aneurysmal subarachnoid hemorrhage (SAH). A consensus committee reviewed existing data in this field and prepared the recommendations in 1994. In an effort to update those recommendations, a systematic literature review was conducted to identify all relevant randomized clinical trials published between June 30, 1994, and November 1, 2006. The committee's recommendations were made by applying the standard American Heart Association evidence rating scheme (see the "Rating Scheme for Strength of the Evidence" field).

Rating Scheme for the Strength of the Recommendations

Classes of Recommendation

Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment

Class IIa: The weight of evidence or opinion is in favor of the procedure or treatment

Class IIb: Usefulness/efficacy is less well established by evidence or opinion

Class III: Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful

Also see the table "Applying Classification of Recommendations and Level of Evidence" in the "Rating Scheme for the Strength of Evidence" field.

Cost Analysis
  • In evaluations of the clinical efficacy of screening for asymptomatic intracranial aneurysms, the costs of screening should be weighed against the risks and consequences of SAH. Several assumptions must be made to estimate these costs, for example, about how an aneurysm would be managed if detected, although this unrealistically simplifies the medical decision-making process. Several factors, including aneurysm incidence, risk of rupture (natural history), and risk of treatment, influence the analysis of cost-effectiveness for asymptomatic unruptured aneurysms. Of these factors, the risk of rupture is the most important. To date, there have been no population-based clinical studies of cost-effectiveness of screening for intracranial aneurysms.
  • In populations with the familial intracranial aneurysm syndrome, although screening detects an increased incidence of intracranial aneurysms, the cost-effectiveness of screening has not been demonstrated.
  • One group performed a cost-utility analysis, estimating that transferring a subarachnoid hemorrhage (SAH) patient from a low- to a high-volume hospital would result in a gain of 1.60 quality-adjusted life-years at a cost of $10,548 per quality-adjusted life-year.
  • Hypertensive hypervolemic therapy has become a mainstay in the management of cerebral vasospasm. In one study, costs were higher and complications were more frequent for the hyperdynamic therapy group.
Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

This statement was approved by the American Heart Association (AHA) Science Advisory and Coordinating Committee on October 3, 2008. Expert peer review of AHA Scientific Statements is conducted at the AHA National Center.

Recommendations

Major Recommendations

Definitions for the levels of evidence (A–C) and classes of recommendations (I–III) are provided at the end of the "Major Recommendations" field.

Prevention of Subarachnoid Hemorrhage (SAH): Summary and Recommendations

  1. The relationship between hypertension and aneurysmal SAH is uncertain. However, treatment of high blood pressure with antihypertensive medication is recommended to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ injury (Class I, Level of Evidence A).
  2. Cessation of smoking is reasonable to reduce the risk of SAH, although evidence for this association is indirect (Class IIa, Level of Evidence B).
  3. Screening of certain high-risk populations for unruptured aneurysms is of uncertain value (Class IIb, Level of Evidence B); advances in noninvasive imaging may be used for screening, but catheter angiography remains the gold standard when it is clinically imperative to know if an aneurysm exists.

Natural History and Outcome of Aneurysmal SAH: Summary and Recommendations

  1. The severity of the initial bleed should be determined rapidly because it is the most useful indicator of outcome after aneurysmal SAH, and grading scales that rely heavily on this factor are helpful in planning future care with family and other physicians (Class I, Level of Evidence B).
  2. Case review and prospective cohorts have shown that for untreated, ruptured aneurysms, there is at least a 3% to 4% risk of rebleeding in the first 24 hours—and possibly significantly higher—with a high percentage occurring immediately (within 2 to 12 hours) after the initial ictus, a 1% per day to 2% per day risk in the first month, and a long-term risk of 3% per year after 3 months. Urgent evaluation and treatment of patients with suspected SAH are therefore recommended (Class I, Level of Evidence B).
  3. In the triage of patients for aneurysm repair, factors that may be considered in determining the risk of rebleeding include severity of the initial bleed, interval to admission, blood pressure, gender, aneurysm characteristics, hydrocephalus, early angiography, and the presence of a ventricular drain (Class IIb, Level of Evidence B).

