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Risk of recurrent subarachnoid haemorrhage, death, or dependence and standardised mortality ratios after clipping or coiling of an intracranial https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 36/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate aneurysm in the International Subarachnoid Aneurysm Trial (ISAT): long-term follow-up. Lancet Neurol 2009; 8:427. 187. Wermer MJ, Greebe P, Algra A, Rinkel GJ. Long-term mortality and vascular event risk after aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2009; 80:1399. 188. Nieuwkamp DJ, Algra A, Blomqvist P, et al. Excess mortality and cardiovascular events in patients surviving subarachnoid hemorrhage: a nationwide study in Sweden. Stroke 2011; 42:902. 189. Korja M, Silventoinen K, Laatikainen T, et al. Cause-specific mortality of 1-year survivors of subarachnoid hemorrhage. Neurology 2013; 80:481. 190. Koroknay-P l P, Laakso A, Lehto H, et al. Long-term excess mortality in pediatric patients with cerebral aneurysms. Stroke 2012; 43:2091. 191. Schatlo B, Fung C, Stienen MN, et al. Incidence and Outcome of Aneurysmal Subarachnoid Hemorrhage: The Swiss Study on Subarachnoid Hemorrhage (Swiss SOS). Stroke 2021; 52:344. 192. Tidswell P, Dias PS, Sagar HJ, et al. Cognitive outcome after aneurysm rupture: relationship to aneurysm site and perioperative complications. Neurology 1995; 45:875. 193. Scott RB, Eccles F, Molyneux AJ, et al. Improved cognitive outcomes with endovascular coiling of ruptured intracranial aneurysms: neuropsychological outcomes from the International Subarachnoid Aneurysm Trial (ISAT). Stroke 2010; 41:1743. 194. Mayer SA, Kreiter KT, Copeland D, et al. Global and domain-specific cognitive impairment and outcome after subarachnoid hemorrhage. Neurology 2002; 59:1750. 195. Hackett ML, Anderson CS. 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Medical complications after subarachnoid hemorrhage. Neurosurg Clin N Am 2010; 21:325. 210. Ayling OGS, Ibrahim GM, Alotaibi NM, et al. Anemia After Aneurysmal Subarachnoid Hemorrhage Is Associated With Poor Outcome and Death. Stroke 2018; 49:1859. 211. Butzkueven H, Evans AH, Pitman A, et al. Onset seizures independently predict poor outcome after subarachnoid hemorrhage. Neurology 2000; 55:1315. 212. Claassen J, Peery S, Kreiter KT, et al. Predictors and clinical impact of epilepsy after subarachnoid hemorrhage. Neurology 2003; 60:208. https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 38/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate 213. Gaist D, Vaeth M, Tsiropoulos I, et al. Risk of subarachnoid haemorrhage in first degree relatives of patients with subarachnoid haemorrhage: follow up study based on national registries in Denmark. BMJ 2000; 320:141. 214. Bor AS, Rinkel GJ, Adami J, et al. Risk of subarachnoid haemorrhage according to number of affected relatives: a population based case-control study. Brain 2008; 131:2662. Topic 1127 Version 39.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 39/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate GRAPHICS Glasgow Coma Scale (GCS) Score Eye opening Spontaneous 4 Response to verbal command 3 Response to pain 2 No eye opening 1 Best verbal response Oriented 5 Confused 4 Inappropriate words 3 Incomprehensible sounds 2 No verbal response 1 Best motor response Obeys commands 6 Localizing response to pain 5 Withdrawal response to pain 4 Flexion to pain 3 Extension to pain 2 No motor response 1 Total The GCS is scored between 3 and 15, 3 being the worst and 15 the best. It is composed of three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components of the GCS should be recorded individually; for example, E2V3M4 results in a GCS score of 9. A score of 13 or higher correlates with mild brain injury, a score of 9 to 12 correlates with moderate injury, and a score of 8 or less represents severe brain injury. Graphic 81854 Version 9.