Describe your initial management of this patient?

Key Principles

  • Secure the airway if obtunded
  • Instigate neuroprotective measures
  • Manage hypertension to prevent rebleeding whilst maintaining CPP
  • Secure the aneurysm early
  • Monitor for and manage complications
Resuscitation & Supportive Care
  • Consider need for intubation:
    • Intubation if not maintaining airway
    • May require semi-elective intubation if not protecting adequately or for neuroprotective measures
    • Tape tube in position
  • Manage hypertension / hypotension
    • Until aneurysm secured target systolic blood pressure <180mmHg-160mmHg (ESO/AHA)
    • If required use a titratable IV antihypertensive and invasive arterial monitoring
    • Maintain MAP >90mmHg (ESO)
  • Manage arrhythmias
  • Manage seizures with benzodiazepines, phenytoin and levetiracetam
  • Instigate appropriate neuroprotective measures:
    • Maintain CO2 4.5-6.0 kPa, pO2 >10
    • Sit up, avoid neck lines
    • Analgesics, laxatives, antiemetics to reduce ICP
  • Maintain glucose 6-10mmol and temperature <37.5
  • Careful management of fluids:
    • Urinary catheter and fluid balance monitoring for all patients
    • Aim for euvolaemia
  • Reverse any coagulopathy
  • DVT prophylaxis:
    • Mechanical methods until aneurysm secured
    • LMWH >12 after surgical clipping
Specific Management

Secure the aneurysm:

  • Should be secured within 72 hours
  • Multi-disciplinary decision based on patient and aneurysm characteristics
    • Coiling: first line as better functional outcomes at one year
    • Clipping: for those not amenable to coiling (anatomically and location)
  • Consider tranexamic acid if likely to be a delay in securing aneurysm

Manage complications:

  • Prevention and management of vasospasm:
    • Physical: Targeted hypertensive therapy, maintain euvolaemia
    • Pharmacological: nimodipine prevent hypomagnesemia:
      • Start immediate nimodipine 60mg 4 hourly NG/PO
    • Interventional: Intra-arterial stenting, intra-arterial nimodipine
  • Treat hydrocephalus
    • Emergency EVD placement if obtunded
    • Consider osmotic therapy as temporising measure
Referral & Deposition
  • Needs urgent discussion with neurosurgical teamBest managed at high volume centres with neurosurgical and IR services
  • Operating theatre if urgent EVD placement required
  • ICU if intubated or Neuro HDU prior to securing aneurysm
  • Consider need for cerebral oxygen / pressure monitoring