2013 Hopkins Experience

Seizures - 

After saying that trials don’t recommend it, they use Keppra 1g bid as prophylactic therapy. 

Rebleeding - 

- size of hemorrhage, DCI, and rebleeding are the three biggest causes of morbidity.
- “standard of care that aneurysms should be occluded as soon as possible following the rupture”
- Cochrane review on amicar - reduced rebleeding but increased ischemia
- Amicar - 72hrs if delay but attempt to treat all aneurysms within 24hrs instead.

Vasospasm - 

- 40% of patients with DCI can have TCDs < 120 cm/s. Use as a trend but also use other modalities such as CT perfusion scanning.
- Use nimodipine 60 q 4hrs.

Triple H - 

- Causes pulmonary edema, hyponatremia, and myocardial infarction.
- Hypertension (not hypervolemia) is the only thing that improves cerebral blood flow.
- Initial goal in DCI is to increase BP 20% above baseline and eventually up as high as  220/120 if needed.
- Angioplasty of DCI has 5% major complication rate and 1.1% of vessel rupture. They use only if not improvement in 6-12 hours of triple H.

Inflammation and endothelin receptor antagonists and statins - 

- No role of endothelin antagonists.
- No reason to start statin but continue to used prior to SAH.

Cardiac / Pulmonary -

- Cardiomyopathy is common and can complicate DCI treatment.  Screening is reasonable. 
- Vasospasm is more common in patient’s with pulmonary complications. 
- SBP < 160. MAP > 70 (table)

Renal / Sodium -

- No benefit from prophylactic hypervolemia or triple-H.
- Goal is euvolemia.
- Most patients with hyponatremia have CSW and not SIADH.
- Use fludrocortisone is reasonable in CSW but no prophylactic steroids are used.

Heme / Infectious Disease - 

- Hb > 10 (per table).
- Fevers are dangerous. Tylenol first, surface cooling second. Aggressive tx of infections.
- Periprocedure abc should be used.
- SCDs for all. Heparin 24hrs after secured.

Endocrine - 

- Persistently elevated glucoses > 200mg/dl 7 times more likely of having poor outcomes.
- However, hypoglycemia is also dangerous.
- Target 150mg/dl with SSI. Insulin drips only if needed.
- Table: Use 24hrs of decadron 4mg q6hr x 24hrs.  

Anti-platelets - 

Coil embolizations or stent-assisted coil-embolizations may require anti platelet therapy.