Manifestations and Diagnosis of SAH: Summary and Recommendations

  1. SAH is a medical emergency that is frequently misdiagnosed. A high level of suspicion for SAH should exist in patients with acute onset of severe headache (Class I, Level of Evidence B).
  2. Computed tomography (CT) scanning for suspected SAH should be performed (Class I, Level of Evidence B), and lumbar puncture for analysis of cerebrospinal fluid (CSF) is strongly recommended when the computed tomography scan is negative (Class I, Level of Evidence B).
  3. Selective cerebral angiography should be performed in patients with SAH to document the presence and anatomic features of aneurysms (Class I, Level of Evidence B).
  4. Magnetic resonance angiography (MRA) and CT angiography (CTA) may be considered when conventional angiography cannot be performed in a timely fashion (Class IIb, Level of Evidence B).

Emergency Evaluation and Preoperative Care: Summary and Recommendations

  1. The degree of neurological impairment using an accepted SAH grading system can be useful for prognosis and triage (Class IIa, Level of Evidence B).
  2. A standardized emergency department (ED) management protocol for the evaluation of patients with headaches and other symptoms of potential SAH currently does not exist and should probably be developed (Class IIa, Level of Evidence C).

Medical Measures to Prevent Rebleeding After SAH: Summary and Recommendations

  1. Blood pressure should be monitored and controlled to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure (Class I, Level of Evidence B).
  2. Bedrest alone is not enough to prevent rebleeding after SAH. It may be considered a component of a broader treatment strategy, along with more definitive measures (Class IIb, Level of Evidence B).
  3. Although older studies demonstrated an overall negative effect of antifibrinolytics, recent evidence suggests that early treatment with a short course of antifibrinolytic agents combined with a program of early aneurysm treatment followed by discontinuation of the antifibrinolytic and prophylaxis against hypovolemia and vasospasm may be reasonable (Class IIb, Level of Evidence B), but further research is needed. Furthermore, antifibrinolytic therapy to prevent rebleeding may be considered in certain clinical situations, e.g., in patients with a low risk of vasospasm and/or a beneficial effect of delaying surgery (Class IIb, Level of Evidence B).

Surgical/Endovascular Treatment of Ruptured Aneurysms: Summary and Recommendations

  1. Surgical clipping or endovascular coiling should be performed to reduce the rate of rebleeding after aneurysmal SAH (Class I, Level of Evidence B).
  2. Wrapped or coated aneurysms and incompletely clipped or coiled aneurysms have an increased risk of rehemorrhage compared with those that are completely occluded and therefore require long-term follow-up angiography. Complete obliteration of the aneurysm is recommended whenever possible (Class I, Level of Evidence B).
  3. For patients with ruptured aneurysms judged by an experienced team of cerebrovascular surgeons and endovascular practitioners to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling can be beneficial (Class I, Level of Evidence B). Nevertheless, it is reasonable to consider individual characteristics of the patient and the aneurysm in deciding the best means of repair, and management of patients in centers offering both techniques is probably indicated (Class IIa, Level of Evidence B).
  4. Although previous studies showed that overall outcome was not different for early versus delayed surgery after SAH, early treatment reduces the risk of rebleeding after SAH, and newer methods may increase the effectiveness of early aneurysm treatment. Early aneurysm treatment is reasonable and is probably indicated in the majority of cases (Class IIa, Level of Evidence B).

Hospital Characteristics and Systems of Care: Summary and Recommendations

  1. Early referral to high-volume centers that have both experienced cerebrovascular surgeons and endovascular specialists is reasonable (Class IIa, Level of Evidence B).

Anesthetic Management: Summary and Recommendations

  1. Minimizing the degree and duration of intraoperative hypotension during aneurysm surgery is probably indicated (Class IIa, Level of Evidence B).
  2. There are insufficient data on pharmacological strategies and induced hypertension during temporary vessel occlusion to make specific recommendations, but there are instances when their use may be considered reasonable (Class IIb, Level of Evidence C).
  3. Induced hypothermia during aneurysm surgery may be a reasonable option in some cases but is not routinely recommended (Class III, Level of Evidence B).

