Nursing

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After reading the article you should be able to:

1. Describe the epidemiology of aneurysmal subarachnoid hemorrhage (aSAH).
2. Describe the common side effects of treatment for aSAH.
3. Describe the grading system is used to evaluate the severity of SAH.

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By ELLEN BARKER, MSN, APN, CNRN, CLCP, ABDA

ELLEN BARKER is an advanced practice nurse in private practice, a neuroscience clinial specialist, and the president of Neuroscience Nursing Consultants in Greenville, DE. The author has no financial relationships to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS

A 65-YEAR OLD MALE IN THE EMERGENCY DEPARTMENT (ED) complained of a severe headache and groaned it's "the worst headache of my life." When asked to pinpoint exactly where he hurt, he pointed to the top of his head. He explained that his left ear hurt for the past week, and he thought he was losing his hearing, too. Dizziness, light sensitivity, and an all-over achy feeling made him queasy and nauseous over the three days. That morning, after drinking a cup of coffee, he vomited and was off-balance when he walked. He thought it might be a case of the flu, but his son convinced him he needed medical help and drove his dad to the hospital.

During the exam, he denied any past history of head trauma, and there was no evidence of an accident or injury. The only change in his life was that he'd been under a great deal of stress at work meeting deadlines for year-end reports. Sitting on the exam table, he was oriented to person, place, and time; fully awake; and appeared to only be in mild distress. He tried to convince the nurses that he'd probably feel much better if he could just get some rest, not knowing that he was experiencing an aneurysmal subarachnoid hemorrhage (aSAH) that could kill him. He had no idea that an aSAH is misdiagnosed in up to 12% of cases, but luckily, the nurses used the new 2009 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage, instead of the archaic fifteen-year-old Guidelines.¹

These Guidelines released by the American Heart Association/American Stroke Association (AHA/ASA) are essential when assessing a patient who presents with a new headache. An aSAH should be considered in the differential diagnosis of all patients with a new headache. The new Guidelines may seem mammoth in size, at 33 pages with more than 500 references, but this article emphasizes the importance of comprehensive nursing assessment regarding the patient's initial presentation and the challenge to quickly collect and document a comprehensive history and assessment, and notify the appropriate specialist.

Subarachnoid hemorrhage is a common and devastating condition that affects up to 30,000 individuals annually in the United States. The incidence of aSAH increases with age, occurring most commonly between 40 and 60 years of age and is 1.6 times higher in women than men.¹ The typical clinical presentation of aSAH is one of the most distinctive and dramatic in medicine; however, the vast majority of ruptured aneurysms are still a mystery. When an aneurysm ruptures, it can lead to brain damage and death.²

ASSESSMENT When collecting the history from the patient and/or family, and completing the initial neurological assessment, the nurse should be aware of the following potential risk factors:

» Hypertension
» Cigarette smoking, especially one hour prior to the attack
» Heavy alcohol consumption, or binge drinking
» Drug abuse, especially stimulants, cocaine and heroin use in younger patients
» Possible oral contraception use
» Multiple congenital, genetic, or inherited diseases

The nurse completes a comprehensive neurological assessment, including pupil checks, visual field and acuity tests, sensory and motor changes, and the presence of photophobia. Several neurological grading scales are also used to determine acuity of the patient as explained in the figures. Vital signs and health problems should all be charted and reported to the treating physician or team. Considering the signs and symptoms, nurses and other practitioners should suspect the patient might have suffered an aSAH. Based on the presenting data, nurses will know what orders to expect for further diagnosis.

The Guidelines suggest non-contrast CT of the head and warn that the diagnostic sensitivity of CT scanning is not 100%; thus, diagnostic lumbar puncture should be performed if the initial CT is negative. However, a safety measure is to rule out increased intracranial pressure and cerebral herniation prior to a lumbar puncture. The Guideline authors also caution that these hemorrhages can present as a milder sentinel headache, also called a "warning leak."¹ It is essential that the treating team quickly and correctly analyze the presenting signs and symptoms, review diagnostic studies, and rule out other causes of the patient's headache and symptoms as they request consultation by the neurosurgeon.

