Table 1 List of consensus recommendations
N. | Recommendation | Level |
|---|---|---|
1 | We recommend that all salvageable patients (i.e. patients who may recover, at least to some extent, with appropriate treatment) with a spontaneous SAH, according to local expertise and availability, must undergo a CTA or DSA. | Strong recommendation |
2 | We recommend that SAH patients in coma (GCS score ≤ 8) and/or with inadequate airway protection or respiratory failure need to be sedated, intubated and mechanically ventilated. | Strong recommendation |
3 | We recommend that SAH patients with severe agitation, despite mild sedation and pain control, need to be sedated, intubated and mechanically ventilated. | Strong recommendation |
4 | We recommend the maintenance of a PLTs count > 100.000/mm3 in all salvageable SAH patients candidates for neurosurgical intervention. | Strong recommendation |
5 | We recommend the reversal of antiplatelet drugs in all salvageable SAH patients, candidates for neurosurgical intervention. | Strong recommendation |
6 | We recommend the maintenance of a PT/aPTT value of < 1.5 normal control in all salvageable SAH patients. | Strong recommendation |
7 | We recommend the reversal of anticoagulant drugs in all salvageable SAH patients candidates for neurosurgical intervention. | Strong recommendation |
8 | We recommend, if available, the utilization of POC tests (e.g. TEG and ROTEM) to assess and optimize the coagulation function in salvageable SAH patients taking the NOACs and/or antiplatelets drugs. | Strong recommendation |
9 | We are unable to provide any recommendation regarding the routine administration of tranexamic acid for a short-term therapy (< 24 h from SAH) before aneurysm treatment to prevent rebleeding. | No recommendation |
10 | We recommend in all salvageable comatose SAH patients with acute hydrocephalus to rapidly undergo EVD placement before aneurysm management. | Strong recommendation |
11 | We recommend, before aneurysm treatment, for the management of intracranial hypertension related to acute hydrocephalus, the drainage (EVD available) of small volumes of CSF to reduce the risk of rebleeding. | Strong recommendation |
12 | We recommend, in case of EVD placement before aneurysm/s management, the ICP monitoring, during endovascular coiling. | Strong recommendation |
13 | We recommend the maintenance of a SAP between 120 and 160 mmHg to avoid aneurysmal rebleeding and to ensure an adequate CPP. Individualized arterial pressure targets considering patient’s clinical history (i.e., arterial hypertension) and/or radiological signs of intracranial hypertension seem reasonable. | Strong recommendation |
14 | We recommend the maintenance of SAP values close to the lower limit (120 mmHg) in patients without a history of arterial hypertension and/or radiological signs of elevated ICP. | Strong recommendation |
15 | We recommend the maintenance of SAP values close to the upper limit (160 mmHg), avoiding fluctuations, for patients with a history of arterial hypertension and/or radiological signs of elevated ICP. | Strong recommendation |
16 | We recommend, in case of ICP monitoring, the maintenance of a CPP of 70 mmHg*. * for an accurate CPP estimation the arterial transducers need to be zeroed at the level of the tragus. | Strong recommendation |
17 | We recommend against seizure prophylaxis in salvageable SAH patients without seizures (observed clinically and/or with EEG). | Strong recommendation |
18 | We recommend that ruptured cerebral aneurysm/s be secured early according to local protocols and resources. | Strong recommendation |
19 | We recommend a strict collaboration between the interventional neuroradiologist, the neurosurgeon, the neurointensivist/anesthesiologist to find the best strategy (clips or coils) to secure the ruptured cerebral aneurysm/s. | Strong recommendation |