Management of Cerebral Vasospasm: Summary and Recommendations

  1. Oral nimodipine is indicated to reduce poor outcome related to aneurysmal SAH (Class I, Level of Evidence A). The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain.
  2. Treatment of cerebral vasospasm begins with early management of the ruptured aneurysm, and in most cases, maintaining normal circulating blood volume and avoiding hypovolemia are probably indicated (Class IIa, Level of Evidence B).
  3. One reasonable approach to symptomatic cerebral vasospasm is volume expansion, induction of hypertension, and hemodilution (triple-H therapy) (Class IIa, Level of Evidence B).
  4. Alternatively, cerebral angioplasty and/or selective intraarterial vasodilator therapy may be reasonable after, together with, or in the place of triple-H therapy, depending on the clinical scenario (Class IIb, Level of Evidence B).

Management of Hydrocephalus: Summary and Recommendations

  1. Temporary or permanent cerebrospinal fluid diversion is recommended in symptomatic patients with chronic hydrocephalus after SAH (Class I, Level of Evidence B).
  2. Ventriculostomy can be beneficial in patients with ventriculomegaly and diminished level of consciousness after acute SAH (Class IIa, Level of Evidence B).

Management of Seizures: Summary and Recommendations

  1. The administration of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period (Class IIb, Level of Evidence B).
  2. The routine long-term use of anticonvulsants is not recommended (Class III, Level of Evidence B) but may be considered for patients with risk factors such as prior seizure, parenchymal hematoma, infarct, or middle cerebral artery aneurysms (Class IIb, Level of Evidence B).

Management of Hyponatremia: Summary and Recommendations

  1. Administration of large volumes of hypotonic fluids and intravascular volume contraction should generally be avoided after SAH (Class I, Level of Evidence B).
  2. Monitoring volume status in certain patients with recent SAH using some combination of central venous pressure, pulmonary artery wedge pressure, fluid balance, and body weight is reasonable, as is treatment of volume contraction with isotonic fluids (Class IIa, Level of Evidence B).
  3. The use of fludrocortisone acetate and hypertonic saline is reasonable for correcting hyponatremia (Class IIa, Level of Evidence B).
  4. In some instances, it may be reasonable to reduce fluid administration to maintain a euvolemic state (Class IIb, Level of Evidence B).

Definitions:

Classes of Recommendation

Class I: Conditions for which there is evidence for and/or general agreement that the procedure or treatment is useful and effective

Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment

Class IIa: The weight of evidence or opinion is in favor of the procedure or treatment

Class IIb: Usefulness/efficacy is less well established by evidence or opinion

Class III: Conditions for which there is evidence and/or general agreement that the procedure or treatment is not useful/effective and in some cases may be harmful

Levels of Evidence

Therapeutic Recommendations

Level of Evidence A: Data derived from multiple randomized clinical trials

Level of Evidence B: Data derived from a single randomized trial or nonrandomized studies

Level of Evidence C: Consensus opinion of experts

Diagnostic/Prognostic Recommendations

Level of Evidence A: Data derived from multiple prospective cohort studies using a reference standard applied by a masked evaluator

Level of Evidence B: Data derived from a single grade A study or ≥1 case-control studies or studies using a reference standard applied by an unmasked evaluator

Level of Evidence C: Consensus opinion of experts

Applying Classification of Recommendations and Level of Evidence

  SIZE OF TREATMENT EFFECT
  CLASS I

Benefit >>> Risk

Procedure/Treatment

SHOULD be performed/ administered
CLASS IIa

Benefit >> Risk
Additional studies with focused objectives needed

IT IS REASONABLE to perform procedure/administer treatment
CLASS IIb

Benefit > Risk
Additional studies with broad objectives needed; additional registry data would be helpful

Procedure/Treatment
MAY BE CONSIDERED
CLASS III

Risk > Benefit

Procedure/Treatment should NOT be performed/administered SINCE IT IS NOT HELPFUL AND MAY BE HARMFUL
Estimate of Certainty (Precision) of Treatment Effect LEVEL A