INTERVENTIONS Although some patients drive to the hospital on their own, the majority of patients with symptoms, especially with complaints of a severe acute headache, arrive by ambulance. The Guidelines recommend rapid transport, advanced notification of the hospital's emergency department, and avoiding on-scene delays.¹ In the ED, implement acute evaluation of the airway, breathing, and circulation. Historically, many EDs do not have standardized management protocol to evaluate patients with headaches and other symptoms of potential SAH. New rebleeding recommendations from the Guidelines include monitoring and controlling blood pressure to maintain normal circulating blood flow for adequate cerebral perfusion pressure (CPP), bed rest, and possibly a short course of antifibrinolytics. According to the Guidelines, antifibrinolytic therapy may reduce rebleeding but has not been shown to improve outcomes.

The degree of neurological impairment using accepted SAH grading systems can be useful for triage and prognosis, and the Guidelines recommend that the following neurological assessment scales be recorded:

» Glasgow Coma Score
» Fisher's CT Grading of SAH
» Hunt-Hess Clinical Grading
» World Federation of Neurological Surgeons Scale SAH Grade

Nurses, as part of the treating team, will collectively consider whether their hospital is an appropriate center to admit and treat the patient. If the treating team, with consultation of the patient and family, agree to a transfer, the nurse will expedite the move with the flight or ambulance personnel. Also important is to immediately prepare the patient, all records, and the family for the transfer, and to and phone in a report to the nurse at the receiving referral center.

Admission Nurses familiar with aSAH know that the saccular or berry aneurysm resembles a small sack and is the most common type of aneurysm. Complications from a rupture include hyperemia and brain ischemia, increased intracranial pressure (ICP), vasospasm, and the breakdown of the cerebral blood-brain barrier (BBB). The combination of the burst aneurysm and escaping blood displace brain tissue, which can rapidly destroy brain function. "Time is brain" is a major consideration at this time.¹

As soon as the patient is admitted, be prepared to implement interventions to protect against rebleeding. Up to 14% of SAH patients start bleeding again, within two hours after the initial hemorrhage.

NURSING CARE INCLUDES:

» Keep the head of bed elevated unless ordered otherwise.
» Administer medications as ordered.
» Monitor cardiac and respiratory status.
» Continue serial headache pain evaluations.
» Perform neurological assessments to include the Full Outline of Unresponsiveness (FOUR) Score.³
» Document changes in mental status and motor/sensory status.
» Analyze lab results.

CLOSELY MONITOR FOR

» Seizures
» Nausea
» Vomiting
» Nuchal rigidity
» Blurred vision
» Diplopia
» Photophobia.

Critically ill patients may require intubation with mechanical ventilation, external ventricular drain, or other life-saving interventions.

The Guidelines strongly recommend that patients receive selective cerebral angiography to document the aneurysm's anatomic features. Multiple aneurysms may affect up to 30% of affected patients.² Diagnostic study results that demonstrate the patient has multiple aneurysms become an important consideration for the nurse during the diagnosis and treatment for a single aneurysm. The risk of another rupture remains high during the critical recovery phase.

TREATMENT OPTIONS With the goal of quickly excluding the aneurysm from the cerebral circulation to prevent further bleeding, the treating team will work fast to evaluate the patient's treatment options. The International Subarachnoid Aneurysm Trial (ISTAT) is described in the Guidelines as the only prospective, randomized trial to date comparing surgery and endovascular techniques. The ISAT reports that at one year, there was no significant difference in mortality rates (8.1% versus 10.1% endovascular versus surgical). Disability rates were greater in surgical versus endovascular patients (21.6% versus 15.6%). Combined morbidity and mortality was significantly greater in surgically treated patients than those treated with endovascular techniques (30.9% versus 23.5%; absolute risk reduction 7.4%, p-0.0001). During the short follow-up period in ISAT, the rebleeding rate for coiling was 2.9% versus 0.9% for surgery.

