Evidence-Based Treatment for a Patient with Aneurysmal Subarachnoid Hemorrhage_Chinese Journal of Evidence-Based Medicine

Authors：

YUE Zengchang ,  LIU Ming , ZHANG Shihong , ZHAO Meiying

Department of Neurology, West China Hospital, Sichuan University, Chengdu 610041, China;

Corresponding author：

LIU Ming, Email: wyplmh@hotmail.co

Keywords：

Subarachnoid hemorrhage; Aneurysm; Evidence-based treatment

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Objective 　To identify an evidence-based treatment for a patient with aneurysmal subarachnoid hemorrhage (aSAH).
Methods 　We first put forward clinical problems about how to prevent complications and how to treat ruptured aneurysm of aSAH, then searched The Cochrane Library (Issue 4, 2006), Ovid ACP Journal Club (1991 to 2006), Ovid MEDLINE (1966 to 2006), NGC (1998 to 2006) and CBM (1978 to 2006) to identify systematic reviews, randomized controlled trials, controlled clinical trials and treatment guidelines.
Results 　Eleven studies and five guidelines were included. Current evidence indicated that nimodipine was effective for prophylaxis of poor outcome after vasospasm, while tirilazad was not effective in female patients with good grades. The effectiveness of other treatments to prevent complications was not clear. Evidence on the use of antifibrinolytics for the prevention of re-bleeding was inconsistent. If a ruptured aneurysm was considered suitable for both surgical clipping and endovascular coiling, coiling was associated with a better outcome. According to the available evidence and guidelines, considering the patient’s conditions and preferences, nimodipine and antifibrinolytics were administered to prevent complications and her aneurysm was treated by early endovascular embolization. She did not experience vasospasm or re-bleeding during her hospital stay. Short-term follow-up showed a good outcome. Long-term prognostic benefits after endovascular therapy need to be confirmed by prolonged follow-up.
Conclusions 　Therapies based on the best clinical evidence and guidelines should be given to prevent complications and improve outcome for patients after an aSAH.

Citation： YUE Zengchang,LIU Ming,ZHANG Shihong,ZHAO Meiying. Evidence-Based Treatment for a Patient with Aneurysmal Subarachnoid Hemorrhage. Chinese Journal of Evidence-Based Medicine, 2007, 07(2): 147-152. doi: Copy

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14.	Lanzino G, Kassell NF, Dorsch NW, et al. Double-blind, randomized, vehicle-controlled study of high-dose tirilazad mesylate in women with aneurysmal subarachnoid hemorrhage. Part I. A cooperative study in Europe, Australia, New Zealand, and South Africa. J Neurosurg, 1999, 90(6): 1011–1017.
15.	Lanzino G, Kassell NF. Double-blind, randomized, vehicle-controlled study of high-dose tirilazad mesylate in women with aneurysmal subarachnoid hemorrhage. Part II. A cooperative study in North America. J Neurosurg, 1999, 90(6): 1018–1024.
16.	Roos YBWEM, Rinkel GJE, Vermeulen M, et al. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage.The Cochrane Library, 2006, Issue 4.
17.	Hillman J, Fridriksson S, Nilsson O, et al. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg, 2002, 97(4): 771–778.
18.	Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet, 2005, 366(9488): 809–817.
19.	Van der Schaaf I, Algra A, Wermer M, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. The Cochrane Library, 2006, Issue 4.
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21.	Baltsavias GS, Byrne James V, Halsey Jim B, et al. Effects of Timing of Coil Embolization after Aneurysmal Subarachnoid Hemorrhage on Procedural Morbidity and Outcomes. Neurosurg, 2000, 47(6): 1320–1331.
22.	刘鸣. 应正确评价和使用循证医学证据. 中国循证医学杂志, 2006, 6(2): 77～79.