Multiple population evaluated*

Data derived from multiple randomized clinical trials or meta-analysis
  • Recommendation that procedure or treatment is useful/effective
  • Sufficient evidence from multiple randomized trials or meta-analyses
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from multiple randomized trials or meta-analyses
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Sufficient evidence from multiple randomized trials or meta-analyses
LEVEL B

Limited population evaluated*

Data derived from a single randomized clinical trials or nonrandomized studies
  • Recommendation that procedure or treatment is useful/effective
  • Evidence from single randomized trial or nonrandomized studies
  • Recommendation in favor of treatment or procedure being useful/effective
  • Some conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation's usefulness/efficacy less well established
  • Greater conflicting evidence from single randomized trial or nonrandomized studies
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Evidence from single randomized trial or nonrandomized studies
LEVEL C

Very limited population evaluated*

Only consensus opinion of experts, case studies or standard of care.
  • Recommendation that procedure or treatment is useful/effective
  • Only expert opinion, case studies, or standard-of-care
  • Recommendation in favor of treatment or procedure being useful/effective
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation's usefulness/efficacy less well established
  • Only diverging expert opinion, case studies, or standard-of-care
  • Recommendation that procedure or treatment is not useful/effective and may be harmful
  • Only expert opinion, case studies, or standard-of-care

*Data available from clinical trials or registries about the usefulness/efficacy in different subpopulations, such as gender, age, history of diabetes, history of prior myocardial infarction, history of heart failure, and prior aspirin use. A recommendation with Level of Evidence B or C does not imply that the recommendation is weak. Many important clinical questions addressed in the guidelines do not lend themselves to clinical trials. Even though randomized trials are not available, there may be a very clear clinical consensus that a particular test or therapy is useful or effective.

Note: In 2003, the American College of Cardiology/American Heart Association (ACC/AHA) Task Force on Practice Guidelines developed a list of suggested phrases to use when writing recommendations. All guideline recommendations have been written in full sentences that express a complete thought, such that a recommendation, even if separated and presented apart from the rest of the document (including headings above sets of recommendations), would still convey the full intent of the recommendation. It is hoped that this will increase readers' comprehension of the guidelines and will allow queries at the individual recommendation level. (See Table 3 in the original guideline document for a list of suggested phrases for writing recommendations.)

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is identified and graded for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits
  • Appropriate prevention, management, and treatment of aneurysmal subarachnoid hemorrhage (SAH)
  • Reduction in morbidity and mortality from aneurysmal SAH
Potential Harms
  • Antifibrinolytic agents have an increased rate of ischemic complications.
  • Procedural complications, including aneurysmal perforation and ischemic complications, can occur with surgical and endovascular methods for treatment.
  • The initiation of hemodynamic therapy is associated with significant risks, including the possibility of cardiac failure, electrolyte abnormality, cerebral edema, bleeding diathesis resulting from dilution of clotting factors, and potential but apparently rare rupture of unsecured unruptured aneurysms.
  • There are significant risks associated with angioplasty of cerebral vessels such as vessel occlusion, vessel rupture, thrombus formation, and aneurysm clip displacement.
  • Interhospital transfers may have a negative impact on outcomes in other neurological conditions, and patients with subarachnoid hemorrhage (SAH) may be particularly susceptible to complications associated with transfer because of the time dependence of outcome related to early rebleeding and the sensitivity of unsecured aneurysms to fluctuations in blood pressure.
  • The high initial incomplete obliteration and late recurrence rates in aneurysms treated with endovascular techniques, even in the most experienced centers, work to offset the lower procedural complication rate demonstrated in recent studies.
  • In one large, prospective, randomized trial, greater disability rates in surgical versus endovascular patients (21.6% versus 15.6%) meant that combined morbidity and mortality was significantly greater in surgically treated patients than in those treated with endovascular techniques (30.9% versus 23.5%; absolute risk reduction, 7.4%; P=0.0001). During the relatively short follow-up period, the rebleeding rate was 2.9% for coiling versus 0.9% for surgery; 139 coiled patients required additional treatment compared with 31 patients treated by clipping.

