Treating Brain Hemorrhage Early Improves Outcomes
Treating brain bleeding quickly, and at hospitals that handle many brain attack emergencies can help ensure the best outcomes for patients, according to updated guidelines published today in Stroke: Journal of the American Heart Association.
“A sudden, severe headache (sometimes described as “the worst headache of my life”) should raise suspicion of a subarachnoid hemorrhage, and patients and healthcare providers should treat it as a serious emergency,” said Joshua Bederson, M.D., chair of the guidelines committee and chairman of the Mount Sinai Medical Department of Neurosurgery in New York City. “It’s very important for people to know the signs of a brain bleed and know to get help quickly. Treatment protocols are most effective when we can get to the patient early.”
Subarachnoid hemorrhage (SAH) occurs when a blood vessel bursts and bleeds into the subarachnoid space in the brain (the lining between the surface of the brain and the brain tissue). Most SAHs are caused by a ruptured aneurysm, but there are other causes, such as trauma to the head. The death rate for SAH is about 45 percent in the first 30 days after the event, and about half of survivors are significantly impaired.
An aneurysm is a small, ballooned-out area of a blood vessel that is weaker than the rest of the vessel wall. It forms over several years in young and middle-aged adults.
“The majority of aneurysms do not rupture, and as much as 1 percent of the population dies of old age with a small, unruptured aneurysm,” said Bederson.
Since the American Heart Association last released guidelines in 1994, advances in the field include developments to treat multiple, simultaneous pathological processes that occur at the onset of the hemorrhage, he said.
Highlights of the updated guidelines are:
• Early definitive aneurysm treatment is indicated for most patients, and can reduce death and disability.
• SAH – one of the most deadly neurological emergencies – is misdiagnosed as often as 12 percent of the time, with a four-fold greater likelihood of death or disability in misdiagnosed patients. “The most common diagnostic error is failure to obtain a CT scan. When patients complain of severe headache with acute onset, doctors should look for a subarachnoid hemorrhage,” Bederson said.
• Receiving care at institutions offering both endovascular and cerebrovascular surgical expertise is highly beneficial to the SAH patient, and high-volume institutions have significantly better outcomes than low-volume hospitals with less experience treating these patients.
• “The triage of acute neurological disorders to designated stroke centers is most likely very beneficial for patients with subarachnoid hemorrhage,” Bederson said.
• Noninvasive diagnostic imaging tools developed in the last 15 years are often excellent alternatives to catheter angiography. CT angiography and magnetic resonance angiography have evolved significantly since 1994, and small aneurysms can be detected with much greater reliability now than they used to be, Bederson said. However, catheter angiography remains the gold standard for detecting aneurysms and directing treatment.
• Standardized protocols are necessary for managing these patients — particularly in the early stages — in the emergency department.
• Since 1994, a new medical specialty called neuro critical care has evolved, made up of fellowship-trained neurologists, neurosurgeons and others for the optimal management these complex patients.
• Endovascular coiling, which involves treating the aneurysm through a catheter, can be beneficial in selected cases. It’s often performed to avoid brain surgery.