Neurocritical Care for Poor-grade (WFNS Grade V) Subarachnoid Hemorrhage

<p>Subarachnoid hemorrhage (SAH) is an acute systemic event that not only affects the central nervous system but also other vital organs, especially in severe cases. Neuroresuscitation, as well as respiratory and circulatory stabilization, are essential prerequisites for radical aneurysm repair.</p><p>Poor outcomes in SAH are mainly caused by early brain injury (EBI) within 72 h of its onset. At our institution, we immediately start therapeutic hypothermia targeted at 33.5°C to mitigate EBI and accomplish radical treatment for a ruptured aneurysm for eligible patients, that is, patients with Grade V of the World Federation of Neurological Surgeons grading system, are under 75 years old, and whose pupils are not fixed and dilated. After maintaining a core temperature of 33.5°C using the surface cooling method for 3 days, patients are rewarmed at a rate of 1°C/day or slower. When the temperature reaches 36°C around Day 7, an endovascular cooling system is applied to maintain normothermia during the high-risk period of delayed cerebral ischemia until Day 14. Cardiopulmonary function, intravascular volume, blood glucose, serum electrolytes, and other parameters are carefully assessed and managed according to the recommendations of the Neurocritical Care Society's Multidisciplinary Consensus Conference. Shivering should be assessed and treated according to the protocol. Brain function was monitored using a simplified continuous amplitude-integrated electroencephalogram. The frequency and duration of fever above 38°C and cerebral infarction significantly decreased, and the rate of good outcome (good recovery and moderate disability, assessed by the Glasgow Outcome Scale at 6 months), showed a trend toward improvement from 32% to 55% after the introduction of endovascular fever control. Our attempts suggest that active temperature management together with neurocritical care is safe and beneficial.</p>