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Causes of Subarachnoid Hemorrhage

Discuss about the Neuroscience Nursing: Subarachnoid Hemorrhage.

Rupture of the Middle Cerebral Artery aneurysm results in the development of approximately 80% of the cases of subarachnoid hemorrhage that are non-traumatic. These aneurysms predominantly develop at the branching points or vessel bifurcations. Middle cerebral artery aneurysm is a type of intracranial aneurysm (also known as berry aneurysms) and most of these occur near or within the circle of Willis (Wen et al. 2012, pp.688-699). However, the most common location of the intracranial aneurysms is at the anterior communicating artery and the middle cerebral artery bifurcation and collectively constitutes about 60% of the overall aneurysms. 10 – 20% of the aneurysms develop at the basilar and vertebral arteries (Zanaty et al. 2014, pp.381-387). Subarachnoid hemorrhage is responsible for about 6% of the cases of strokes and affects about 6 to 9 people in a population of 100,000. About 85% of the patients suffer bleeding due to intracranial aneurysms and 10% from the non-aneurysmal and prei-mesencephalic hemorrhage (Pierot et al. 2013, pp.27-35). 5% of the bleeding is attributed to the vascular abnormalities that include vasculitis, arteriovenous malformation and tumor-associated abnormal blood vessels. The mean age of occurrence is 50 years, affects the younger population and women are at a higher risk compared to men for subarachnoid hemorrhage (Kalani et al. 2013, pp.428-436). Furthermore, numerous researches have been carried out till date on subarachnoid hemorrhage however, limited study has been conducted to explain the neurosurgical interventions of middle cerebral artery aneurysm with a subarachnoid hemorrhage. In this assignment, the researcher will carry out an extensive literature review to determine the neurological interventions of middle cerebral artery aneurysm with a subarachnoid hemorrhage from the primary sources.

Diringer (2009, p.432) carried out a study to demonstrate the management of the subarachnoid hemorrhage due to the rupture of the intracranial aneurysm. The article has demonstrated a detailed encounter of the pathological condition with the prevailing consequences and the required interventions. Neurological interventions presented in this article included neurological function assessment with angiography preparation. Neurological deterioration has been identified as the chief symptom of the disorder with seizures. This article was beneficial in understanding the condition from the neurological aspect however, much attention was not given to the management of the disease from the neurological perspectives with a deeper understanding of the various parameters of intervention. Similarly, The complications of the disease and their management have been well discussed with provision of the early clinical care management with common pharmacological interventions The main arguments raised by the article stated that blood vessels get constricted because of the pathological changes, relaxation of the intracranial arteries are impaired followed by the narrowing of the lumen and thickening of the wall. These results in a decrease in the cerebral blood flow that causes infarction and ischemia. The article has well explained the pathophysiology that was well supported by the medical intervention which stated that catheter angiography and transcranial Doppler can be employed for measuring the velocities of blood flow. On the other hand, the management can be done by several prophylactic measures and nimodipine is the preferred pharmacological intervention for vasospasm. Lumbar CSF draining has been the proposed non-pharmacological intervention for preventing the accumulation of blood in the subarachnoid space and reduces the risk of occurrence of vasospasm. 

Neurological Interventions for Subarachnoid Hemorrhage Management

In contrast with the previous article, another similar article by Connolly et al. (2012, pp.1711-1737) took the argument forward for narrowing the gaps from the previous study by stating the guidelines related to the management of the aneurismal subarachnoid hemorrhage. One of the neurological interventions discussed in this article is cerebral angiography and it has been identified as a widely used technique for the condition. Although it has been accepted that computed tomographic angiography is the best intervention process for the treatment of aneurysm with surgical clipping, it is still a controversy to determine whether its usage is suitable in cases where endovascular therapy can be an alternative. The authors carried out an exceptionally detailed identification of the various technological specifications of the instruments and concluded that 3-dimensional cerebral angiography was found to be more effective and sensitive than its 2-dimensional counterpart. The article did a thorough discussion of the treatment of the cerebral aneurysms by pharmacological and non-pharmacological interventions. Medical measures should be adopted for the early treatment for reducing the risk of re-bleeding due to ruptured middle cerebral artery aneurysm. For this, acute hypertension resulting out of aneurismal subarachnoid hemorrhage has to be controlled with medications like nicardipine as it provides smoother control of blood pressure over sodium nitroprusside and labetalol. Antifibrinolytic therapy has also been found to be effective in reducing aneurysm re-bleeding in case of delayed aneurysm obliteration. Endovascular and surgical methods for the treatment of ruptured middle cerebral artery aneurysm includes microsurgical clip obliteration and the article provided sufficient evidence to support the efficacy of this method. Furthermore, arguments have been placed by the author stating that aneurysm recurrence and incomplete occlusion is critically dependent on the dome size and the neck diameter. Increasing the rate of complete obliteration is possible by the inclusion of high porosity stent, it should be supported with dual-antiplatelet periprocedural therapy for the prevention of the arterial thromboembolism. Microsurgical approaches with pure platinum coils are the method of choice for the current endovascular technology. It is difficult to treat middle cerebral artery aneurysm by the method of coil embolization and therefore, surgical treatment is the best possible option for its treatment. This article was very informative but lacked in several other aspects of nursing intervention for the treatment of the condition.

