AssessmentandManagementofSubarachnoidHaemorrhageatDorset

CountyHospital
Background Subarachnoidhaemorrhage
(SAH)isanuncommonformofstrokethat
isusuallyduetoruptureofasaccular
aneurysmandoccursinagenerallyyounger
populationthanischaemic stroke.

Authors:SCappleman,JFordham,MPulletz

Outcome Untreatedisoftenpoor:around
halfdiewithin1monthofthe
haemorrhage,andofthosewhosurvivethe
firstmonth,halfremaindependentforhelp
withactivitiesofdailyliving.However,
survivalimprovesto85%inpatientswith
confirmedSAHadmittedtoaneurosurgical
unit.

TheNationalConfidentialEnquiryinto
PatientOutcomeandDeath(NCEPOD)
beganastudyin2012aimedatexploring
remediablefactorsintheprocessofcare
ofpatientsadmittedwiththediagnosisof
[SAH]whichreviewedcasenotesof
patientsdiagnosedwithSAHina12
monthperiod.
OurstudyOuraimwastoreviewthe
currentmanagementofSAHatDCH
focussingoninitialassessment,timetoCT
anduseofnimodipinetocontrolfor
vasospasm.

NationalguidelinesforSAHmanagement
donotexistinisolation,insteadembedded
innationalstroke andheadache
managementguidelines.

Method Medicalrecordswere
retrospectivelyreviewedofallpatients
codedforSAHinthe32monthperiodJan
2010 Aug2013.

NICEStroke2008guidelines recommend
forpresentationofsuddensevere
for
presentation of sudden severe
headache+alteredGCSimmediateCT
brainand,Ifnormal,LPafter12h14d.

Results 19patientswerefound,8
excluded (incomplete notes onset at
excluded(incompletenotes,onsetat
anotherhospital/afteradmission,
traumatic)leaving11foranalysis.
Tableofauditstandardsandcompliance

OnceSAHdiagnosed:
referimmediatelytoatertiary
neurosciencecentre
startonoralnimodipine60mg4hourly
unlessCI
dontgiveantifibrinolytics orsteroids
Inthespecialistservicethepatientshould
have:
CTangiographytoidentifythesiteof
bleeding
specifictreatmentbyendovascular
embolisation orsurgicalclippingif
appropriate...within48hoursofictus,
especiallyforgoodgradepatients.

Compliance

100%ofpatientswithadiagnosisofsubarachnoidhaemorrhage
(SAH)shouldhavehadadocumentedGCSoninitialassessment

9/11

82%

100%ofpatientswithadiagnosisofSAHshouldhavehada
documentedexaminationofpupilsoninitialassessment

9/11

82%

100%ofpatientsadmittedwithadiagnosisofSAHshouldhave
hadadocumentedexaminationofmotorfunctiononinitial
assessment

7/11

64%

100%ofpatientswithadiagnosisofSAHshouldhaveaCThead
within12hoursofadmission

10/10

100%

2/6

33%

Standard

100%ofpatientswithadiagnosisofSAHshouldhavehad
nimodipinepriortotransfertoatertiarycentre.
nimodipine
prior to transfer to a tertiary centre.

Therapyinsubarachnoidhaemorrhage
MedicalNimodipineisacalciumchannelblockerusedto
preventvasospasm,whichisacommoncomplicationofSAH.
Itmaypresentasnewneurologicalsymptomsandsignsand
leadtodelayedischaemia,withpooroutcome.Nimodopine
istheonlymedicationshowntoimproveoutcomeinSAH.
SurgicalEndovascularcoilinginvolvesinsertionofa
catheterviathefemoralveinandpassageofadetachable,usuallyplatinum,
wireintotheaneurysmuntilitisfilled.Usingthismethod,arelativerisk
reductionof7.4%hasbeendemonstratedovertraditionalcraniotomyand
clipping;theaimistoreducehighriskrebleeds.

Conclusions Theassessmentanddocumentationof
patientswithSAHcanbeimproved,especiallywith
regardtoneurologicaldeficit.Useofnimodipinecan
alsobeimproved.
Ongoingimprovementprojectsincludeteaching
sessionsintheEmergencyDepartmentandproduction
ofhospitalguidelinesandinformationposters.

References:vanGijn,J&Rinkel,GJE.Subarachnoidhaemorrhage:diagnosis,causesandmanagementBrain(2001)124(2):249278doi:10.1093/brain/124.2.249;SocietyofBritishNeurosurgeons2006;
NationalClinicalGuidelineforStroke,StrokeWorkingParty2008;NICEclinicalguideline68Stroke:Diagnosisandinitial managementofacutestrokeandtransientischaemicattack(TIA);CollegeofEmergency
Medicine2008GuidelinefortheLoneSevereHeadache;NationalConfidentialEnquiryintoPatientOutcomeandDeath(2013)ManagingtheFlow?Areviewofthecarereceivedbypatientswhowerediagnosed
withananeurysmalsubarachnoidhaemorrhage;SBarker&COgilvey(1996)Efficacyofprophylacticnimodipinefordelayedischemicdeficitaftersubarachnoidhemorrhage:ametaanalysis.Journalof
Neurosurgery84(3)405414Molyneuxetal(2005)InternationalSubarachnoidAneurysmTrial(ISAT)ofneurosurgicalclippingversusendovascularcoilingin2143patientswithrupturedintracranialaneurysms:
arandomisedtrial.Lancet366:809817