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 40/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Hunt and Hess grading system for patients with subarachnoid hemorrhage Grade Neurologic status 1 Asymptomatic or mild headache and slight nuchal rigidity 2 Severe headache, stiff neck, no neurologic deficit except cranial nerve palsy 3 Drowsy or confused, mild focal neurologic deficit 4 Stuporous, moderate or severe hemiparesis 5 Coma, decerebrate posturing Based upon initial neurologic examination. Adapted from: Hunt W, Hess R. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 1968; 28:14. Graphic 69179 Version 5.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 41/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate World Federation of Neurological Surgeons subarachnoid hemorrhage grading scale Grade GCS score Motor deficit 1 15 Absent 2 13 to 14 Absent 3 13 to 14 Present 4 7 to 12 Present or absent 5 3 to 6 Present or absent GCS: Glasgow Coma Scale. Data from: Report of World Federation of Neurological Surgeons Committee on a Universal Subarachnoid Hemorrhage Grading Scale. J Neurosurg 1988; 68:985. Graphic 65468 Version 3.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 42/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate [1] Fisher grade of cerebral vasospasm risk in subarachnoid hemorrhage Group Appearance of blood on head CT scan 1 No blood detected 2 Diffuse deposition or thin layer with all vertical layers (in interhemispheric fissure, insular cistern, ambient cistern) less than 1 mm thick 3 Localized clot and/or vertical layers 1 mm or more in thickness 4 Intracerebral or intraventricular clot with diffuse or no subarachnoid blood CT: computed tomography. Reference: 1. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by CT scanning. Neurosurgery 1980; 6:1. Graphic 81122 Version 4.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 43/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Modified Fisher (Claassen) subarachnoid hemorrhage CT rating scale Grade Head CT criteria 0 No SAH or IVH 1 Minimal SAH and no IVH 2 Minimal SAH with bilateral IVH 3 Thick SAH (completely filling one or more cistern or fissure) without bilateral IVH 4 Thick SAH (completely filling one or more cistern or fissure) with bilateral IVH CT: computed tomography; SAH: subarachnoid hemorrhage; IVH: intraventricular hemorrhage. From: Claassen J, Bernardini GL, Kreiter K, et al. E ect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke 2001; 32:2012. Graphic 57558 Version 5.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 44/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Ogilvy and Carter grading system to predict outcome for surgical management of intracranial aneurysms Criteria Points Age 50 or less 0 Age greater than 50 1 Hunt and Hess grade 0 to 3 (no coma) 0 Hunt and Hess grade 4 and 5 (in coma) 1 Fisher scale score 0 to 2 0 Fisher scale score 3 and 4 1 Aneurysm size 10 mm or less 0 Aneurysm size greater than 10 mm 1 Giant posterior circulation aneurysm size 25 mm or more 1 The total score ranges from 0 to 5, corresponding to grades 0 to 5 Adapted from: Ogilvy CS, Carter BS. A proposed comprehensive grading system to predict outcome for surgical management of intracranial aneurysms. Neurosurgery 1998; 42:959. Graphic 70705 Version 4.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 45/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Direct oral anticoagulant reversal agents for life-threatening bleeding (imminent risk of death from bleeding) Reversal agent (all are given intravenously) Anticoagulant Dabigatran (Pradaxa; oral thrombin inhibitor) Idarucizumab (Praxbind). Dose: 5 grams* Oral factor Xa inhibitors: Andexanet alfa (AndexXa). Dosing for the Apixaban (Eliquis) initial bolus and subsequent infusion depend on the dose level of the factor Xa inhibitor and Edoxaban (Lixiana, Savaysa) the interval since it was last taken. Rivaroxaban (Xarelto) OR- 4-factor PCC (Kcentra, Beriplex P/N, Octaplex). Dosing can be done with a fixed dose of 2000 units OR a weight-based dose of 25 to 50 units per kg. Reversal agents carry a risk of life-threatening thrombosis and should only be used under the direction of a specialist with expertise in their use and/or in a patient at imminent risk of death from bleeding. In general, a single dose is given; dosing may be