I. Prevention of subarachnoid hemorrhage
1, The relationship between hypertension and aneurysmal subarachnoid space is not clear. However, patients with hypertension should take medication to control blood pressure to prevent ischemic and hemorrhagic stroke and damage to the heart, kidneys, and other organs (Class I, Level A evidence).
2. Smoking cessation reduces the risk of subarachnoid hemorrhage, although the relationship is indirect (Class IIa, Level B evidence).
3, The value of aneurysm screening in high-risk groups is not very certain (Class IIb, Level B evidence); noninvasive tests can be applied, but angiography remains the gold standard for clinical diagnosis of aneurysms.
II. Natural history and outcome of aneurysmal SAH
1.The severity of the first bleeding should be assessed as soon as possible after the first bleeding, which is important for predicting the outcome and making treatment plans (Class I, Level B evidence).
2, For untreated ruptured aneurysms, the rebleeding rate is at least 3-4% within the first 24 hours after the first bleed, especially within 12 hours, and then within a month of bleeding, the daily probability of bleeding is 1%-2%. after 3 months, the annual risk of bleeding is 3%. Patients with suspected subarachnoid hemorrhage should be seen early (Class I, Level B evidence).
3. The following factors have an impact on the probability of rebleeding: severity of the first bleeding, interval between bleeding and admission, blood pressure, gender, aneurysm characteristics, hydrocephalus, early cerebral angiography and extraventricular drainage (Class IIb, Level B evidence).
III. Diagnosis of SAH
1.SAH is an emergency, but it is often misdiagnosed. Sudden severe headache should be highly suspected as subarachnoid hemorrhage (Class I, Level B evidence).
2, Patients suspected of SAH should undergo CT examination (Class I, Level B evidence). if the CT result is negative, lumbar puncture for cerebrospinal fluid examination is highly recommended (Class I, Level B evidence).
3, Patients with subarachnoid hemorrhage should undergo cerebral angiography to determine the presence of an aneurysm and its specific features (Class I, Level B evidence).
4. When cerebral angiography is not available, MRA or CTA may be considered (Class IIb, Level B evidence).
IV. Emergency evaluation and preoperative treatment
1.Severity grading of SAH patients should be performed to help predict prognosis and patient sorting (Class IIa, Level B evidence).
2. There is no standard diagnostic procedure for patients with headache and other potential SAH symptoms.
V. Drug therapy to prevent rebleeding after SAH
1.Blood pressure should be monitored, and the balance between hypertension-related rebleeding and hypotension-induced cerebral ischemia should be mastered, and attention should be paid to the maintenance of cerebral perfusion pressure (Class I, Level B evidence).
2. Bed rest alone is not enough for spider blood patients to prevent rebleeding. Comprehensive and effective therapeutic measures are necessary (Class IIb, Level B evidence).
3, Although older studies have shown that antifibrinolytic therapy is generally ineffective. New evidence suggests that antifibrinolytic drugs should be applied preoperatively for a short period of time and can be discontinued after proper management of the aneurysm, with prophylactic dilation and antivascular spasm drugs (Class IIb, Level B evidence). However, further studies are needed. In patients at low risk of vasospasm and/or late treatment, antifibrinolytic agents may be considered (Class IIb, Level B evidence).
VI. Open and interventional treatment for ruptured aneurysm subarachnoid hemorrhage
1. Subarachnoid hemorrhage caused by ruptured aneurysm should be treated with surgical clamping or interventional embolization to reduce the rebleeding rate. (Class I, Level B evidence)
2. Patients with incomplete surgical clamping or incomplete embolization after aneurysm encapsulation have a higher rebleeding rate than those with complete aneurysm management and should be followed up with long-term imaging and complete aneurysm management when possible. (Class I, Level B evidence)
3. Upon admission, patients with aneurysmal subarachnoid hemorrhage should be evaluated by a team of physicians with experience in cranial clamping and interventional treatment. When either cranial clamping or interventional embolization is feasible, interventional treatment is more favorable. (Class I, Level B evidence). Neurosurgical centers that can offer both treatments are more advantageous in treatment, although, of course, the patient’s own characteristics should be taken into account when deciding on the choice of treatment option (Class IIa, Level B evidence).
4. Although previous studies have shown no significant difference in overall outcome between early and late treatment after spider blood. However, early treatment can reduce the rebleeding rate, and the availability of new approaches has improved the outcome of early treatment of aneurysms. Therefore, early treatment is recommended for most patients (Class IIa, Level B evidence).
VII. About the hospital
1. Patients should be sent to a hospital with both experienced cerebrovascular surgeons and experienced neurointerventional specialists as early as possible (Class IIa, Level B evidence).
VIII. About anesthesia
1. During aneurysm surgery, the duration and degree of blood pressure reduction should be minimized (Class IIa, Level B evidence).
2. There is not enough evidence to support the need to elevate blood pressure during temporary vascular blockade, and there are no recommendations regarding the use of medication. However, it would be reasonable for a physician to do so (Class IIb, Level C evidence).
3. Subhypothermia is an option in certain aneurysm procedures, but is not routinely recommended (Class III, Level B evidence).
IX. Management of cerebral vasospasm
1. Oral nimodipine has been shown to be effective in relieving cerebral vasospasm after aneurysmal subarachnoid hemorrhage (Class I, Level A evidence). Other calcium antagonists, either oral or intravenous, are uncertain.
2, Treatment of cerebral vasospasm should be initiated after early treatment of aneurysms, and maintenance of normovolemia is recommended (Class IIa, Level B evidence).
3, 3H treatment with high blood volume, high blood pressure, and high blood dilution is reasonable (Class IIa, Level B evidence).
4. Depending on the condition, cerebral angioplasty and/or selective intra-arterial application of vasodilating drugs can be performed along with 3H treatment (Class IIb, Level B evidence).
X. Management of hydrocephalus
1, Patients with symptomatic chronic hydrocephalus after subarachnoid hemorrhage may undergo temporary extraventricular drainage or permanent cerebrospinal fluid shunt (Class I, Level B evidence).
2. For patients with ventricular enlargement and impaired consciousness after acute subarachnoid hemorrhage, extraventricular drainage is feasible (Class IIa, Level B evidence).
X. Management of epilepsy
1. Prophylactic antiepileptic drugs may be considered after subarachnoid hemorrhage (Class IIb, Level B evidence).
2. Routine long-term application of antiepileptic drugs is not recommended, except for those with risk factors for epilepsy, such as a history of epilepsy, intracerebral hematoma, cerebral infarction, or middle cerebral artery aneurysm (Class IIb, Level B evidence).
XI. Hyponatremia
1.Avoid applying large amounts of low-osmolarity rehydration fluid after SAH, and do not advocate blood volume reduction (Class I, Level B evidence).
2, Blood volume changes can be monitored by comprehensive monitoring of central venous pressure, pulmonary artery wedge pressure, inlet and outlet fluid volume and weight changes.
3, Hyponatremia can be treated with fludrocortisone acetate and hypertonic saline (Class IIa, Level B evidence)
4. In some cases, fluid intake should be controlled to maintain normal blood volume (Class IIb, Level B evidence).