MENA-SINO aSAH Decision Algorithms

Resource-Stratified Decision Trees for Aneurysmal Subarachnoid Hemorrhage

MENA-SINO aSAH Decision Algorithms

MENA-SINO aSAH Decision Algorithms

Resource-Stratified Decision Trees for Aneurysmal Subarachnoid Hemorrhage

Initial Assessment
Decision Point
Action Required
Critical/Time-Sensitive

Tier 1: Basic Emergency Care Algorithm

Suspected aSAH Patient
Sudden severe headache, altered consciousness, or neurological deficits
Initial Assessment & Stabilization

Immediate Actions (First 15 minutes):

  • ABC assessment and stabilization
  • IV access and basic monitoring
  • Clinical grading (Hunt & Hess or WFNS)
  • Blood pressure management (SBP 140-180 mmHg)
  • Glucose and electrolyte check
CT Scanner Available?
YES: Non-contrast CT
Within 6 hours of symptom onset
⏰ Time Critical: CT within 1 hour if possible
CT Shows SAH?
aSAH Confirmed
Proceed to transfer preparation
High Clinical Suspicion?
Consider LP if >6 hours from onset
NO: Lumbar Puncture
If clinically stable and no contraindications

LP Procedure:

  • Check for contraindications
  • Visual inspection for xanthochromia
  • Send for cell count and protein
  • Document opening pressure
Xanthochromia Present?
aSAH Confirmed – Immediate Management

Essential Medications (if available):

  • Nimodipine 60mg PO q4h (preferred) or 1-2mg/h IV
  • Seizure prophylaxis if high-risk features
  • Pain management (avoid morphine if possible)
  • DVT prophylaxis (mechanical if bleeding risk)
Transfer Safe & Feasible?
Consider distance, transport, weather, security
EMERGENCY TRANSFER
Pre-transfer Contact:
📞 Call receiving facility
📋 Provide SBAR handoff
🚑 Arrange transport with monitor

Transfer Checklist:

  • Stable airway and breathing
  • IV access secured
  • Medications continued
  • All imaging copied
  • Family notification
Stabilize Locally
Prepare for delayed transfer
Consider tranexamic acid 1g IV q8h until transfer possible (max 72 hours)

Monitoring & Reassessment:

  • Neurological checks q1-2h
  • Blood pressure monitoring
  • Reassess transfer feasibility q6h
  • Family communication
  • Document all interventions

Tier 2: Intermediate Capability Algorithm

aSAH Patient Received
Direct admission or transfer from Tier 1
Comprehensive Assessment

Advanced Evaluation:

  • Complete neurological examination
  • CTA if available (preferred within 6h)
  • Basic laboratory panel
  • ECG and chest X-ray
  • Reassess clinical grade
Aneurysm Identified on CTA?
Treatment Capability Assessment

Local Capability Check:

  • Neurosurgeon available?
  • Endovascular capability?
  • Anesthesia and OR ready?
  • ICU bed available?
  • Blood bank prepared?
Can Treat Locally?
Consider aneurysm complexity
Proceed with Treatment
Target: Within 24 hours
⏰ Rebleeding risk highest in first 24 hours

Treatment Selection:

  • Anterior circulation: Consider both options
  • Posterior circulation: Prefer coiling
  • Young patients: Consider clipping durability
  • Elderly patients: Consider coiling safety
Stabilize & Transfer to Tier 3
Urgent Consultation:
📞 Direct physician-to-physician contact
📧 Send imaging via secure transfer
🏥 Arrange expedited transfer
No Aneurysm Visible
Consider non-aneurysmal SAH or occult aneurysm
Consider transfer to Tier 3 for DSA if high clinical suspicion and negative CTA
Post-Treatment Management

ICU Monitoring (Days 1-14):

  • Neurological assessments q1-2h
  • Blood pressure management
  • Vasospasm surveillance (TCD if available)
  • Fluid balance and electrolytes
  • Early mobilization when safe
Complications Developing?
Vasospasm, hydrocephalus, medical issues
Manage Complications

Available Interventions:

  • Induced hypertension for vasospasm
  • EVD for hydrocephalus
  • Medical optimization
  • Consider transfer if refractory
Continue Standard Care
Plan for rehabilitation and discharge

Tier 3: Comprehensive Centers Algorithm

aSAH Patient Received
All patients + complex transfers from Tier 1/2
Multidisciplinary Assessment

Team Evaluation:

  • Neurosurgery evaluation
  • Neurointerventional assessment
  • Neurocritical care consultation
  • Anesthesia planning
  • Advanced imaging (DSA if needed)
Treatment Planning Conference
Optimal modality selection

Decision Factors:

  • Aneurysm location and morphology
  • Patient age and comorbidities
  • Clinical grade and timing
  • Operator expertise
  • Research protocol eligibility
Optimal Treatment Selection
No resource constraints
Endovascular Treatment

Advanced Options:

  • Simple coiling
  • Balloon-assisted coiling
  • Stent-assisted coiling
  • Flow diversion (select cases)
  • WEB devices
Surgical Treatment

Advanced Techniques:

  • Microsurgical clipping
  • Bypass procedures
  • Clot evacuation
  • CSF diversion
  • Combined approaches
Advanced Monitoring & Management

Comprehensive Care:

  • Multimodality neuromonitoring
  • Advanced vasospasm management
  • Endovascular rescue procedures
  • Specialized nursing care
  • Early rehabilitation
Refractory Complications?
Severe vasospasm, medical complications
Advanced Interventions

Rescue Options:

  • Intra-arterial vasodilators
  • Balloon angioplasty
  • Advanced ICU management
  • Experimental protocols
Standard Recovery
Comprehensive rehabilitation
Long-term Follow-up Planning

Comprehensive Follow-up:

  • Imaging surveillance protocol
  • Neuropsychological assessment
  • Quality of life evaluation
  • Return to work planning
  • Family screening if indicated
Regional Support Role:
📞 Consultation for Tier 1/2 centers
📚 Training and education
📊 Quality improvement initiatives
🔬 Research leadership

MENA-SINO aSAH Guidelines © 2024 | For internal medical use only
Always consider local resources, patient factors, and clinical judgment

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