Step 13: Look for ECG changes

•Alterations of the electrocardiogram are the most frequent cardiac abnormality in patients with SAH due to sympathetic activation causing reversible cardiac injury.

•These include prolongation of the QT interval, ST segment elevation or depression, and increased amplitude or deep inversion of the T waves (“cerebral” T waves).

•These are believed to be caused by a derangement of autonomic control of the heart and usually do not require treatment.

•Occasionally, arrhythmias may be precipitated, which need to be managed accordingly (see Chap. 22).

Step 14: Prognostication

•Unfavorable outcome was associated with increasing age, worsening neurological grade, ruptured posterior circulation aneurysm, larger aneurysm size, more SAH on admission computed tomography, intracerebral hematoma or intraventricular hemorrhage, elevated systolic blood pressure on admission, fever 8 days after SAH, use of anticonvulsants, symptomatic vasospasm and cerebral infarction.

•The use of prophylactic or therapeutic hypervolemia or induced hypertension was associated with a lower risk of unfavorable outcome.

Suggested Reading

1.E. Sander Connolly, Jr, Alejandro A. Rabinstein et al. Guidelines for the management of aneurysmal subarachnoid haemorrhage. A statement for healthcare professionals from, American Heart Association./American stroke Association. Stroke 2012;43:1711–1737.

These recommendations are intended to summarize the best available evidence for treatment of patients with aneurysmal SAH and to identify areas of future research. Treatments for specific patients need to be individualized.

2.Selman WR, Hsu D, Tarr RW, Ratcheson RA. Intracranial aneurysms and subarachnoid haemorrhage. In: Bradley WG, editors. Neurology in clinical practice. 5th ed., Vol. II. Philadelphia: Butterworth-Heinemann; 2008. p. 1243–58.

3.Chumnanvej S, Dunn IF, Kim DH. Three-day phenytoin prophylaxis is adequate after subarachnoid hemorrhage. Neurosurgery. 2007;60(1):99–102.

A 3-day regimen of phenytoin prophylaxis was found to be adequate to prevent seizures in subarachnoid hemorrhage patients. Drug reactions were significantly reduced, but seizures rates did not change paradigm.

4.Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38:2315–21.

Although most prognostic factors for outcome after SAH are present on admission and are not modifiable, a substantial contribution to outcome is made by factors developing after admission and which may be more easily influenced by treatment.

Websites

1.http://www.strokeahajournals.org Updated Guidelines on SAH