[cactus1972]

Новый гайдлайн АНА/ASA по ведению нетравматического САК

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Положения, добавленные и/или обновленные по сравнению с предыдущей версией

The 5 new class I (level B) recommendations are as follows:

-After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment.

-Digital subtraction angiography with 3-dimensional rotational angiography is indicated for detection of aneurysm in patients with aSAH (except when the aneurysm was previously diagnosed by noninvasive angiography) and for planning treatment (to determine whether an aneurysm is amenable to coiling or to expedite microsurgery).

-Between the time of aSAH symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk for stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure.

-In the absence of a "compelling" contraindication, patients who undergo coiling or clipping of a ruptured aneurysm should have delayed follow-up vascular imaging (timing and modality to be individualized), and re-treatment, by repeat coiling or clipping, should be strongly considered if there is a clinically significant (eg, growing) remnant.

-Heparin-induced thrombocytopenia and deep venous thrombosis are both infrequent but not uncommon occurrences after aSAH. Early identification and targeted treatment are recommended, but further research is needed to identify the ideal screening paradigms.

The 9 revised recommendations are as follows:

-For patients with an unfavorable delay in obliteration of aneurysm, a significant risk for rebleeding, and no compelling medical contraindications, short-term ( < 72 hours) therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the risk for early aneurysm rebleeding. (Class IIa, Level B)

-Experienced cardiovascular surgeons and endovascular specialists should determine a multidisciplinary treatment approach based on characteristics of the patient and the aneurysm. (Class I, Level C)

-For patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered. (Class I, Level B)

-Low-volume hospitals should consider early transfer of patients with aSAH to high-volume centers. (Class I, Level B)

-Maintaining euvolemia and normal circulating blood volume is recommended to prevent disseminated intravascular coagulation (DCI). (Revised, Class I, Level B)

-Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it. (Class I, Level B)

-Cerebral angioplasty and/or selective intra-arterial vasodilator therapy is "reasonable" in patients with symptomatic cerebral vasospasm, particularly those who are not rapidly responding to hypertensive therapy. (Class IIa, Level B)

-aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario). (Class I, Level B)

-aSAH-associated chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion. (Class I, Level B)