A Narrative Review of Adherence to Subarachnoid Hemorrhage Guidelines

Over the past 2 decades, a large number of guidelines for aneurysmal subarachnoid hemorrhage (aSAH) management have been proposed. The primary aim of these "evidence-based" guidelines is to improve the care of aSAH patients by summarizing and making current knowledge readily available to clinicians. However, an investigation into aSAH guidelines, their changes along time and their successful translation into clinical practice is still lacking. We performed a literature search of historical events and subarachnoid hemorrhage guidelines using the Entrez PubMed NIH, Embase, and Cochrane databases for articles published up to November of 2016. Data were summarized for guidelines on aSAH management and cross-sectional studies of their application. A total of 11 guidelines and 10 cross-sectional studies on aSAH management were analyzed. The use of nimodipine for the treatment of SAH is the only recommendation that remained consistent across guidelines over time (r=0.82; P<0.05). A shift in the definitive treatment for aneurysms from open surgical clipping to endovascular coiling was also noted (r=-0.91; r=0.96; P<0.005). In addition, definitive treatment for aneurysm is being performed earlier. The use of triple-H therapy and the long-Term administration of anticonvulsive therapy has decreased. Finally, written protocols for aSAH management were not consistently used across tertiary care institutions (r=-0.46; P=0.43; confidence interval,-0.95 to-0.70). We conclude that guidelines related to the management of patients with SAH have evolved from a consensus-based approach into an evidence-based approach. