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New guidelines on the management of aneurysmal subarachnoid hemorrhage (aSAH) from the Stroke Council of the American Heart Association are now available.  Robert H. Rosenwasser, M.D., professor and chair, Department of Neurological Surgery at Jefferson Medical College of Thomas Jefferson University served as part of a special writing group – made up of ten of the leading neurosurgeons and vascular neurologists in the country – to establish these new guidelines which are currently available in the online edition of Stroke.  More than 27,000 Americans suffer ruptured intracranial aneurysms each year.  An estimated ten to 15 percent of patients die before reaching the hospital.  Mortality rates reach as high as 45 percent within the first thirty days and about half die in the first six months.

“Even though aSAHs can be lethal, there have been great advances in treatment since the first and only guidelines on their management were published in 1994 which necessitated the revision,” said Dr. Rosenwasser, who also was a co-author on the Guidelines for the Early Management of Adults with Ischemic Stroke issued by the American Heart Association/ American Stroke Association in 2007.  “Advancements in imaging, critical care and new clinical procedures utilizing coils and catheters, allow for better patient outcomes, so the way in which a ruptured aneurysm or ischemic strokeare diagnosed and treated needed to be adjusted to reflect current times.”

To address these changes, the Stroke Council formed a writing group to re-evaluate the initial recommendations from fourteen years ago. The committee conducted a MEDLINE search, retaining all relevant literature published between June 1994 and November 2006, which met the criteria of a randomized trial or a nonrandomized, concurrent, cohort study, with the goal of addressing subjects that were covered in the initial guidelines.

Among the recommendations being made are that aSAH patients be treated at high-volume centers where endovascular interventions, as well as neurosurgical services, are available. Guideline authors also caution that despite having among the most dramatic presentations in medicine, these hemorrhages can present as a milder, sentinel headache, and aSAH should be considered in the differential diagnosis of all patients with new headache.

Other major conclusions in the new guidelines include:

• aSAH is frequently misdiagnosed, in up to 12 percent of cases. For the initial evaluation of headache, CT scanning for suspected aSAH is strongly recommended followed by lumbar puncture if the CT is negative. A standard management protocol for the evaluation of patients with headaches and other symptoms that may potentially relate to aSAH does not currently exist and should be developed;
• Early versus later treatment of the aneurysm reduces the risk for re-bleeding after SAH, and so early surgery is reasonable and probably indicated in the majority of cases;
• The relationship between hypertension and aSAH is uncertain, but management of blood pressure to prevent other clinical problems is recommended. Quitting smoking is reasonable although the evidence for this association is indirect; and
• Screening for unruptured aneurysms in high-risk populations is of uncertain value. Noninvasive imaging may be used for such screening, but catheter angiography remains the 'gold standard' when it is clinically imperative to know if an aneurysm exists.

Editor’s Note:  The complete article can be accessed by logging onto the following address: http://stroke.ahajournals.org/cgi/content/abstract/STROKEAHA.108.191395v1