An argument was put forward by Mery, Amin-Hanjani and Charbel (2008, pp.979-982) stated that the ICG (intraoperative indocyanine green) video angiography for the confirmation of aneurysm obliteration is not secure and there have been cases reporting rupture and growth of the angiographically obliterated aneurysms. ICG video angiography is a valuable tool that is employed when the features of aneurysms are complex and direct clipping becomes challenging. Its efficacy can also be compared with catheter intraoperative angiography. However, the study demonstrated that ICG had a false indication of the aneurysm obliteration and applies to the catheter angiography. Therefore, follow up on a long term basis is recommended with angiographic evaluation with cerebral angiogram for the securing of aneurysm.

Pharmacological Interventions for Subarachnoid Hemorrhage Management

To discuss on the management of subarachnoid bleeding with special focus on normalizing cerebral perfusion pressure, a research work was conducted by Umamaheswara Rao (2007, p.12) to demonstrate the pharmacological management of traumatic brain injury based on cerebral perfusion pressure. The author demonstrated cerebral perfusion pressure as the difference between the intracranial pressure and the mean arterial pressure. Subarachnoid hemorrhage due to middle cerebral artery aneurysm is a form of brain injury and its management includes drainage of cerebrospinal fluid through ventriculostomy, systemic vasopressor and vascular expansion. On the other hand, pharmacological interventions include mannitol in the dose of 0.5-1.0g/kg for maintaining the cerebral perfusion pressure at 70mmHg and albumin infusions for mobilization of the extracellular water into the intravascular compartment. Norephinephrine or phenylephrine without or with dopamine is used for achieving the required mean arterial pressure.. However, the non-pharmacological interventions were missing in this article and to research further on this aspect, the literature search was carried on.


For carrying forward the argument, a similar study was carried out by (Meyer et al. 2010, pp.706-721) suggested some other pharmacological interventions for improving the neural recovery after the aneurysmal subarachnoid hemorrhage. The other pharmacological interventions include midazolam, opioids, barbiturates, propofol, and hypertonic saline. However, the researchers argued that the cannabinoids were found to be ineffective and the corticosteroids were reported to be contraindicated in the treatment of the condition. Similarly, the long term benefits from these interventions rarely resulted in the improved and long-term outcomes for the patient. This suggested that further investigation is required to identify the non-pharmacological interventions for the management.

