"Today's Treatment Guidelines 2019 Edition" p916-918Purchase

I wrote the section on "subarachnoid hemorrhage" and summarized the diagnosis and treatment guidelines for subarachnoid hemorrhage for general practitioners and working doctors.

subarachnoid hemorrhage
subarachnoid hemorrhage (SAH)
Hiroshi Nakaguchi, Director of Neurosurgery, Mitsui Memorial Hospital (Tokyo)
Referenced guidelines:
Stroke Treatment Guidelines 2015 [Amendment 2017](JAPAN)
▶Treatment points
・As subarachnoid hemorrhage has a high mortality rate, primary care physicians should make an accurate diagnosis and start appropriate treatment early in order to save lives.
・Re-rupture has a high fatality rate, and it is critically important to prevent re-rupture until radical surgery for an aneurysm is completed.
・Severe hypertension, restlessness, and headache are common immediately after onset, and the basic initial treatment is to reduce blood pressure, sedation, and analgesia.
・The curative treatment for cerebral aneurysm is craniotomy clipping and cerebral endovascular treatment (coil embolization).
・As postoperative management, it is important to prevent and treat (delayed) cerebral vasospasm 3 to 14 days after onset and acute to chronic hydrocephalus.
pathology and diagnosis
○A pathology
・Bleeding into the subarachnoid space (cerebrospinal fluid space) occurs when a cerebral artery suddenly cuts. Emergency services are often requested due to sudden severe headaches, vomiting, and disturbance of consciousness, but there are also cases in which patients are seen as outpatients.
Rupture of cerebral aneurysm accounts for more than 95% of the causes, and in Japan, the incidence rate is about 20 per 100,000 people per year. Involvement is also suggested. Other causes of bleeding include cerebral arteriovenous malformation, but are not discussed in this section.
・The turning point at the time of discharge was 30% in the poor turning point group requiring assistance or less, and 23% died (table).
・Severity classification at first visit (Hunt and Kosnik scale) grade I to II (mild to severe headache) III (somnolence/confusion) IV (stupor) V (moribund) It is strongly correlated with turning points at discharge.
Severity and outcome of superficial subarachnoid hemorrhage

