(1) Dehydration to lower cranial pressure.
The peak of secondary cerebral edema is often 4 to 7 days after cerebral hemorrhage, and will be gradually relieved later. Adjustment can be given according to the level of cerebral pressure measured by lumbar puncture, but do not rush to reduce the dosage within 10 days after the hemorrhage for the time being, and then the dosage can be gradually reduced until it is stopped.
(2) Hormone.
Dexamethasone or methylprednisolone drip can relieve secondary cerebral edema and contrast reactions during the acute phase of hemorrhage, and can be applied continuously for 1 week to 10 days, with the dose reduced by half in the middle. Pay attention to the combined application of acid suppressants (such as famotidine, loxacillin, etc.) to prevent stress ulcers.
(3) Antispasmodic.
Subarachnoid hemorrhage and its metabolites can stimulate cerebral arteries causing spasm, often worst during 3 days to 2 weeks after hemorrhage, and the calcium antagonist nimodipine is a commonly used antispasmodic. Nimodipine can be pumped intravenously at a rate of 5 ml/h. Blood pressure should be monitored during the pumping period, and the pumping rate should be reduced or temporarily discontinued if blood pressure is low to prevent cerebral hypoperfusion. Nimodipine can be applied intravenously for 2 weeks, after which it is switched to oral administration for 1 to 2 months.
(4) Volume expansion.
Colloid fluids such as low molecular dextrose or van Boven can be used to expand the volume, which can help improve cerebral perfusion and microcirculation. It is appropriate to maintain the patient’s blood pressure at a slightly higher level in the normal range to ensure cerebral perfusion.
(5) Rehydration.
Both mannitol and tachypnea are potassium-depleting diuretics, so pay attention to potassium rehydration during dehydration. Blood biochemistry should be strictly monitored to prevent disorders of water and electricity balance. Encourage the patient to eat a liquid or semi-liquid diet. If there is vomiting or the patient cannot eat due to impaired consciousness, pay attention to intravenous nutrition and nasal feeding if necessary.
(6) Discontinuation of hemostatic drugs.
After aneurysm embolization, the threat of rebleeding is removed; hypercoagulable state and secondary cerebral vasospasm become the main threat, so the focus of the next treatment shifts to the prevention and treatment of cerebral ischemia accordingly.
(7) Lumbar puncture.
Lumbar puncture is an irreplaceable and important measure to prevent and treat cerebral vasospasm and delayed hydrocephalus after subarachnoid hemorrhage. The first step after successful puncture is to measure the cerebral pressure, if it is higher than 250 mmH2O, the blood cerebrospinal fluid should be released after a rapid sedation of 250 ml of 20% mannitol or 40 mg of tachyzoites into the pot intravenously. If the natural flow rate of cerebrospinal fluid is too fast at the beginning, the needle core can be used to half block the end of the needle to reduce the flow rate. Each lumbar puncture can release 20-40ml of cerebrospinal fluid, or until the natural flow of cerebrospinal fluid is extremely slow. Lumbar puncture is usually done daily or every other day. If the subarachnoid hemorrhage is large, lumbar pool drainage may be considered. Note that the drainage bag should be 10 to 15 cm above the head; too low a position can cause excessive drainage of cerebrospinal fluid and thus cause hypocranial pressure headache. Generally, after 3 to 14 days, the cerebrospinal fluid will change from red to light red, then yellow to clear, at which time the lumbar puncture or lumbar pool drainage can be stopped. Lumbar pool drainage should generally not exceed 1 week to prevent retrograde intracranial infection. It should be emphasized that if the patient is expected to have high cerebral pressure, lumbar puncture or lumbar pool drainage should be performed with caution or prohibited to avoid medically induced brain herniation. Specifically, relative contraindications to lumbar puncture or lumbar pool drainage include poor clinical status of the patient (Hint-Hess classification grade 4 or 5), CT showing displacement of midline structures, severe hydrocephalus, severe hydrocephalus, or combined ventricular casts. Such patients may require other interventions such as ventricular puncture, decompression by debridement slice, etc.
(8) Symptomatic management.
This includes antiemetic, sedation, prevention and control of hydroelectric balance disorders, prevention and control of seizures, and prevention and control of gastrointestinal, respiratory, and urinary complications.
(9) CT review.
If the patient has neurological localization signs (such as hemiparesis, aphasia, etc.), it indicates cerebral vascular spasm causing cerebral infarction, and CT should be reviewed to evaluate the location and extent of infarction. If the patient has sudden coma and grand mal seizure after surgery (rare), it suggests re-rupture and bleeding of the aneurysm, and CT should be reviewed urgently for identification. In a few patients, rebleeding is still possible after aneurysm embolization. Recent rebleeding is related to incomplete embolization of the aneurysm or poor thrombus formation in the lumen of the aneurysm, while distant rebleeding suggests recurrence of the aneurysm. In addition, some patients may have delayed traffic hydrocephalus 3-4 weeks or more after hemorrhage, which is related to the obstruction of arachnoid granules causing cerebrospinal fluid circulation disorder, clinically manifested as unresponsiveness, progressive dementia, unstable walking, urinary incontinence, etc. At this time, CT should be reviewed to understand the degree of ventricular dilatation, and if necessary, ventriculoperitoneal shunt should be performed.
(10) Hyperbaric oxygen.
For patients with neurological localization signs, if the vital signs are stable, early hyperbaric oxygen can be performed to help the recovery of neurological function.
(11) Early functional exercise.
If the condition allows, encourage the patient to move early and follow the principle of gradual exercise of sitting-standing-standing-walking. Early activity can help reduce the incidence of pneumonic pneumonia and lower limb venous thrombosis.
(12) Special medication.
Special medication here refers to the application of anticoagulation and antiplatelet drugs, mainly for patients with aneurysms treated with stents combined with spring-ring technique embolization. The stent is placed as a foreign body in the aneurysm-carrying artery and requires strict postoperative anticoagulation and antiplatelet therapy.
Postoperative anticoagulation: 12,500 IU of sodium heparin + 50 ml of physiological saline pumped intravenously at a pumping rate of 4 ml/h, which is generally equivalent to 1,000 IU of sodium heparin per hour, with careful monitoring of the coagulation phase during pumping. The standard for systemic heparinization is to maintain the APTT (activated partial thromboplastin time) at 45-75 s. If the APTT is <45 s, increase the pump speed to 5 ml/h; if >75 s, decrease the pump speed to 2 ml/h or suspend the use for 2 hours. Personal experience is that a pump rate of 3 to 4 ml/h basically meets the criteria for systemic heparinization in adults. Heparin is discontinued if the patient develops bleeding tendencies such as nasal or oral mucosal bleeding and hematuria during heparinization. Those without bleeding tendency stop intravenous heparinization 24h postoperatively and switch to low molecular heparin calcium 5000IU subcutaneously q12h×2~3 days.
Postoperative antiplatelet: aspirin 200mg×6 months; Poliovel 75mg×6 weeks.
(13) Post-discharge follow-up and review.
The recurrence rate after intracranial aneurysm embolization is reported to be between 5% and 10%, therefore, patients are advised to review DSA for six months after surgery to know whether there is recurrence. After discharge from the hospital, outpatient review is required every year, and imaging review is required if necessary.
In conclusion, the treatment of ruptured intracranial aneurysm subarachnoid hemorrhage is a comprehensive treatment, and the interventional treatment of the aneurysm itself (either interventional embolization or craniotomy clamping) is only one of the first steps, and the subsequent treatment is still very complicated and cumbersome, so we hope that the competent doctors will pay high attention to it.