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Journal Information
Vol. 31. Issue 9.
Pages 649-650 (November - December 2016)
Vol. 31. Issue 9.
Pages 649-650 (November - December 2016)
Letter to the Editor
DOI: 10.1016/j.nrleng.2014.10.010
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Clinical practice guidelines for subarachnoid haemorrhage. Diagnosis and treatment
Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento
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J. Vivancos
Corresponding author
jvivancos@neurogps.com.es

Corresponding author.
, F. Gilo, R. Frutos, J. Maestre, A. García-Pastor, F. Quintana, Á. Ximénez-Carrillo, for the ad hoc committee of the SEN Study Group for Cerebrovascular Diseases
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Dear Editor:

We would like to thank the authors for their comments on the clinical management guidelines for subarachnoid haemorrhage. We agree that subarachnoid haemorrhage should be considered a neurological emergency and managed in the same way as other acute cerebrovascular diseases. Although this type of stroke is less frequent, it affects younger populations and therefore has a significant impact on patients, their families, and society at large. Both stroke and intensive care units are equipped for managing these patients in our setting. Admission by one unit or the other depends on severity: patients with a good level of consciousness (Hunt and Hess grades I and II) are usually admitted to stroke units, whereas patients in poorer clinical condition are managed in intensive care units.1 We also agree on the need to establish a more precise time frame for early aneurysm treatment; however, due to the lack of randomised studies2 and the fact that the studies evaluating this aspect have a retrospective design, it is difficult to determine whether the time frame should be the first 24 or 72 hours.3 Some observational studies suggest that ‘ultra-early’ treatment (<24 hours) is beneficial for these patients.4 The guidelines of the American Heart Association/American Stroke Association recommend treating aneurysms as soon as possible to prevent rebleeding,5 and the guidelines of the European Stroke Organisation recommend treatment within the first 72 hours.6

As for vasospasm, numerous studies suggest that delayed cerebral ischaemia may not be due to this complication: some patients have been reported to have vasospasm but not delayed cerebral ischaemia, and vice versa. This is consistent with the paradoxical case of nimodipine, the only drug proven to improve functional prognosis with a level of evidence ‘1a’ and a grade of recommendation ‘A’. Nonetheless, it does not reduce the risk of vasospasm.7 This may be explained by the fact that delayed cerebral ischaemia is caused by multiple factors, such as microthrombosis, ion alterations, metabolic changes, systemic imbalances, or cortical spreading depression.8 Research shows conflicting results regarding the potential benefits of certain agents for preventing this complication. The recently-published STASH trial found no benefits for use of simvastatin.9

Subarachnoid haemorrhage is the stroke type most frequently requiring a multidisciplinary approach. We feel that neurologists should play a more active role in the treatment of this entity and care protocols should be more homogeneous among tertiary centres providing care to these patients.

Conflicts of interest

The authors have no conflicts of interest to declare.

Appendix A

E. Díez Tejedor (coordinator), Blanca Fuentes (secretary), María Alonso de Leciñana, José Álvarez-Sabin, Juan Arenillas, Sergio Calleja, Ignacio Casado, Mar Castellanos, José Castillo, Antonio Dávalos, Fernando Díaz-Otero, José Antonio Egido, Juan Carlos Fernández, Mar Freijo, Jaime Gállego, Antonio Gil-Núñez, Pablo Irimia, Aida Lago, Jaime Masjuan, Joan Martí-Fábregas, Patricia Martínez-Sánchez, Eduardo Martínez-Vila, Carlos Molina, Ana Morales, Florentino Nombela, Francisco Purroy, Marc Ribó, Manuel Rodríguez-Yañez, Jaime Roquer, Francisco Rubio, Tomás Segura, Joaquín Serena, Patricia Simal, and Javier Tejada.

References
[1]
F. Gilo-Arrojo, A. Ximénez-Carrillo, L. López, J. Vivancos.
¿Es una unidad de ictus un buen recurso asistencial para el manejo de la hemorragia subaracnoidea espontánea?.
Rev Neurol, 50 (2010), pp. 495-510
[2]
J.A. Matias-Guiu, C. Serna-Candel.
Early endovascular treatment of subarachnoid hemorrhage.
Interv Neurol, 1 (2013), pp. 56-64
[3]
S.C. Oudshoorn, G.J. Rinkel, A.J. Molyneux, R.S. Kerr, S.M. Dorhout Mees, D. Backes, et al.
Aneurysm treatment <24 versus 24-72h after subarachnoid hemorrhage.
Neurocrit Care, 21 (2014), pp. 4-13
[4]
T.J. Phillips, R.J. Dowling, B. Yan, J.D. Laidlaw, P.J. Mitchell.
Does treatment of ruptured intracranial aneurysms within 24h improve clinical outcome?.
Stroke, 42 (2011), pp. 1936-1945
[5]
E.S. Connolly Jr., A.A. Rabinstein, J.R. Carhuapoma, C.P. Derdeyn, J. Dion, R.T. Higashida, 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, et al.
Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke, 43 (2012), pp. 1711-1737
[6]
T. Steiner, S. Juvela, A. Unterberg, C. Jung, M. Forsting, G. Rinkel, European Stroke Organization.
European Stroke Organization guidelines for the management of intracranial aneurysms and subarachnoid haemorrhage.
Cerebrovasc Dis, 35 (2013), pp. 93-112
[7]
J.B. Bederson, E.S. Connolly Jr., H.H. Batjer, R.G. Dacey, J.E. Dion, M.N. Diringer, American Heart Association, et al.
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.
[8]
J. Woitzik, J.P. Dreier, N. Hecht, I. Fiss, N. Sandow, S. Major, COSBID study group, et al.
Delayed cerebral ischemia and spreading depolarization in absence of angiographic vasospasm after subarachnoid hemorrhage.
J Cereb Blood Flow Metab, 32 (2012), pp. 203-212
[9]
P.J. Kirkpatrick, C.L. Turner, C. Smith, P.J. Hutchinson, G.D. Murray, STASH Collaborators.
Simvastatin in aneurysmal subarachnoid haemorrhage (STASH): a multicentre randomised phase 3 trial.
Lancet Neurol, 13 (2014), pp. 666-675

Please cite this article as: Vivancos J, Gilo F, Frutos R, Maestre J, García-Pastor A, Quintana F, et al. Guía de actuación clínica en la hemorragia subaracnoidea. Sistemática diagnóstica y tratamiento. Neurología. 2016;31:649–650.

Further information about the members of the ad hoc committee of the SEN Study Group for Cerebrovascular Diseases is shown in the Appendix A.

Copyright © 2014. Sociedad Española de Neurología
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