mRS: modified Rankin Scale, WFNS classification: World Federation of Neurological Surgeons classification
Good outcome group: mRS 0-2 = 53% Poor outcome group: mRS 3-6 = 47%
(Edited by Yoshiyasu Kobayashi: Stroke Data Bank 2015. p. 161, Nakayama Shoten. 2015)
○B Diagnosis
・Subarachnoid hemorrhage can be diagnosed in almost 100% by head CT within 3 days of onset, but may not be diagnosed after that. MRI FLAIR method (+brain MRA) or lumbar puncture to check for subarachnoid hemorrhage. The cerebrospinal fluid remains xanthochromic until 3 to 4 weeks after onset.
・Sudden oculomotor nerve palsy and aggravating headache may be precursors of cerebral aneurysm rupture, so it is advisable to perform MRI FLAIR, DWI, and brain MRA as soon as possible.
Treatment policy
A initial treatment
1.Grade I-II (mild group at first visit) Patients with suspected subarachnoid hemorrhage should immediately undergo neurological findings, vital signs check, emergency blood sampling, and head CT. A continuous intravenous infusion of the drug should be started, and if possible, the balloon catheter should be placed after the blood pressure has sufficiently decreased.
At the neurosurgery hospital, radical surgery is performed for cerebral aneurysms based on the results of cerebral angiography (CTA or MRA, DSA when details are unknown). Sudden changes can occur even if the patient is mildly ill on admission.
2.Grade III-IV (moderate to severe group at first visit)
Steady implementation of emergency A (airway maintenance), B (ventilation), and C (blood pressure/cardiac management). Cerebral blood flow disorder occurs at 70 mmHg or less, so be careful not to over-lower blood pressure. Takotsubo cardiomyopathy is seen in a few percent, and QT prolongation (0.48 seconds or more) should be noted as it may subsequently transition to fatal ventricular arrhythmia. Since upper gastrointestinal ulcers are common, a gastric catheter is placed and a proton pump inhibitor is administered as a prophylaxis.
3.Grade V (most severe group at first visit)
Respirator management is started in the treatment room, but Grade V patients have a high mortality rate and aggressive treatment is generally not indicated.
4. Prescription example
a.Antihypertensive
prescription example
Perdipine injection 60-300 μg/kg/hour continuous intravenous injection Systolic blood pressure below 140 mmHg
b. Analgesia
prescription example
Fentanyl injection 0.5-5 μg/kg/hour continuous intravenous injection
c.Sedation
prescription Example Use one of the following
1) Serusin injection 5 mg intravenously up to 4 times in total
2) Dormicum injection 0.03-0.18mg/kg/hour continuous intravenous injection
3) Precedex injection 0.2-0.7 μg/kg/hour continuous intravenous injection
4) 1% Diprivan injection 0.4-1.0mL/kg/hour continuous intravenous injection
Points for proper use of Rx
1) has a moderate sedative effect and causes respiratory depression. Half-life is 30 hours.
2) has a moderate sedative effect and causes delirium during withdrawal. Half-life is 2.8 hours.
Although 3) has a weak sedative effect, it causes less respiratory depression and delirium.
4) has a strong sedative and antiemetic effect, and wakes up within a few minutes of discontinuation. I need a separate line.
d.When intracranial pressure rises
prescription example
Glyceol injection, 200 mL once, 2-4 times a day, intravenous drip
e.Anticonvulsants
prescription example
E Keppra Injection 500 mg twice a day, without intravenous drip
f. Gastric ulcer prevention
prescription example
Takepron injection, 30 mg twice a day, intravenous drip (many changes in formulation, flushing with saline before and after)
B Surgical treatment
To prevent rerupture, perform radical surgery within 24 hours of onset (within 72 hours at the latest). Advances in cerebral endovascular treatment have enabled coil embolization of a considerable number of cerebral aneurysms.Both clipping and coiling are possible. In such cases, coil embolization is recommended [American Heart Association (AHA)/American Stroke Association (ASA) Guidelines 2012]. Clipping surgery is performed in cases of difficulty, large cerebral hemorrhage, or in the absence of a cerebral endovascular specialist.
Ventricular drainage is performed for acute hydrocephalus, and ventriculoperitoneal shunt or lumbar peritoneal shunt is performed for chronic hydrocephalus.
C Postoperative management
In principle, normal blood pressure and normal plasma volume should be maintained.
1. Prevention and treatment of late-onset cerebral vasospasm: Cerebrospinal fluid pressure is controlled by osmotic diuretic drip and ventricular or lumbar drainage. Note, etc.). Check the degree of cerebral vasospasm by brain MRA (after coiling) or CTA (after clipping) 1 week before and after onset. Attempt to dilate the stenotic site with Eryl local arterial injection and balloon catheter.
Examples of prescriptions The following are used to prevent cerebral vasoconstriction.
Fasugil hydrochloride injection 30 mg three times a day intravenous drip
2. Treatment of central diabetes insipidus
For central diabetes insipidus after anterior communicating artery aneurysm surgery (hourly urine output of 250 ml or more for 3 hours or urine specific gravity of 1.008 or less), water-soluble pitrescin subcutaneous injection (2 units) ) or desmopressin nasal spray (twice a day).
▶ Consultation with specialists
・Patients who complain of sudden severe headache should be diagnosed by referring to the "Diagnostic Points" above, or should be advised to see a neurosurgeon immediately.
・If subarachnoid hemorrhage is diagnosed, perform "A initial treatment" and transport the patient to a neurosurgical hospital by ambulance.
▶Points for patient explanation
・Please explain to your family based on the above "Pathology and Diagnosis - Treatment Points".
▶Points of Nursing/Nursing Care
・From the initial response immediately after the onset until the completion of the radical surgery, care should be taken to minimize talking and treatment, and to avoid shocks during transport.
・During ventricular drainage, pay attention to excessive discharge of cerebrospinal fluid and obstruction of the drain (100-200 ml per day as a guideline).