repeated in rare situations in which the oral anticoagulant persists for longer in the circulation, such as severe kidney dysfunction. Andexanet dosing is as follows: If the patient took rivaroxaban >10 mg, apixaban >5 mg, or dose unknown within the previous 8 hours: Andexanet 800 mg bolus at 30 mg/minute followed by 960 mg infusion at 8 mg/minute for up to 120 minutes. OR- If the patient took rivaroxaban 10 mg or apixaban 5 mg, or if 8 hours have elapsed since the last dose of a factor Xa inhibitor: Andexanet 400 mg bolus at 30 mg/minute followed by 480 mg infusion at 4 mg/minute for up to 120 minutes. Refer to UpToDate topics on treatment of bleeding in patients receiving a DOAC or perioperative management of patients receiving a DOAC for additional information on administration, risks, and alternative therapies. DOAC: direct oral anticoagulant; PCC: prothrombin complex concentrate; FEIBA: factor eight inhibitor bypassing activity. If idarucizumab is unavailable, an activated PCC (FEIBA, 50 to 80 units per kg intravenously) may be a reasonable alternative. Graphic 112299 Version 9.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 46/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate External ventricular drain An external ventricular drain (EVD) is a small catheter inserted through the skull usually into the lateral ventricle, which is typically connected to a closed collecting device to allow for drainage of cerebrospinal fluid. The EVD can also be connected to a transducer that records intracranial pressure. Graphic 56391 Version 2.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 47/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Protocol for management of hyponatremia in patients with subarachnoid hemorrage For Na level <133 mEq/L or a decrease of 6 mEq/L in 24 to 48 hours: 1. NaCl tabs 3 g PO/NGT every 6 hours 2. Initiate 3 percent NaCl infusion at 20 mL/hour IV 3. Check serum Na every 6 hours a. If Na <130 mEq/L: Increase rate by 20 mL/hour (max rate = 80 mL/hour) If on hold at present, initiate 3 percent NaCl infusion at 20 mL/hour IV b. If Na = 130 to 135 mEq/L: Increase rate by 10 mL/hour (max rate = 80 mL/hour) If on hold at present, initiate 3 percent NaCl infusion at 10 mL/hour IV c. If Na = 136 to 140 mEq/L: No change d. If Na 140 mEq/L: Hold infusion NaCl: sodium chloride; PO: by mouth; NGT: nasogastric tube; IV: intravenously. Reproduced from: Woo CH, Roa VA, Sheridan W, Flint A. Performance characteristics of a sliding-scale hypertonic saline infusion protocol for the treatment of acute neurologic hyponatremia. Neurocrit Care 2009; 11:228, with kind permission from Springer Science + Business Media B.V. Copyright 2009. Graphic 65772 Version 15.0 https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 48/49 7/7/23, 11:27 AM Aneurysmal subarachnoid hemorrhage: Treatment and prognosis - UpToDate Contributor Disclosures Robert J Singer, MD No relevant financial relationship(s) with ineligible companies to disclose. Christopher S Ogilvy, MD Consultant/Advisory Boards: Cerevasc [Hydrocephalus]; Contour [Aneurysms]; Medtronic [Chronic subdural hematoma]. All of the relevant financial relationships listed have been mitigated. Guy Rordorf, MD No relevant financial relationship(s) with ineligible companies to disclose. Jos Biller, MD, FACP, FAAN, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Alejandro A Rabinstein, MD Grant/Research/Clinical Trial Support: Chiesi [Small investigator- initiated project]. Consultant/Advisory Boards: AstraZeneca [Secondary stroke prevention]; Brainomix [AI for stroke diagnostics]; Novo Nordisk [Stroke risk]; Shionogi [Stroke neuroprotection]. Other Financial Interest: Boston Scientific [Adverse event adjudication committee member for stroke risk reduction device in patients with atrial fibrillation]. All of the relevant financial relationships listed have been mitigated. Richard P Goddeau, Jr, DO, FAHA No relevant financial relationship(s) with ineligible companies to disclose. Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence. Conflict of interest policy https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis/print 49/49