Results of an Online Survey on Intensive Care Management of Patients with Aneurysmal Subarachnoid Hemorrhage in German-Speaking Countries

Abstract

Background: The clinical course of patients with aneurysmal SAH (aSAH) is often dynamic and highly unpredictable. Since its management varies between hospitals despite guidelines, this survey aimed to assess the current state of intensive care treatment for aSAH in the German-speaking region and provide insights that could aid standardization of care for aSAH patients in the intensive care setting. Methods: From February 2023 to April 2023, medical professionals of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI), the Initiative of German Neuro-Intensive Trial Engagement (IGNITE) network and manually recorded clinics with intensive care units were invited to participate in a standardized anonymous online questionnaire including 44 questions. The questionnaire was validated in multiple steps by experts of different specialties including those from the DIVI. A descriptive data analysis was carried out. Results: A total of 135 out of 220 participants answered the survey completely. The results showed that most patients were treated in anesthesia-led intensive care units at university and maximum care hospitals. Aneurysms were usually treated within 24 h after bleeding. If vasospasm was detected, induced hypertension was usually implemented as the first treatment option. In refractory vasospasm, interventional spasmolysis with calcium antagonists was usually carried out (81%), despite unclear evidence. There were significant discrepancies in blood pressure target values, particularly after aneurysm repair or after delayed cerebral ischemia (DCI), as well as in hemoglobin limit values for erythrocyte substitution. Despite the limited level of evidence, most institutions used temperature management (68%), including hypothermia (56%), for severe cases. Conclusions: While we anticipated variations between individual intensive care facilities, our survey identified numerous similarities in the treatment of aSAH patients. Methods such as interventional spasmolysis and temperature management were used frequently despite limited evidence. Our results can serve as a fundamental framework for formulating recommendations for intensive care treatment and planning of multicenter studies.

Keywords: intensive care medicine; multimodal monitoring; subarachnoid hemorrhage; vasospasm.

Figure 1

Results of the questions regarding the type of hospital, ICU, and medical position on the ward. The X-axis represents the percentage of answers we received for each answer aligned on the Y-axis. (A) indicates the proportions of different types of hospitals. (B) shows what medical discipline leads the ICU. (C) highlights the contribution of the medical position of the respondents.

Figure 2

Results of the questions regarding target blood pressure and CPP values in patients with aSAH. The X-axis represents the percentage of responses we received for each answer shown on the Y-axis (systolic blood pressure, CPP and MAP). (A) indicates the target systolic blood pressure before treatment of the aneurysm. (B) indicates target blood pressure after aneurysm repair when no signs of vasospasm appeared. (C) shows target blood pressure after aneurysm repair under the condition of vasospasm. For questions B and C, multiple-choice answers were allowed. Most respondents indicated they would aim to keep the blood pressure before aneurysm repair below 140 mmHg, post-intervention MAP > 90–100 mmHg, and post-intervention with vasospasm MAP > 100 mmHg and CPP > 70–90 mmHg.

Figure 3

Results: Results of the question regarding the transition from CSF drainage via EVD to lumbar drainage over time. The X-axis represents the percentage of responses we received for each answer shown on the Y-axis (different time frames for the change in EVD usage), indicating that lumbar drains are still not part of routine practice.

Figure 4

Results of the question regarding treatment options after vasospasm detection. The X-axis represents the percentage of responses we received for each answer shown on the Y-axis, which included various treatment options. Induced hypertension was the most common treatment, followed by interventional spasmolysis with calcium antagonists.

Figure 5

Results of the question regarding hemoglobin values and erythrocyte replacement in patients with aSAH, either without (A) or after (B) the detection of delayed ischemic deficit. The X-axis represents the percentage of responses we received for each answer shown on the Y-axis, which included different hemoglobin value thresholds. Most respondents indicated they would initiate erythrocyte replacement at hemoglobin levels below 8 mg/dL, both with and without DCI.