Resuscitation and critical care of poor-grade subarachnoid hemorrhage

Ricardo J. Komotar, Michael Schmidt, Robert M. Starke, Jan Claassen, Katja E. Wartenberg, Kiwon Lee, Neeraj Badjatia, E. Sander Connolly, Stephan A. Mayer

Research output: Contribution to journalArticle

107 Scopus citations

Abstract

AS OUTCOMES HAVE improved for patients with aneurysmal subarachnoid hemorrhage, most mortality and morbidity that occur today are the result of severe diffuse brain injury in poor-grade patients. The premise of this review is that aggressive emergency cardiopulmonary and neurological resuscitation, coupled with early aneurysm repair and advanced multimodality monitoring in a specialized neurocritical care unit, offers the best approach for achieving further improvements in subarachnoid hemorrhage outcomes. Emergency care should focus on control of elevated intracranial pressure, optimization of cerebral perfusion and oxygenation, and medical and surgical therapy to prevent rebleeding. In the postoperative period, advanced monitoring techniques such as continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis can detect harmful secondary insults, and may eventually be used as end points for goal-directed therapy, with the aim of creating an optimal physiological environment for the comatose injured brain. As part of this paradigm shift, it is essential that aggressive surgical and medical support be linked to compassionate end-of-life care. As neurosurgeons become confident that comfort care can be implemented in a straightforward fashion after a failed trial of early maximal intervention, the usual justification for withholding treatment (survival with neurological devastation) becomes less relevant, and lives may be saved as more patients recover beyond expectations.

Original languageEnglish (US)
Pages (from-to)397-410
Number of pages14
JournalNeurosurgery
Volume64
Issue number3
DOIs
StatePublished - Mar 1 2009
Externally publishedYes

Keywords

  • Antifibrinolytic therapy
  • Brain tissue oxygen monitoring
  • Cardiopulmonary resuscitation
  • Cerebral aneurysms
  • Electroencephalography
  • Microdialysis
  • Subarachnoid hemorrhage

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

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  • Cite this

    Komotar, R. J., Schmidt, M., Starke, R. M., Claassen, J., Wartenberg, K. E., Lee, K., Badjatia, N., Connolly, E. S., & Mayer, S. A. (2009). Resuscitation and critical care of poor-grade subarachnoid hemorrhage. Neurosurgery, 64(3), 397-410. https://doi.org/10.1227/01.NEU.0000338946.42939.C7