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New AHA SAH Guidelines – Spoon-Feed Version

June 28, 2023

Written by Carmen Wolfe

Spoon Feed
Aneurysmal subarachnoid hemorrhage (aSAH) is a deadly condition. Here’s a quick summary of the 40-page AHA/ASA evidence-based guidelines for diagnosis and management.

And the evidence says……
This clinical practice guideline is a monster review paper covering all aspects of care for aSAH. Here are the most important points for EM physicians:

  • Clinical decision rules: The Ottawa SAH rule is a sensitive tool that can rule out SAH in a small subset of patients without the need for imaging
  • Diagnostic pathways: If presenting within six hours of headache onset and without neurological deficit, a non-contrast head CT is sufficient to rule out SAH. If presenting after six hours or with a neurological deficit, a negative head CT should be followed by LP* to assess for xanthrochromia. They acknowledge that ACEP allows for LP or CTA as the next diagnostic step, but due to the imperfect sensitivity of CTA to detect aneurysms, especially small ones, they unequivocally recommend LP as the better choice.
  • Definitive treatment: Patients need repair of ruptured aneurysms as early as feasible, preferably < 24 hours, either through endovascular coiling or neurosurgical clipping.
  • Blood pressure management: Keep it steady. BP variability and excessive BP reductions are harmful. Evidence tells us that MAP should be > 65 mmHg but is insufficient to provide an exact ceiling target for systolic BP, though previous guidelines suggest < 160 or < 180.
  • Seizure prophylaxis: Prophylactic antiseizure meds aren’t routine after aSAH but may be recommended in high risk patients. Don’t use phenytoin; it’s associated with excess morbidity and mortality.
  • Transfer: Patients do better if treated by a multidisciplinary team in a high-volume center; get on the phone and arrange a transfer ASAP if necessary

How will this change my practice?
The AHA/ASA clearly recommends lumbar puncture after negative non-contrast head CT in the work-up for aSAH. I’ll add this information to the shared decision-making discussion I have with patients when faced with the need for further testing via LP or CTA.

*Editor’s note: There is low certainty evidence that the window of time after headache onset may be extended up to 24 hours when using modern CT scanners with superior imaging quality. ~Clay Smith

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 May 22. doi: 10.1161/STR.0000000000000436. Epub ahead of print.

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