Current status of problems with initial treatment for aneurysmal subarachnoid hemorrhage

Abstract

Subarachnoid hemorrhage(SAH)has a poor prognosis with a mortality rate of 25-50%. Because re- rupture is highly associated with mortality, a correct diagnosis must be made as soon as possible and the appropriate initial treatment must be performed. Delayed diagnosis due to failure in obtaining a computed tomography(CT)scan or missed diagnosis of SAH on CT can sometimes results in a fatal outcome. A lumbar puncture or magnetic resonance imaging is necessary to diagnose SAH even after a negative CT scan in cases wherein SAH is suspected based on symptoms. Although there is a general consensus that analgesia, sedation, and blood pressure lowering should be performed in the initial treatment of SAH, for sedation and blood pressure control protocols have not been defined. In cases with a poor-grade SAH, intracranial pressure(ICP)and cardiovascular complications should be properly managed. Placement of an external ventricular drain is recommended for acute hydrocephalus. Three-dimensional computed tomography angiography(3D-CTA)has recently been used for identifying the bleeding source. However, 3D digital subtraction angiography(3D-DSA)is more useful for the decision making between clipping and coiling.