Fawaz Al-Mufti1,2, Stephan A Mayer2, Gurmeen Kaur1,2, Daniel Bassily3, Boyi Li3, Matthew L Holstein3, Jood Ani3, Nicole E Matluck3, Haris Kamal2, Rolla Nuoman4, Christian A Bowers5, Faizan S Ali1, Hussein Al-Shammari1, Mohammad El-Ghanem6, Chirag Gandhi2, Krishna Amuluru7. 1. Department of Neurology, 8138Westchester Medical Center, Westchester Medical Center, Valhalla, USA. 2. Department of Neurosurgery, 8138Westchester Medical Center, Westchester Medical Center, Valhalla, USA. 3. School of Medicine, 8137New York Medical College, New York Medical College, Valhalla, USA. 4. Department of Neurology, 8138Westchester Medical Center, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, USA. 5. Department of Neurosurgery, University of New Mexico, Albuquerque, USA. 6. Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA. 7. Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA.
Abstract
BACKGROUND AND PURPOSE: Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS: We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS: Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS: Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
BACKGROUND AND PURPOSE: Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS: We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS: Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS: Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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