Chinese Stroke Association guidelines for clinical management of cerebrovascular disorders: executive summary and 2019 update of clinical management of spontaneous subarachnoid haemorrhage

Aim Spontaneous subarachnoid haemorrhage (SAH) caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke. Although the incidence of SAH is relatively low among all cerebrovascular diseases, the mortality is the highest. The critical management of SAH is challenging. We provide this evidence-based guideline to present current and comprehensive recommendations for the diagnosis and treatment of non-trauma SAH. Methods A formal literature search of MEDLINE (1

# Abstract
Aim Spontaneous subarachnoid haemorrhage (SAH) caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke. Although the incidence of SAH is relatively low among all cerebrovascular diseases, the mortality is the highest. The critical management of SAH is challenging. We provide this evidence-based guideline to present current and comprehensive recommendations for the diagnosis and treatment of non-trauma SAH. Methods A formal literature search of MEDLINE (1 January 1990-30 June 2019) was performed. Data were synthesised with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The Chinese Stroke Association's levels of evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by Chinese Stroke Association's Stroke Fellow Committees. It is intended that this guideline be fully updated every 3 years. results Evidence-based guidelines are presented for the care of patients presenting with non-trauma SAH. The focus of the guideline was subdivided into transfer and systems of care, diagnosis flowchart, aetiology and differentiation, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, management of vasospasm and delayed cerebral ischaemia, management of hydrocephalus, management of seizures and management of medical complications. Conclusions The guideline offers a framework for SAH management. Early professional and aggressive care of SAH might help dramatically.
Spontaneous subarachnoid haemorrhage (SAH) caused by ruptured cerebral aneurysm is a severe subtype of haemorrhagic stroke with an incidence between 1 and 27 per 100 000 persons per year. The incidence of SAH varied by region and ethnicity. It was higher in women and increased with ageing.The annual incidence of SAH in the Chinese population also varies among different studies. In northern China, the incidence is generally higher, about 6.2 per 100 000 persons per year in Baotou, Inner Mongolia.In central and southern regions of China, the incidence is relatively low, about 2.2 per 100 000 persons per year (95% CI 1.2 to 5.4) in Changsha, 1.1 per 100 000 persons per year in Shanghai,1.2 per 100 000 persons per year in Shunde, Guangdong Province, 4 and 3.02-4.45 per 100 000 persons per year in Chengdu.However, it is as high as 6.25 per 100 000 persons per year in Taiwan 6 and as low as 1.6 per 100 000 persons per year (95% CI 0.8 to 4.1) in Beijing.There were a few studies on the prevalence of SAH in Asia. Only one national study in South Korea reported that the prevalence of SAH was 19.8~21.0 per 100 000 persons per year.Excluding injuries and iatrogenic factors, common causes of spontaneous SAH include aneurysms, cavernous haemangioma, venous thrombosis, arteriovenous malformations and cerebral arteriovenous fistula,cerebral amyloid angiopathy,tumour bleeding, special vasculitis/encephalitis 10 and abnormal blood coagulation.Rare causes of SAH include postpartum eclampsia and reversible cerebral vasoconstriction syndrome.According to the anatomical site that a SAH develops and is seen on head CT scan, SAH is classified into convex SAH and non-convex SAH. The former is more common in venous system embolism, venous sinus thrombosis and cerebral amyloid angiopathy, while the latter is more common in aneurysmal rupture.
Open access The flowchart of SAH diagnoses. DWI, diffusion-weighted imaging; MRA, magnetic resonance angiography; SAH, subarachnoid haemorrhage; SWI, susceptibility-weighted imaging; CEMRA, contrast enhancement magnetic resonance angiography; CEMRV, contrast enhancement magnetic resonance venogram; CTV, computed tomographic venogram Acute intensive care should be provided to all patients with SAH. Acute-phase monitoring and symptomatic treatment to prevent complications are the priorities. The focus of such management may vary depending on the levels of stroke centres that can provide. For a comprehensive stroke centre, the most sophisticated and modern approach emphasising on interventional, neurosurgical and multidiscipline team approach is recommended.
This current guideline is one of the seven guidelines by the Chinese Stroke Association. The methodology on literature review, assignment of level of evidence and grade of recommendation has been published earlier. This guideline mainly concentrated on the discussion and recommendation related to spontaneous SAH on these four sections: the diagnosis and severity assessment of SAH, the early management of SAH, and the treatment and prevention of complications of SAH. The full text of this guideline is available in the online supplemental material.

## Section 1: diagnosis and severity assessment of spontaneous sah
The diagnostic flowchart is shown in .
This section made the recommendations for the areas of SAH care in clinical and imaging diagnoses, aetiology of SAH and SAH severity assessment.

## For patients with an aneurysm suitable for either inter-
ventional or microsurgical treatment, interventional therapy is preferred (class I, level of evidence A). For patients with SAH older than 70 and with a Hunt-Hess Scale score between 4 and 5, endovascular treatment is preferred (class IIa, level of evidence B). 4. Antifibrinolytic drugs may help reduce the risk of rebleeding after SAH in a short term, but these are unable to improve the long-term clinical outcomes. If the patient still has a significant risk of rebleeding before intervention and there is no absolute contraindication, tranexamic acid can be used for a short term (<72 hours) (class IIb, level of evidence B). However, it should not be used in patients during postsurgical or endovascular therapy (class III, level of evidence C).

## Section 3: complications
This section discussed the treatment recommendations of common and rare neurological complications such as high intracranial pressure and hydrocephalus, CVS and DCI, secondary epilepsy, pneumonia, deep vein thrombosis (DVT) prophylaxis, hypotension, refractory hyponatraemia, hypoxaemia, acute pulmonary oedema and acute heart failure. If not contraindicated, prophylactic treatment with antibiotics and early use of tracheostomy might be beneficial (class IIb, level of evidence C). 3. Asymptomatic lower extremity DVT is not uncommon in patients with SAH and is associated with prolonged hospital stay and poor prognosis (class IIa, level of evidence A). 4. The risk of DVT is relatively high in male patients postaneurysmal surgery who are bedridden and with severe SAH (class IIa, level of evidence B). Subcutaneous or intravenous heparin may be effective to prevent DVT if not contraindicated (class IIb, level of evidence B). 5. Routine 3-hour therapy is not recommended in patients with SAH. It may benefit some patients with hypovolaemia (class III, level of evidence B). 6. For patients with refractory hyponatraemia, syndrome of inappropriate antidiuretic hormone secretion or cerebral salt wasting syndrome, sodium correction with restriction of fluids may be indicated and close monitoring of central venous pressure may be helpful (class IIb, level of evidence C).