As a support and continuation to the previous study, Meyer et al. (2010, pp.694-705) carried out a review to determine the non-pharmacological interventions for managing and maintaining cerebral perfusion pressure and blood pressure. This study demonstrated the non-pharmacological interventions in alignment with the findings from the previous study and was a conglomeration of the findings from several other studies. The nursing interventions proposed in this study include adjustment of the head posture, rotation of the body position, hyperbaric oxygen, hypothermia and hyperventilation. Elevation of the head over the heart level reduces intracranial pressure by the facilitation of the venous outflow without adjusting the cardiac output and cerebral perfusion pressure. Therapy of continuous is used for avoiding the complications due to immobilization that includes pulmonary emboli, deep vein thrombosis and bedsores. Prone position increases cerebral perfusion pressure and oxygenation in the patients with acute respiratory insufficiency. Hyperventilation causes cerebral vasoconstriction that leads to the reduction in cerebral blood volume and cerebral blood flow. Hypothermia is regarded as a neuro-protective strategy used for reducing cerebral damage due to aneurysm and it exerts the effects of neuro-protection by the reduction of neuronal metabolism. Subarachnoid hemorrhage might cause hypoxia and brain hypoperfusion and hyperbaric oxygen increases the partial pressure of oxygen that enters the brain for reducing the deleterious effects of hypoxia. On the other hand, two of the invasive procedures discussed in the study are decompressive craniectomy and cerebrospinal fluid drainage. Cerebral perfusion pressure is maintained by decompressive craniectomy by managing the elevated pressure through surgical removal of a section of the skull and limits the damage. Elevated cerebral perfusion pressure and blood pressure is controlled by ventricular cerebrospinal fluid drainage and it is done with the insertion of catheters in the brain. Analyzing both the studies for pharmacological and non-pharmacological interventions, it can be stated that the different regions of the brain requires different cerebral perfusion pressure levels at different points of time after the rupture of the middle cerebral artery aneurysm with subarachnoid hemorrhage. Optimal cerebral perfusion pressure is an imaginary concept and the techniques of brain monitoring like cerebral microdialysis, monitoring of oxygen tension in brain tissues and jugular venous oximetry provides specific and complimentary information. Based on this, the best cerebral perfusion pressure and blood pressure is selected for maintenance for a patient over the time.

Non-Pharmacological Interventions for Subarachnoid Hemorrhage Management

The feasibility of the previous study was established by critically appraising the research work carried out by Damkliang et al. (2015, pp. 3365-3373) which stated that evidence-based care bundle could be an effective nursing intervention for the management of the aneurysmal subarachnoid hemorrhage. The non-pharmacological interventions learnt from this article were monitoring of end-tidal carbon dioxide, assessment frequency of blood pressure, respiratory rate and pulse rate and patient positioning.

This argument was further carried over by Abd-Elsayed, Wehby and Farag (2014, pp.418-425) where the researchers stated that anesthetic management of intracranial aneurysm is possible to prevent hemorrhagic stroke. High blood pressure should be avoided to prevent aneurysm rupture and further damage and low blood pressure must be avoided to reduce the cerebral perfusion pressure. Similarly, the preferred colloid is albumin and erythropoietin has been effective in lowering the vasospasm incidence and delaying cerebral ischemia.


For a patient suffering from ruptured middle cerebral artery aneurysm with subarachnoid hemorrhage, fluid and electrolyte management is another crucial intervention that forms a part of the neurosurgical management of the condition. To elaborate this fact, D’Souza (2015, p.222) carried out a study on aneurysmal subarachnoid hemorrhage and its management through various interventions. Patients are likely to suffer from the fluid and electrolyte abnormalities in case of intracranial aneurysm as a part of neuroendocrine abnormalities. On the other hand, hyponatremia is a more common occurrence under such circumstances while hypernatremia is a lesser occurring sequence. Hyponatremia is a condition that co-exists due to two factors which includes syndrome of inappropriate antidiuretic hormone secretion and the syndrome of cerebral salt washing. Its etiology is has been considered as multifactorial and includes the elevated levels of natriuretic peptides, angiotensin-II, renin and hypoaldosteronism. Hypernatremia is also seen in the patients suffering from subarachnoid hemorrhage and is considered to be iatrogenic that is secondary to hypertonic saline or mannitol infusion. While hyponatremia is not associated with mortality, hypernatremia is associated with it. Solutions containing glucose should be avoided as hyperglycemia gets aggravates global and focal transient cerebral ischemia. Therefore, proper balance of fluid and electrolytes is essential in case of subarachnoid hemorrhage.

In context to the neurological assessment and risk of aneurysmal subarachnoid hemorrhage, Taki et al. (2011, pp. 437-445) carried out a study to examine the poor outcomes of the treatment of the ruptured aneurysms with either endovascular treatment or microsurgery. It was a cohort study which demonstrated that the ischemic and thromboembolic events are the well known risks during the process of coiling. The other complications found were post coiling ischemic complications and post-clipping hemorrhagic complications that had an independent and significant impact on the poor outcome after the aneurysmal subarachnoid hemorrhage. Larger size of the aneurysms is associated with increased complication risks by modality and smaller aneurysms are difficult to treat with the application of coiling. The commonly used neurological assessments for aneurysmal subarachnoid hemorrhage are TCD (Transcranial Doppler) and NIRS (Near-Infrared Spectroscopy). It is difficult to perform neurological assessment in the patients who are in a state of unconsciousness (Budohoski et al. 2012, pp. 3230).


