Critical Care Management of Subarachnoid Hemorrhage and Ischemic Stroke

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This article addresses current critical care management strategies for patients with aneurysmal subarachnoid hemorrhage (SAH) and ischemic stroke. The chronology of typical SAH care is discussed, with an emphasis on the treatment of poor-grade SAH and on current monitoring techniques. Acute diagnosis and treatment of the life-threatening ischemic strokes is reviewed, emphasizing the care of patients with acute basilar artery occlusion and the malignant middle cerebral artery syndrome. Up-to-date estimates of the long-term outcomes of these syndromes are reviewed.

Section snippets

Epidemiology

Ischemic cerebral infarction accounts for 80% of all stroke in the United States,14 but most patients will not require ICU admission. SAH is a generally more morbid disease, with a 30% to 50% overall mortality rate,15 and virtually all patients at least briefly require ICU admission. Therefore, intensivists are likely to care for similar numbers of patients with ischemic stroke and SAH.

Catastrophic ischemic stroke syndromes are listed in Table 1. Typically, life-threatening ischemic strokes

General considerations

Like all critical illnesses, the management of stroke begins with assessment of the airway, breathing, and circulation. Many patients present with an acute decrease in level of arousal, poor tone in the posterior pharynx, and dulling of airway protective reflexes. These patients are at immediate risk for aspiration, hypoventilation, hypoxia, and respiratory failure. Patients in the acute phase of neurologic decline with moderate to severe respiratory compromise should be intubated without

Aneurysmal subarachnoid hemorrhage

Hunt and Hess grades 1 to 3 (Table 2) carry a favorable prognosis, and almost always warrant aggressive treatment. Although patients may suffer complications such as hydrocephalus, vasospasm, or delayed cerebral ischemia (DCI), the outcome of their care is expected to be good, with most patients experiencing good or complete neurologic recovery.29 Conversely, “poor-grade” subarachnoid hemorrhage is a catastrophic disease, and without aggressive neurosurgical and medical therapy, most patients

Ischemic stroke

Ischemic stroke is a heterogeneous group of diseases with extremely variable prognosis, acute management, and critical care concerns. Intensivists must rapidly distinguish between potentially catastrophic large vessel or posterior circulation strokes, and smaller lacunar or embolic events. The intensive care of patients with large or critical ischemic strokes is based on four goals: (1) reperfusion; (2) the prevention of infarct expansion, recurrence, or hemorrhagic conversion; (3) the

Summary

Patients with severe brain injury from SAH and ischemic stroke have seen an improvement in survival and long-term neurologic outcome over the past decade when aggressive surgical and medical neuroprotective measures are used. Many patients once considered to have a fatal brain injury can now be treated with the prospect of an acceptable recovery. The critical care management of these patients relies on rapid evaluation and surgical triage, early and aggressive monitoring, and treatment of both

References (141)

  • P.J. Lindsberg et al.

    Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis

    Stroke

    (2006)
  • T. Brandt et al.

    Thrombolytic therapy of acute basilar artery occlusion: variables affecting recanalization and outcome

    Stroke

    (1996)
  • B. Eckert et al.

    Endovascular therapy of acute vertebrobasilar occlusion: early treatment onset as the most important factor

    Cerebrovasc Dis

    (2002)
  • E.I. Levy et al.

    Factors affecting survival rates for acute vertebrobasilar artery occlusions treated with intra-arterial thrombolytic therapy: a meta-analytical approach

    Neurosurgery

    (1999)
  • R. Gupta et al.

    Hemicraniectomy for massive middle cerebral artery territory infarction: a systematic review

    Stroke

    (2004)
  • S. Laureys et al.

    The locked-in syndrome: what is it like to be conscious but paralyzed and voiceless?

    Prog Brain Res

    (2005)
  • J.E. Doble et al.

    Impairment, activity, participation, life satisfaction, and survival in persons with locked-in syndrome for over a decade: follow-up on a previously reported cohort

    J Head Trauma Rehabil

    (2003)
  • W. Rosamond et al.

    Heart disease and stroke statistics–2008 update: a report from the American Heart Association statistics committee and stroke statistics subcommittee

    Circulation

    (2008)
  • J.W. Hop et al.

    Case-fatality rates and functional outcome after subarachnoid hemorrhage: a systematic review

    Stroke

    (1997)
  • W. Hacke et al.

