Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage

Outcomes Measures in Subarachnoid Hemorrhage Research

Despite advancements in acute management, morbidity rates for subarachnoid hemorrhage (SAH) remain high. Therefore, it is imperative to utilize standardized outcome scales in SAH research for evaluating new therapies effectively. This review offers a comprehensive overview of prevalent scales and clinical outcomes used in SAH assessment, accompanied by recommendations for their application and prognostic accuracy. Standardized terminology and diagnostic criteria should be employed when reporting pathophysiological outcomes such as symptomatic vasospasm and delayed cerebral ischemia. Furthermore, integrating clinical severity scales like the World Federation of Neurosurgical Societies scale and modified Fisher score into clinical trials is advised to evaluate their prognostic significance, despite their limited correlation with outcomes. The modified Rankin score is widely used for assessing functional outcomes, while the Glasgow outcome scale-extended version is suitable for broader social and behavioral evaluations. Avoiding score dichotomization is crucial to retain valuable information. Cognitive and behavioral outcomes, though frequently affected in patients with favorable neurological outcomes, are often overlooked during follow-up outpatient visits, despite their significant impact on quality of life. Comprehensive neuropsychological evaluations conducted by trained professionals are recommended for characterizing cognitive function, with the Montreal Cognitive Assessment serving as a viable screening tool. Additionally, integrating psychological inventories like the Beck Depression and Anxiety Inventory, along with quality-of-life scales such as the Stroke-Specific Quality of Life Scale, can effectively assess behavioral and quality of life outcomes in SAH studies.

Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist

Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.