To further progress the research, Guida et al. (2012, p.59) carried out a study to demonstrate that pregnancy is a risk factor in case of aneurysmal subarachnoid hemorrhage. It can be devastating for both the child and the mother if the condition occurs in times of pregnancy. Appropriate treatment and early diagnosis are the only ways to survive and therefore, in case of pregnant women presenting with acute headache, seizures, palsy or nuchal rigidity, the gynecologists and obstetricians should be familiar with these nosocomial entity. Involvement of a neuroradiologist and neurosurgeon will play an exceptionally crucial role in the management of aneurysmal subarachnoid hemorrhage in pregnant women. In such cases, endovascular coiling is most effective for reducing bleeding.

Vasospasm is a major complication in case of aneurysmal subarachnoid hemorrhage and to explore the management of the condition, Gump and Laskowitz (2008, pp.354-360) carried out a study to identify and manage this post-hemorrhagic complication. Identification of vasospasms is carried out angiographically, by clinical signs of regional or focal ischemia and by significant reduction that is visible in the diameters of arterial lumen. The common risk factor for the development of vasospasm includes distribution and volume of the subarachnoid blood and the preventive measures are not effective. The treatment strategies adopted for the management of vasospasm includes angioplasty, hyperdynamic therapy and the intra-arterial injection of the vasodilators. However, the strategies of novel treatment focus on protection of the cerebrum, identification of the genetic factors that are predisposed towards vasospasm and targeting the inflammatory cascade components.

This finding was further argued by Schmidt et al. (2010, pp.895-902) who proposed pharmacological management of vasospasm in case of post-aneurysmal subarachnoid hemorrhage. The researchers found that the intraarterial administration of milrinone and nicardipine requires using vasopressors for maintaining the arterial blood pressure. It was proved from the findings that even with higher doses of the vasoconstrictors, the mortality rate was low and systemic acidosis or the end organ ischemic damage was minimal. It also improved the efficiency of the cerebral vessels that were affected by vasospasm.

From the review of the literatures, it is evident that ruptured middle cerebral artery aneurysm with subarachnoid hemorrhage is a global health burden with permanent disability and higher fatality rates. Considering the death rate and global burden of the disease from the past decade, there has been an increase in the routine mortality data that went on to include one-third of the population of the world. The overall prognosis is dependent on the volume of the delayed cerebral ischemia, rebleeding and initial bleed. Neurogenic pulmonary edema and cardiac manifestations are the severity of the condition (Miura et al. 2013, pp.519-521). Although extensive research has been done to investigate the identification and management of the condition, more research is needed for investigating the preventive measures for the occurrence of intracranial aneurysms and aneurysmal subarachnoid hemorrhages. Although appropriate neurological interventions are available, the mortality and morbidity rates are high with multifactorial pathophysiology that is not yet understood (Rodríguez-Hernández et al. 2013, pp.415-427). The body of evidence for the management of the condition is gradually expanding and several trials are ongoing that might bring about results for enhancing and improving the short term and long term patient outcomes.

References

Abd-Elsayed, A.A., Wehby, A.S. and Farag, E., 2014. Anesthetic management of patients with intracranial aneurysms. The Ochsner Journal,14(3), pp.418-425.

Budohoski, K.P., Czosnyka, M., Smielewski, P., Kasprowicz, M., Helmy, A., Bulters, D., Pickard, J.D. & Kirkpatrick, P.J. 2012, "Impairment of cerebral autoregulation predicts delayed cerebral ischemia after subarachnoid hemorrhage: a prospective observational study", Stroke; a journal of cerebral circulation, vol. 43, no. 12, pp. 3230.

Connolly, E.S., Rabinstein, A.A., Carhuapoma, J.R., Derdeyn, C.P., Dion, J., Higashida, R.T., Hoh, B.L., Kirkness, C.J., Naidech, A.M., Ogilvy, C.S. and Patel, A.B., 2012. Guidelines for the management of aneurysmal subarachnoid hemorrhage a guideline for healthcare professionals from the American heart association/American stroke association. Stroke, 43(6), pp.1711-1737.

D’Souza, S., 2015. Aneurysmal subarachnoid hemorrhage. Journal of neurosurgical anesthesiology, 27(3), p.222.