    Malignant middle cerebral artery territory infarction: clinical course and prognostic signs

    Arch Neurol

    (1996)
  • C. Aulmann et al.

    Validation of the prognostic accuracy of neurosurgical admission scales after rupture of cerebral aneurysms

    Zentralbl Neurochir

    (1998)
  • J.L. Juarez et al.

    Aneurysmal subarachnoid hemorrhage

    N Engl J Med

    (2006)
  • J. Claassen et al.

    Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited

    Stroke

    (2001)
  • W.M. Coplin et al.

    Implications of extubation delay in brain-injured patients meeting standard weaning criteria

    Am J Respir Crit Care Med

    (2000)
  • M. Clancy et al.

    In patients with head injuries who undergo rapid sequence intubation using succinylcholine, does pretreatment with a competitive neuromuscular blocking agent improve outcome? A literature review

    Emerg Med J

    (2001)
  • F. Bilotta et al.

    Endotracheal lidocaine in preventing endotracheal suctioning-induced changes in cerebral hemodynamics in patients with severe head trauma

    Neurocrit Care

    (2008)
  • B.J. Duke et al.

    Traumatic bilateral jugular vein thrombosis: case report and review of the literature

    Neurosurgery

    (1997)
  • B. Scheer et al.

    Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine

    Crit Care

    (2002)
  • A. Nieszkowska et al.

    Impact of tracheostomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients

    Crit Care Med

    (2005)
  • J. Griffiths et al.

    Systematic review and meta-analysis of the timing of tracheostomy in adult patients undergoing artificial ventilation

    Br Med J

    (2005)
  • M.J. Rumbak et al.

    A prospective, randomized study comparing early percutaneous dilational tracheostomy to prolonged translaryngeal intubation (delayed tracheostomy) in critically ill medical patients

    Crit care Med

    (2004)
  • S. Levine et al.

    Rapid disuse atrophy of diaphragm fibers in mechanically ventilated humans

    N Engl J Med

    (2008)
  • S.A. Mayer et al.

    Subarachnoid hemorrhage

  • E.R. Ransom et al.

    External ventricular drainage response in poor grade aneurysmal subarachnoid hemorrhage: effect on preoperative grading and prognosis

    Neurocrit Care

    (2007)
  • Komotar RJ, Schmidt JM, Starke RM, et al. Resuscitation and critical care of poor grade subarachnoid hemorrhage....
  • H.P. Adams et al.

    Nonaneurysmal subarachnoid hemorrhage

    Ann Neurol

    (1991)
  • J. Van Gijn et al.

    Subarachnoid haemorrhage: diagnosis, causes and management

    Brain

    (2001)
  • F.A. Sehba et al.

    Mechanisms of acute brain injury after subarachnoid hemorrhage

    Neurol Res

    (2006)
  • J. Mocco et al.

    Potential mechanisms and clinical significance of global cerebral edema following aneurysmal subarachnoid hemorrhage

    Neurosurg Focus

    (2007)
  • C. Muroi et al.

    Neurogenic pulmonary edema in patients with subarachnoid hemorrhage

    J Neurosurg Anesthesiol

    (2008)
  • S.A. Mayer et al.

    Myocardial injury and left ventricular performance after subarachnoid hemorrhage

    Stroke

    (1999)
  • V.H. Lee et al.

    Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction

    J Neurosurg

    (2006)
  • A.M. Naidech et al.

    Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage

    Circulation

    (2005)
  • J.M. Schmidt et al.

    Cerebral infarction associated with acute subarachnoid hemorrhage

    Neurocrit Care

    (2007)
  • O.W. Sakowitz et al.

    Contemporary management of aneurysmal subarachnoid hemorrhage in Germany: results of a survey among 100 neurosurgical departments

    Neurosurgery

    (2006)
  • R.M. Starke et al.

    Impact of a protocol for acute antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage

    Stroke

    (2008 Jul 24)
  • J.I. Suarez et al.

    Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team

    Crit Care Med

    (2004)
  • N.S. Bardach et al.

    Regionalization of treatment for subarachnoid hemorrhage: a cost-utility analysis

    Circulation

    (2004)
  • M.A. Koenig et al.

    Reversal of transtentorial herniation with hypertonic saline

    Neurology

    (2008)
  • S. Himmelseher

    Hypertonic saline solutions for treatment of intracranial hypertension

    Curr Opin Anaesthesiol

    (2007)
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