The current standard of care calls for microsurgical clipping or endovascular coiling. In microsurgical clipping a small clip seals off the aneurysm from the outside, but first a neurosurgeon removes part of the skull to locate the aneurysm. By placing a metal clip on the aneurysm's neck, the blood stops flowing into the area. The clip remains in place and reduces the risk of bleeding in the future.⁴

In endovascular coiling a flexible tube called microcatheter is feed through a small puncture wound in groin through an artery to site of aneurysm. Platinum coils are pushed through the microcatheter into the aneurysm. An electrical charge cuts the end of the coils once inside the aneurysm. The microcatheter is withdrawn when the aneurysm is full of coils. The coils obstruct blood flow into the aneurysm and blood clots around the coils, which preventing it from bursting.⁴

Treatment modality is determined by numerous factors, including the patient, aneurysm, and institutional factors. Favorable outcomes are more likely in institutions that treat high volumes of patients with SAH, in institutions that offer endovascular services, and in selected patients whose aneurysms are coiled rather than clipped.¹

POST-TREATMENT NURSING The nurses' role is a critical factor in the post-treatment management. Vital signs need close monitoring, and serial neurological assessments are key. Patient care includes:

POST-ANESTHESIA MANAGEMENT Cerebral vasospasm: seen in 30% to 70% of patients with a typical onset between three to five days

» Hydrocephalus
» Seizures
» Hyponatremia
» Respiratory status to prevent respiratory complications, such as pneumonia
» Cardiopulmonary with a catecholamine surge that may set off a cascade of events, such as a sympathetic storm; increased intracranial pressure; alterations in temperature, blood pressure, heart rate, respiratory rate, and pupil size; excessive salivation; extensor posturing; or cardiac dysfunction
» Immobility to prevent pressure ulcers

One of the most serious post treatment complications is vasospasm. The use of Trans Cranial Doppler (TCD) monitoring is inconclusive regarding TCD sensitivity, and specificity has been controversial. However, the Lindegaard ratios—ratio of the velocity in the brain vessel of choice to the velocity in the ipsilateral extracranial internal carotid artery—have been shown to be helpful in following trends and useful in guiding therapy. Other modalities, such as diffusion perfusion, MRI, and xenon-CT cerebral perfusion studies, are complementary in guiding management. To reduce morbidity and mortality from vasospasm, one recommendation is oral nimodipine (Nimotop), using the routine dose of 60 mg every 4 hours for 21 days from the day of ictus. If you have to give nimodipine per tube, the hard capsules can be placed in 15 mL of hot water for 5 minutes, then the medication easily drawn up with a catheter-tipped syringe and administered. Do not attempt to pierce the hard capsule with a needle to withdraw medication.

Triple-H therapy—hypervolemia, induced hypertension, and hemodilution therapy—is also described as a mainstay in the management of cerebral vasospasm; however, only one randomized study has been performed to assess its efficacy, according to the Guidelines.

Cerebral perfusion pressure is the mean arterial pressure minus the intracranial pressure, so maintaining a higher-than-normal blood pressure is the goal in order to maintain cerebral perfusion, especially in a brain that may be in the process of reabsorbing blood from a bleed. Nurses must be cautious when using Triple-H therapy due to potential complications, such as pulmonary edema, cardiac side effects, congestive heart failure, and dilutional hyponatremia. The management of hyponatremia, which occurs in 10% to 30% of SAH patients, and volume contraction, is included in the Guidelines. The administration of large amounts of fluids (hypervolemic therapy) ameliorates volume contraction.

Other therapies for managing cerebral vasospasm in the Guidelines are balloon angioplasty, which reverses cerebral vasospasm in large proximal conducting vessels but has not been shown to improve ultimate outcome. In addition, angioplasty reduces angiographic spasm, promoting an increase in cerebral blood flow and reducing deficits.

