WORST-CASE SCENARIO - MANAGEMENT IN POOR-GRADE ANEURYSMAL SUBARACHNOID HEMORRHAGE

The present paper reviews critical care management of patients with a poor-grade subarachnoid hemorrhage (SAH) and highlights current perspectives in initial management in the neurologic intensive care unit, using Medline for the years 1976-1993. The selection for this review was based on the quality of the original work. The literature was selected to demonstrate the clinical course and published treatment options. The literature was reviewed to summarize the most pertinent critical care issues and neurosurgical options in the first hours after the impact. Approximately one-third of the patients with SAH present comatose to the neurointensive care unit. Early neurosurgical intervention can be considered in patients with SAH and intracerebral hemorrhage, patients with acute hydrocephalus to reduce intracranial pressure, and in patients who recover from an early rebleed. Cardiopulmonary care is extremely complex. Pulmonary edema may be neurogenic (sympathetic storm) or associated with myocardial stunning and may be effectively treated with dobutamine. Fluids and blood pressure management are comparatively important in this regard. Advances in fluid management have significantly improved survival, and correction of hyponatremia with fluid restriction has been found to increase the risk of cerebral infarction. Treatment of acute hypertension is largely conservative. Patients who remain in a poor clinical state should be considered for endovascular coil treatment. Patients with SAH who presented in a poor initial clinical state (poor-grade SAH) demonstrate important systemic effects. Management includes treatment of pulmonary edema, hyponatremia, and hypertension. Obliteration of the aneurysm with coils may become a possible treatment in patients with SAH in poor grade.