Damkliang, J., Considine, J., Kent, B. & Street, M. 2015, "Using an evidence‐based care bundle to improve initial emergency nursing management of patients with severe traumatic brain injury", Journal of Clinical Nursing, vol. 24, no. 23-24, pp. 3365-3373.

Diringer, M.N., 2009. Management of aneurysmal subarachnoid hemorrhage.Critical care medicine, 37(2), p.432.

Guida, M., Altieri, R., Palatucci, V., Visconti, F., Pascale, R., Marra, M., Locatelli, G., Saponiero, R., Tufano, R., Bifulco, F. and Piazza, O., 2012. Aneurysmal subarachnoid haemorrhage in pregnancy: a case series.Translational medicine@ UniSa, 2, p.59.

Gump, W. and Laskowitz, D.T., 2008. Management of post-subarachnoid hemorrhage vasospasm. Current atherosclerosis reports, 10(4), pp.354-360.

Kalani, M.Y.S., Zabramski, J.M., Hu, Y.C. and Spetzler, R.F., 2013. Extracranial-intracranial bypass and vessel occlusion for the treatment of unclippable giant middle cerebral artery aneurysms. Neurosurgery, 72(3), pp.428-436.

Mery, F.J., Amin-Hanjani, S. and Charbel, F.T., 2008. Is an angiographically obliterated aneurysm always secure?. Neurosurgery, 62(4), pp.979-982.

Meyer, M.J., Megyesi, J., Meythaler, J., Murie-Fernandez, M., Aubut, J.A., Foley, N., Salter, K., Bayley, M., Marshall, S. and Teasell, R., 2010. Acute management of acquired brain injury part I: an evidence-based review of non-pharmacological interventions. Brain injury, 24(5), pp.694-705.

Meyer, M.J., Megyesi, J., Meythaler, J., Murie-Fernandez, M., Aubut, J.A., Foley, N., Salter, K., Bayley, M., Marshall, S. and Teasell, R., 2010. Acute management of acquired brain injury part II: an evidence-based review of pharmacological interventions. Brain injury, 24(5), pp.706-721.

Miura, Y., Ishida, F., Umeda, Y., Tanemura, H., Suzuki, H., Matsushima, S., Shimosaka, S. and Taki, W., 2013. Low wall shear stress is independently associated with the rupture status of middle cerebral artery aneurysms.Stroke, 44(2), pp.519-521.

Pierot, L., Klisch, J., Cognard, C., Szikora, I., Mine, B., Kadziolka, K., Sychra, V., Gubucz, I., Januel, A.C. and Lubicz, B., 2013. Endovascular WEB flow disruption in middle cerebral artery aneurysms: preliminary feasibility, clinical, and anatomical results in a multicenter study.Neurosurgery, 73(1), pp.27-35.

Rodríguez-Hernández, A., Sughrue, M.E., Akhavan, S., Habdank-Kolaczkowski, J. and Lawton, M.T., 2013. Current management of middle cerebral artery aneurysms: surgical results with a “clip first” policy.Neurosurgery, 72(3), pp.415-427.

Schmidt, U., Bittner, E., Pivi, S. and Marota, J.J., 2010. Hemodynamic management and outcome of patients treated for cerebral vasospasm with intraarterial nicardipine and/or milrinone. Anesthesia & Analgesia, 110(3), pp.895-902.

Taki, W., Sakai, N., Suzuki, H. & PRESAT Group 2011, "Determinants of poor outcome after aneurysmal subarachnoid hemorrhage when both clipping and coiling are available: Prospective Registry of Subarachnoid Aneurysms Treatment (PRESAT) in Japan", World neurosurgery, vol. 76, no. 5, pp. 437-445.

Umamaheswara Rao, G.U., 2007. Cerebral perfusion pressure based management of traumatic brain injury. Internet J Anesthesiol, p.12.

Wen, H.T., Rhoton Jr, A.L., Figueiredo, E.G. and Teixeira, M.J., 2012. Middle cerebral artery aneurysms. Ã¨â€žÂ³Ã§Â¥Å¾Ã§ÂµÅ’外科ジャーナル, 21(9), pp.688-699.

Zanaty, M., Chalouhi, N., Tjoumakaris, S.I., Gonzalez, L.F., Rosenwasser, R. and Jabbour, P., 2014. Flow diversion for complex middle cerebral artery aneurysms. Neuroradiology, 56(5), pp.381-387.

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