Early seizures are another potential issue, and occur in 6% to 18% of SAH patients. Administering prophylactic anticonvulsants may be considered in the immediate post-hemorrhagic periods; long-term use is not recommended. After a hemorrhage from a SAH, blood can collect in the ventricles or around the base of the brain, and there is a possibility of cerebrospinal fluid buildup. This can result in acute hydrocephalus with ventricular enlargement within 72 hours, and occurs in about 20% to 30% of SAH patients. Temporary or permanent cerebrospinal fluid diversion is recommended in symptomatic patients with chronic hydrocephalus following SAH. Ventriculostomy can be performed in the acute phase, along with placement of a shunt for chronic long-term benefits.

CONCLUSION Recognizing the early signs and symptoms of a ruptured aneurysm with SAH is essential to ensure the patient's best chance of a good outcome from this devastating neurological emergency. Nurses working collaboratively using the newest Guidelines with neurology neurosurgical teams and managing the patient from admission to discharge helps promote best practice and an improved outcome. Nurses are encouraged to review the Guidelines and use this valuable resource to work with their team members to write and implement new hospital protocols.

References

1. Bederson, J.B., Connolly, E.S., et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Jan. 22. [Epub ahead of print] http://stroke.ahajournals.org/cgi/content/full/40/3/994?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=guidelines+for+the+management+of+aneurysmal&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Accessed Feb. 19, 2009.

2. Pillai, P., DeLaune, A., et al. Management of aneurysms, subarachnoid hemorrhage, and arteriovenous malformation. In Barker E. (Ed.). Neuroscience Nursing: A spectrum of care. (3rd ed.). 2008. St. Louis: Mosby/Elsevier.

3. Stead, L.G., Wijdicks, E.F., et al. Validation of a new coma scale, the FOUR score, in the emergency department. Neurocritical Care. 2009;10(1):50-54.

4. Penn State Milton S. Hershey Medical Center, the Department of Neurosurgery. Cerebral aneurysm. 2009. http://www.pennstatehershey.org/web/neurosurgery/patientcare/specialtyservices/cerebralaneurysm Accessed on Feb. 18, 2009.

5. Barker, E. Neuroscience Nursing: A spectrum of care. (3rd ed.). 2008. St. Louis: Mosby/Elsevier.

6. Hamilton, J.C., Kom-Naveh, L., & Crago, E.A. Case studies in cardiac dysfunction after acute aneurysmal subarachnoid hemorrhage. Journal of Neuroscience Nursing. 2008;(40)5:269-274.

Many grading systems are used to evaluate the severity of a SAH. Clinical assessments include the Hunt and Hess Scale, Fisher Scale, Glasgow Coma Scale, and World Federation of Neurological Surgeons Scale.

SINCE THE PREVIOUS guidelines were released in 1994, there have many advances in neurological care and treatments. Highlights of the new 2009 Guidelines follow.

Early definitive aneurysm treatment is indicated for most patients and can reduce death and disability.

SAH is misdiagnosed in as many as 12% of cases. Misdiagnosis results in a fourfold greater risk of death or disability. Patients who complain of severe headache with acute onset should be checked for SAH.

It is highly beneficial for SAH patients to receive care at hospitals that offer both endovascular and cerebrovascular surgical expertise. SAH patients also have significantly better outcomes when treated at hospitals with a great deal of experience treating SAH patients, compared to hospitals with little experience.

Catheter angiography remains the gold standard for detecting aneurysms and directing treatment.

Standardized emergency department protocols are necessary for managing SAH patients, particularly in the early stages.

Endovascular coiling can be beneficial in certain cases. This method is often used to avoid brain surgery.

SOURCES: 1. Bederson JB, Connolly ES, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke. 2009 Jan. 22. [Epub ahead of print] http://stroke.ahajournals.org/cgi/content/full/40/3/994?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=guidelines+for+the+management+of+aneurysmal&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT Accessed Feb. 19, 2009.