Subarachnoid Haemorrhage

Question 1

A 36-year-old female patient is listed for emergency embolisation of a cerebral aneurysm following a grade IV subarachnoid haemorrhage. She is intubated and ventilated following a drop in her GCS in the emergency department. She takes sertraline for depression but has no other known medical conditions.
What are the treatment options for this patient?

Answer 1

1) Conservative

2) Pharmacological

3) Interventional

Question 2

Treatment options (detail)

Answer 2

Conservative
* Supportive therapy on the neuro-intensive care unit to maintain adequate cerebral perfusion pressure and optimal gas exchange.
* Avoidance of extremes of blood pressure to minimise the risk of re-bleeding and ischaemia.
* Excellent blood glucose and core temperature control (primarily treatment of pyrexia).
* Consideration of seizure prophylaxis.

Pharmacological
* 60mg oral nimodipine (via a nasogastric tube) every 4hours for 21 days to minimise the risk of vasospasm.

Interventional
* Surgical clipping.
* Endovascular coiling.

Question 3

What are the benefts of coiling over clipping for this patient?

Answer 3

• The International Subarachnoid Aneurysm Trial (ISAT) evaluated the difference between clipping and coiling for subarachnoid haemorrhage secondary to aneurysm rupture.
• Coiling demonstrated a reduced risk of mortality at 1 year, but with a slightly higher incidence of re-bleeding.

Question 4

What are the complications associated with a subarachnoid haemorrhage?

Answer 4

• Re-bleeding (minimal if the aneurysm is secured).
• Hydrocephalus.
• Cerebral vasospasm (most common at days 3–21).
• Arrhythmias and ischaemic cardiac events. A troponin rise is
  commonly seen following a subarachnoid haemorrhage, likely due to endocardial ischaemia secondary to an increase in aferload and endogenous vasopressor release at the ictus. Patients with poorer-grade bleeds may also develop Takotsubo’s cardiomyopathy.
• Aspiration, pneumonia and pulmonary oedema (particularly if co-existing heart disease is present).
• Endocrine pathology e.g. cerebral salt wasting syndrome, diabetes insipidus, SIADH.

Question 5

What are the concerns associated with anaesthetising this patient?

Answer 5

1) Remote site anaesthesia

2) Specific concerns (pathology)

Question 6

Concerns (detail)

Answer 6

Remote site anaesthesia:

• Appropriate staffing required e.g. ODP, senior anaesthetist or emergency help.
• Lack of familiar or appropriate monitoring and equipment, and potentially out of hours.
• Lack of an appropriate recovery area.
• Poor lighting and limited access to the patient during the procedure.

Specific concerns associated with the pathology:

• Critically unwell patient undergoing an emergency high-risk procedure that requires an experienced senior anaesthetist for optimal management.
• High risk of perioperative complications.
• There may be poor compliance from the patient if they are not sedated,
  but have an altered GCS.
• Risks associated with induction of anaesthesia in a potentially unstarved patient at a remote site.
• The patient may need an external ventricular drain before or after the
  procedure if hydrocephalus is evolving.

Question 7

How would you manage this patient during her procedure?

Answer 7

• Take a thorough preoperative history and conduct the relevant examination and appropriate investigations. The patient is intubated so a history can be taken from a family member and from her GP/ hospital notes.
• Ensure a completed consent form and WHO checklist and discuss the patient with the multidisciplinary team and a consultant neuroanaesthetist.
• Consider the best location for the initial management of the patient prior to the procedure e.g. in neurocritical care if unstable.

Question 8

How would you manage this patient during her procedure (continued)?

Answer 8

• Apply AAGBI standard monitoring and insert an arterial cannula for invasive blood pressure monitoring with large bore intravenous access present.
• Prepare the appropriate emergency drugs and equipment including the resuscitation and difficult airway trolleys. Check the position of the endotracheal tube following the transfer.
• Insert a temperature probe, catheter and nasogastric tube (if required) prior to the procedure to facilitate adequate monitoring, drug administration and passage of high contrast volumes.
• Depending on the clinical situation before the procedure and any procedural concerns or complications, the patient may be extubated, but they may also require ongoing care in the high dependency or intensive care unit.