Clinical management guidelines for subarachnoid haemorrhage. Diagnosis and treatment.

OBJECTIVE: To update the Spanish Society of Neurology's guidelines for subarachnoid haemorrhage diagnosis and treatment. MATERIAL AND METHODS: A review and analysis of the existing literature. Recommendations are given based on the level of evidence for each study reviewed. RESULTS: The most common cause of spontaneous subarachnoid haemorrhage (SAH) is cerebral aneurysm rupture. Its estimated incidence in Spain is 9/100 000 inhabitants/year with a relative frequency of approximately 5% of all strokes. Hypertension and smoking are the main risk factors. Stroke patients require treatment in a specialised centre. Admission to a stroke unit should be considered for SAH patients whose initial clinical condition is good (Grades I or II on the Hunt and Hess scale). We recommend early exclusion of aneurysms from the circulation. The diagnostic study of choice for SAH is brain CT (computed tomography) without contrast. If the test is negative and SAH is still suspected, a lumbar puncture should then be performed. The diagnostic tests recommended in order to determine the source of the haemorrhage are MRI (magnetic resonance imaging) and angiography. Doppler ultrasonography studies are very useful for diagnosing and monitoring vasospasm. Nimodipine is recommended for preventing delayed cerebral ischaemia. Blood pressure treatment and neurovascular intervention may be considered in treating refractory vasospasm. CONCLUSIONS: SAH is a severe and complex disease which must be managed in specialised centres by professionals with ample experience in relevant diagnostic and therapeutic processes.

Recomendaciones sobre el uso del Doppler transcraneal para determinar la existencia de paro circulatorio cerebral como apoyo diagnóstico de la muerte encefálica / Recommendations of the use of transcranial Dooppler to determine the existence of cerebral circulatory arrest as diagnostic support of brain death

Introducción. La muerte encefálica (ME) se define como el cese completo e irreversible de función de todas las estructuras neurológicas intracraneales. Aunque el diagnóstico de la ME es clínico, pueden utilizarse exploraciones complementarias para confirmarlo, que según la legislación española en determinadas circunstancias son obligatorias. La detección de signos de paro circulatorio cerebral (PCC) en un paciente con exploración clínica de ME confirma el diagnóstico. Objetivo. Revisar la utilidad del Doppler transcraneal (DTC) para confirmar el diagnóstico de ME y establecer unos criterios uniformes para la realización de esta exploración. Métodos. Basándose en una revisión de la literatura se elaboró la guía para la realización e interpretación del DTC para confirmar el diagnóstico clínico de ME. Los miembros en activo de la Sociedad Española de Neurosonología (SONES) revisaron el documento hasta alcanzar un consenso. Resultados. En pacientes con diagnóstico clínico de ME existen una serie de patrones de flujo en el DTC que indican la existencia de PCC. El PCC se confirma cuando se registra flujo reverberante, espigas sistólicas o ausencia de flujo en ambas arterias cerebrales medias y en la arteria basilar. Se recomienda realizar dos exámenes distintos con un intervalo entre ellos de 30 min. Conclusiones. El DTC es una técnica sencilla, rápida e inocua capaz de diagnosticar PCC. La presencia de flujo reverberante y/o espigas sistólicas o la ausencia de flujo permite diagnosticar PCC y tiene una especificidad muy elevada en el apoyo diagnóstico de la ME (AU)

Introduction. The clinical criteria for brain death consist of the demonstration of the absence of any clinical sign of encephalic activity. Confirmatory testing is usually not required for the diagnosis of brain death, except in some special situations that the Spanish law details. In these situations demonstrating cerebral circulatory arrest (CCA) by cerebral flow studies is necessary to support the diagnosis of brain death. Objective. To review the use of transcranial Doppler ultrasonography (TCD) for confirming brain death and to establish uniform criteria for the routine use of TCD as a confirmatory test. Methods. Based on literature analysis, the authors developed the guidelines for performance and interpretation of TCD in clinically brain-dead patients, in order to confirm the diagnosis. The active members of the Spanish Neurosonology Society (SONES) reviewed an initial draft, until a consensus was reached. Results. In a clinically brain-dead patient, specific intracranial flow patterns indicating CCA can be visualized by TCD. The specific flow patterns are the presence of reverberating flow and/or systolic spikes, and should be detected in both middle cerebral arteries and also in the basilar artery. We recommend to repeat the examination within 30 minutes to confirm the findings. Conclusions. TCD is a useful method detecting CCA and therefore can be used to confirm brain death in a clinically brain-dead patient. The presence of reverberating flow, systolic spikes or absence of flow in the basilar and both middle cerebral arteries observed in two examinations is highly specific for the prediction of CCA and brain death in all patients (AU)