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Monday, July 22, 2013
When you hear “sudden-onset, severe headache,” Chris Ogilvy, MD, (former, 2013) Director of Operative Neurovascular Surgery at Massachusetts General Hospital, wants you to think “aneurysmal subarachnoid hemorrhage.” It's not that these ruptures are that common—they account for only about 1% of all emergency department headaches, he says. “But if you miss it, the implications are huge.”
The best chance for a good outcome following aneurysmal subarachnoid hemorrhage comes from rapid diagnosis, rapid treatment by an experienced team, and extended post-treatment follow-up. That diagnosis most often arises in the emergency department, with a patient presenting with a sudden-onset, severe headache. “We've done a big outreach program to get physicians to think about this diagnosis,” Dr. Ogilvy says. “Once you think about it, you think about doing what you need to do to diagnose it.” That means first obtaining a CT scan, and if that is negative, a lumbar puncture to look for blood in the cerebrospinal fluid.
The sooner a patient receives treatment, the better his chances are of surviving, and doing so with reduced morbidity. “We try to do a repair within 24 hours of diagnosis,” Dr. Ogilvy says. Rebleeding before repair is a common, and often fatal complication of an unrepaired aneurysm.
While imaging the rupture with an angiogram is still common in many centers, three-dimensional CT angiography is the standard at MGH. Since it doesn't require an intra-arterial injection of contrast, it is less risky, and it is also faster: “We can have the patient evaluated and imaged within 45 minutes of hitting the door, so we can already be making decisions on how best to treat them,” he says. The detailed look at the ruptured aneurysm provide by CT angiography helps in treatment planning, and in explaining to the patient what has happened. “It’s a very visual thing, and it helps patients understand. They see it, and they see why we need surgery or endovascular treatment to fix it. That’s been a huge help over the years.” [include CT image here]
The images provide critical information on the shape and size of the vascular anomaly, key considerations in choosing whether to surgically repair the aneurysm, or block it with a coil delivered endovascularly. Other factors in the choice include patient age and comorbidities.
That treatment doesn't end after a successful operation. “Once you do the procedure, you are not done with that patient by a long shot.” Updated recommendations from the American Heart Association and American Stroke Association are that centers performing fewer than 10 repair procedures per year should consider transferring the patient to a higher-volume hospital, with a multidisciplinary team experienced not only in repair but in the weeks-long management of the patient in the ICU after surgery or coil placement. “This is becoming a disease of tertiary care institutions. The more you do, the better the results,” Dr. Ogilvy says. MGH receives patients referred from all over, “because the ER doctors and surgeons know we are interested in treating these patients, and we can provide cutting-edge treatment once they are here.”
After treatment, patients often spend two weeks in the intensive care unit, being closely monitored for vasospasm. Vasospasm is the most common severe complication, and typically arises five to seven days after hemorrhage. “The patient can get through aneurysm treatment just fine, but then a week later, be having a stroke because the arteries are narrowing,” Dr. Ogilvy says. In the ICU at MGH, patients are monitored at the bedside around the clock by nurses with monitoring techniques that include transcranial Doppler ultrasonography. Treatment options include medical management and angioplasty, depending on the severity of the spasm.
For the best outcome, “you really need to do this in a tertiary center, where you have an interdisciplinary ICU team watching the patient, with treatment available. It takes a lot of care afterward, it is quite labor-intensive, and quite frankly it is not reimbursed all that well. So if you are a private practitioner in a medium-sized community hospital, it can wear you down,” he says.
“We often get transfers of patients from physicians who are exhausted from the around-the-clock monitoring. We offer to take these patients, and we are glad to be able to. At MGH, we have a team to share observation and treatment duties. We want the patient to do well.”
Connolly ES Jr, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB, Thompson BG, Vespa P; American Heart Association Stroke Council; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular Nursing; Council on Cardiovascular Surgery and Anesthesia; Council on Clinical Cardiology. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke. 2012 Jun;43(6):1711-37. doi: 10.1161/STR.0b013e3182587839. Epub 2012 May 3.
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