1. Liu M. How to understand and apply evidence of evidence-based medicine. Chin J of Evid-Based Med, 2006, 6 (2): 77–79.
2. Bureau of Disease Control, MOH; Group of Cerebrovascular Disease, Society of Neurology, CMA; eds. Chinese guideline for prevention and control of cerebrovascular disease (2005). Beijing: Beijingcanyeyiyaokeji Publishing House, 2005. 4–63.
3. Van Gijn J, Rinkel GJE. Subarachnoid haemorrhage: diagnosis, causes and management. Brain, 2001, 124(2): 249–278.
4. Levels of Evidence and Grades of Recommendation. Available from:URL: http://www.cebm.net/levels_of_evidence.asp.
5. Mayberg MR, Batjer HH, Dacey R. Guidelines for the management of aneurismal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke, 1994, 25(11): 2315–2328.
6. Findlay JM. Current management of aneurysmal subarachnoid hemorrhage guidelines from the Canadian Neurosurgical Society. Can J Neurol Sci, 1997, 24(2): 161–170.
7. 卫生部疾病控制司, 中华医学会神经病学分会脑血管病学组, 主编. 中国脑血管病防治指南 (2005年版). 北京: 北京粲业医药科技出版中心, 2005. 4～63.
8. Johnston SC, Higashida RT, Barrow DL, et al. Recommendations for the endovascular treatment of intracranial aneurysms: a statement for healthcare professionals from the Committee on Cerebrovascular Imaging of the American Heart Association Council on Cardiovascular Radiology. Stroke, 2002; 33(10): 2536–2544.
9. Rinkel GJE, Feigin VL, Algra A, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. The Cochrane Library, 2006, Issue 4.
10. Raabe A, Beck J, Berkefeld J, et al. Recommendations for the management of patients with aneurysmal subarachnoid hemorrhage. Zentralblatt fur Neurochirurgie, 2005, 66(2): 79–91.
11. Rinkel GJE, Feigin VL, Algra A, et al. Circulatory volume expansion therapy for aneurysmal subarachnoid haemorrhage. The Cochrane Library, 2006, Issue 4.
12. Treggiari MM, Walder B, Suter PM, et al. Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage. The Cochrane Library, 2006, Issue 4.
13. Dorhout MSM, Rinkel GJ, Hop JW, et al. Antiplatelet therapy in aneurysmal subarachnoid hemorrhage: a systematic review. The Cochrane Library, 2006, Issue 4.
14. Lanzino G, Kassell NF, Dorsch NW, et al. Double-blind, randomized, vehicle-controlled study of high-dose tirilazad mesylate in women with aneurysmal subarachnoid hemorrhage. Part I. A cooperative study in Europe, Australia, New Zealand, and South Africa. J Neurosurg, 1999, 90(6): 1011–1017.
15. Lanzino G, Kassell NF. Double-blind, randomized, vehicle-controlled study of high-dose tirilazad mesylate in women with aneurysmal subarachnoid hemorrhage. Part II. A cooperative study in North America. J Neurosurg, 1999, 90(6): 1018–1024.
16. Roos YBWEM, Rinkel GJE, Vermeulen M, et al. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage.The Cochrane Library, 2006, Issue 4.
17. Hillman J, Fridriksson S, Nilsson O, et al. Immediate administration of tranexamic acid and reduced incidence of early rebleeding after aneurysmal subarachnoid hemorrhage: a prospective randomized study. J Neurosurg, 2002, 97(4): 771–778.
18. Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion. Lancet, 2005, 366(9488): 809–817.
19. Van der Schaaf I, Algra A, Wermer M, et al. Endovascular coiling versus neurosurgical clipping for patients with aneurysmal subarachnoid haemorrhage. The Cochrane Library, 2006, Issue 4.
20. Whitfield PC, Kirkpatrick PJ. Timing of surgery for aneurysmal subarachnoid haemor--rhage. The Cochrane Library, 2006, Issue 4.
21. Baltsavias GS, Byrne James V, Halsey Jim B, et al. Effects of Timing of Coil Embolization after Aneurysmal Subarachnoid Hemorrhage on Procedural Morbidity and Outcomes. Neurosurg, 2000, 47(6): 1320–1331.
22. 刘鸣. 应正确评价和使用循证医学证据. 中国循证医学杂志, 2006, 6(2): 77～79.

Chinese Journal of Evidence-Based Medicine

Evidence-Based Treatment for a Patient with Aneurysmal Subarachnoid Hemorrhage

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