Qualifying Statements

Qualifying Statements

These recommendations are intended to summarize the best available evidence for treatment of patients with aneurysmal subarachnoid hemorrhage (SAH) and to identify areas of future research. Treatments for specific patients need to be individualized.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Getting Better
IOM Domain
Effectiveness
Timeliness

Identifying Information and Availability

Bibliographic Source(s)
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. [509 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2009 Jan 22
Guideline Developer(s)
American Heart Association - Professional Association
American Stroke Association - Disease Specific Society
Source(s) of Funding

American Heart Association

Guideline Committee

The Special Writing Group of the Stroke Council, American Heart Association

Composition of Group That Authored the Guideline

Writing Group: Joshua B. Bederson, MD, Chair; E. Sander Connolly, Jr, MD, FAHA, Vice-Chair; H. Hunt Batjer, MD; Ralph G. Dacey, MD, FAHA; Jacques E. Dion, MD, FRCPC; Michael N. Diringer, MD, FAHA; John E. Duldner, Jr, MD, MS; Robert E. Harbaugh, MD, FAHA; Aman B. Patel, MD; Robert H. Rosenwasser, MD, FAHA

Reviewers: Gavin Britz, Gary Ross Duckwiler, Randall Higashida, R.L. Macdonald, Adnan Qureshi

Financial Disclosures/Conflicts of Interest

The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest.

Writing Group Member Employment Research Grant Other Research Support Speakers' Bureau/
Honoraria
Ownership Interest Consultant/
Advisory Board
Other
Joshua B. Bederson Mt Sinai School of Medicine None None None None None None
E. Sander Connolly, Jr Columbia University None None None None None None
H. Hunt Batjer Northwestern Medical Faculty Foundation None None None None None None
Ralph G. Dacey Washington University School of Medicine NIH/NINDS** None None Stereotaxis, Inc. None None
Jacques E. Dion Emory University Hospital None None None None None None
Michael N. Diringer Washington University None None None None None None
John E. Duldner, Jr Samaritan Regional Health Center None None None None None None
Robert E. Harbaugh Dartmouth Hitchcock Medical Center None None None None MedCool, INc.* None
Aman B. Patel Mt Sinai Hospital None None Boston Scientific*; Cordis* None None None
Robert H. Rossenwasser Thomas Jefferson University None Micrios* None Boston Scientific** None None

This table represents the relationships of writing group members that may be perceived as actual or reasonably perceived conflicts of interest as reported on the Disclosure Questionnaire, which all members of the writing group are required to complete and submit. A relationship is considered to be "significant" if (1) the person receives $10,000 or more during any 12-month period, or 5% or more of the person's gross income; or (2) the person owns 5% or more of the voting stock or share of the entity, or owns $10,000 or more of the fair market value of the entity. A relationship is considered to be "modest" if it is less than "significant" under the preceding definition.

*Modest
**Significant

See the original guideline document for reviewer disclosures.

Guideline Endorser(s)
American Academy of Neurology - Medical Specialty Society
Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the American Heart Association Web site External Web Site Policy.

Print copies: Available from the American Heart Association, Public Information, 7272 Greenville Ave, Dallas, TX 75231-4596; Phone: 800-242-8721

Availability of Companion Documents

None available

Patient Resources

None available

NGC Status

This summary was completed by ECRI Institute on June 30, 2010.

Copyright Statement

Copyright to the original guideline is owned by the American Heart Association, Inc. (AHA). Reproduction of the AHA Guideline without permission is prohibited. Single reprint is available by calling 800-242-8721 (US only) or writing the American Heart Association, Public Information, 7272 Greenville Ave., Dallas, TX 75231-4596. Ask for reprint No. 71-0276. To purchase additional reprints: up to 999 copies, call 800-611-6083 (US only) or fax 413-665-2671; 1000 or more copies, call 410-528-4121, fax 410-528-4264, or email kgray@lww.com. To make photocopies for personal or educational use, call the Copyright Clearance Center, 978-750-8400.

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