Table 1 List of consensus recommendations
N. | Recommendation | Level |
|---|---|---|
1 | We recommend the utilization of intraoperative (if available) and postoperative imaging to verify the correct management of the aneurysm/s and to exclude cerebral ischemia/bleeding related to the procedure (agreement 95.5%, strong recommendation). | Strong recommendation |
2 | We recommend, as soon as possible after cerebral aneurysm/s securing, the assessment of the neurological status excluding confounders such as sedation, hypo/hyperthermia, hypoxia, and hypercapnia. Contraindications to sedation hold can be only ICP instability, radiological signs of intracranial hypertension, and severe respiratory failure. | Strong recommendation |
3 | We recommend to monitor the patient with repeated neurological and/or TCD/TCCD examinations to raise the suspect of DCI associated with cerebral vasospasm. | Strong recommendation |
4 | We recommend, regarding neurological examination, to consider as suggestive of DCI-related vasospasm, the occurrence of a new focal or a global neurologic deficit or a decrease of 2 or more points on the GCS score that lasts for at least 1 h and cannot be explained by another cause. | Strong recommendation |
5 | We recommend, regarding TCD/TCCD examination, to consider signs suggestive of vasospasm: an increase in mean FVMCA of more than 50 cm/s from basal over 24 h and/or a mean FVMCA of at least 120 cm/s (with a suggestive Lindegaard ratio). | Strong recommendation |
6 | We recommend the utilization of CTA and/or DSA to confirm the presence of cerebral vasospasm as the cause of the DCI in case of neurological examination or TCD/TCCD suggestive for vasospasm. | Strong recommendation |
7 | We recommend, in SAH patients with DCI related to cerebral vasospasm, the utilization of advanced perfusion imaging (i.e., CT perfusion, MRI perfusion) to early assess the development of ischemic brain lesions. | Strong recommendation |
8 | We recommend, after cerebral aneurysm/s treatment, in patients without intracranial hypertension and vasospasm, the maintenance of a MAP between 80 and 100 mmHg. | Strong recommendation |
9 | We recommend the maintenance of MAP values close to the lower limit (80 mmHg) for patients without a history of arterial hypertension. | Strong recommendation |
10 | We recommend the maintenance of MAP values close to the upper limit (100 mmHg) for patients with a history of arterial hypertension. | Strong recommendation |
11 | We recommend the maintenance of a CPP ≧ 70 mmHg in patients with intracranial hypertension. | Strong recommendation |
12 | We recommend the maintenance of euvolemia in all salvageable poor-grade SAH patients. | Strong recommendation |
13 | We recommend that oral nimodipine (60 mg every 4 h) be administered (as the first choice) for 21 days after bleeding for DCI prevention. | Strong recommendation |
14 | We recommend the administration of intravenous nimodipine (2 mg/h) in case of feeding intolerance. | Weak recommendation |
15 | We recommend against the administration of oral/intravenous nimodipine in hemodynamically unstable SAH patients (i.e., under inotropes and/or vasopressors therapy). | Weak recommendation |
16 | We recommend to withhold oral/intravenous nimodipine in case of a significant drop in arterial blood pressure (see recommendation 8). | Strong recommendation |
17 | We recommend the maintenance of a magnesium blood level in the normal ranges in all SAH patients for 21 days after bleeding for vasospasm prevention. | Strong recommendation |
18 | We recommend the maintenance of a Hb level > 8 gr/dl in poor-grade SAH patients without DCI-related vasospasm. | Strong recommendation |
19 | We recommend a continuous BCT monitoring in poor-grade SAH patients. | Strong recommendation |
20 | Being fever (regardless of the cause that needs to be investigated) associated with poor outcome after SAH, we recommend the administration of antipyretics for a BCT > 37.5 in poor-grade SAH patients without DCI-related vasospasm. | Strong recommendation |
21 | We recommend ICP monitoring in all salvageable SAH patients in coma (GCS ≤ 8) with radiological signs of intracranial hypertension. | Strong recommendation |
22 | We recommend the management of elevated ICP in all salvageable SAH patients (aneurysm/s secured) taking into account the underlying pathophysiological mechanism responsible of intracranial hypertension. | Strong recommendation |
23 | We recommend, in case of DCI associated with cerebral vasospasm (symptomatic vasospasm), hemodynamic optimization increasing arterial blood pressure as first step of treatment. | Strong recommendation |
24 | We recommend that hemodynamic optimization (i.e., gradual increase of MAP) should be targeted to the resolution of clinical symptoms and/or radiological findings. This process should take into account the patient’s cardiovascular status to minimize the risks associated with MAP augmentation. | Strong recommendation |
25 | We recommend, in case of DCI associated with cerebral vasospasm (symptomatic vasospasm) refractory to an increase in arterial blood pressure (MAP not greater than 120 mmHg), the utilization of invasive intra-arterial procedures. | Strong recommendation |
26 | We recommend that the choice of intra-arterial procedure (i.e., vasodilators, angioplasty) be individualized after discussion with the interventional neuroradiologist (see recommendation 25). | Strong recommendation |
27 | We recommend the maintenance of an Hb level > 9 gr/dl in case of DCI associated with cerebral vasospasm. | Strong recommendation |
28 | We recommend the maintenance of normothermia (a BCT between 36 and 37 °C) in case of DCI associated with cerebral vasospasm. | Strong recommendation |
29 | We recommend that CT perfusion and/or advanced multimodal neuromonitoring (i.e., brain tissue oxygenation monitoring, etc.), if available, be utilized to guide (individualize) therapy for DCI associated with cerebral vasospasm in poor-grade SAH patients where neurological assessment is not possible. | Strong recommendation |
30 | We recommend the utilization of inotropes for refractory vasospasm with the utilization of an advanced hemodynamic monitoring. | Strong recommendation |
31 | We are unable to provide any recommendation regarding the utilization of therapeutic hypothermia in case of DCI related to refractory vasospasm. | No recommendation |
32 | We are unable to provide any recommendation regarding the utilization of metabolic suppression in case of DCI related to refractory vasospasm. | No recommendation |
33 | We are unable to provide any recommendation regarding the utilization of milrinone in case of DCI related to refractory vasospasm. | No recommendation |