Perioperative Management of Severe Subarachnoid Hemorrhage

Abstract

In cases of ruptured cerebral aneurysmal subarachnoid hemorrhage, effective perioperative management is crucial before and after addressing the source of bleeding. Preoperative strategies aimed at reducing the risk of rebleeding include the use of intravenous anesthesia and a moderate reduction in blood pressure. However, the effectiveness of other management approaches, such as administering antifibrinolytic agents, conducting platelet transfusions during antiplatelet therapy, reversing anticoagulants, and applying ventricular drainage, remains unclear.

Postoperative care primarily focuses on the prevention and treatment of cerebral vasospasms. The differences in the effectiveness of clazosentan observed in domestic versus international trials may stem from variations in the dosage or application of combination therapies. Lumbar drainage may decrease the risk of secondary infarction at the time of discharge and improve neurological outcomes at six months.

Other postoperative strategies, such as liberal transfusion practices and the use of prophylactic anti-convulsants, have not been shown to improve outcomes. Conditions such as hyponatremia and meningitis may worsen vasospasms. Additionally, It is important to approach treatment withdrawal during the acute phase with caution, as some patients with severe conditions can still achieve independence due to the ambiguity in predicting their prognosis.

Furthermore, with Japan’s aging population, there are increasing concerns about the economic feasibility of ongoing therapy in the future.