Neurosurgeon Leads Team in Rewriting American Heart Association Stroke Guidelines

Newswise — Patients who suffer a stroke that involves bleeding between the surface of the brain and the brain tissue have a better chance of survival and reduced disability if they are treated within 24-hours " and at a hospital that handles many brain-attack emergencies, according to updated guidelines from the American Heart Association, published today in Stroke: Journal of the American Heart Association.

The condition, called aneurysmal subarachnoid hemorrhage, is often misdiagnosed, even though it is one of the most deadly neurological emergencies. About 45 percent of patients who have such an attack die in the first 30 days, and about half of survivors are left with significant impairment.

"Subarachnoid hemorrhage is misdiagnosed as often as 12 percent, with a four-fold greater likelihood of death or disability in misdiagnosed patients," said Joshua Bederson, M.D., professor and chairman of the Mount Sinai Medical Department of Neurosurgery in New York City, who was chair of the guidelines committee.

"The most common diagnostic error is failure to obtain a CT scan. When patients complain of severe headache with acute onset, doctors should consider the possibility of subarachnoid hemorrhage."

Early definitive aneurysm treatment, defined as within 24 hours, is indicated for most patients, and can reduce death and disability. Standardized protocols are necessary for managing these patients — particularly in the early stages — in the emergency department. "We are calling for evidence-based clinical care pathways to manage all subarachnoid hemorrhage patients in the neuro intensive care unit (ICU)," Bederson said.

The original guidelines were released in 1994 and since then, a new medical specialty, neurocritical care, has evolved to include neurologists, neurosurgeons and others for the optimal management these complex patients. There have also been considerable advances in endovascular techniques, diagnostic methods and surgical and perioperative management, according to the article.

"We now know that multiple, simultaneous pathological processes occur at the onset of the hemorrhage," Bederson said. "We've developed treatments for each of these processes and, in each area, there have been advances in the field."

Patients who receive care at institutions that have both endovascular and cerebrovascular surgical expertise have better outcomes. "Endovascular treatment of aneurysms was not available until 1990," Dr. Bederson said. "So when the last guidelines were written we did not yet have widely available evidence to support the treatment. Now we do." One procedure, endovascular coiling of the ruptured aneurysm, uses a catheter to treat the aneurysm and can be used to avoid surgery in certain patients, Bederson explained.

In addition, high-volume institutions have significantly better outcomes than low-volume hospitals that do not have as much experience in treating these patients. "The triage of acute neurological disorders to designated stroke centers is most likely very beneficial for patients with subarachnoid hemorrhage," Bederson said.

Aneurysmal subarachnoid hemorrhage can occur spontaneously or due to a head injury. An aneurysm is a small bubble that forms over several years on one of the brain's blood vessels in young and middle aged adults. Subarachnoid hemorrhage occurs when an aneurysm bursts and blood is released into the subarachnoid space in the brain, which is the lining between the surface of the brain and the brain tissue.

"The majority of aneurysms do not rupture, and as much as 1 percent of the population dies of old age with a small, unruptured aneurysm," Bederson said. Although catheter angiography remains the gold standard for detecting aneurysms and directing treatment, today there are noninvasive diagnostic imaging tools that can be used as alternatives. CT angiography and magnetic resonance angiography have evolved to detect even small aneurysms with much greater reliability than they used to, according to Bederson.

To update the 1994 recommendations, the guidelines committee conducted a systematic literature review of all relevant randomized clinical trials published between June 30, 1994 and November 1, 2006. The committee's recommendations were made by applying the American Heart Association's standard evidence rating scheme to the conclusions put forth in the articles.

Dr. Bederson's co-authorsE. Sander Connolly, Jr., M.D.; H. Hunt Batjer, M.D.; Ralph G. Dacey, M.D.; Jacques E. Dion, M.D.; Michael N. Diringer, M.D.; John E. Duldner, Jr., M.D., M.S.; Robert E. Harbaugh, M.D.; Aman B. Patel, M.D.; Robert H. Rosenwasser, M.D.

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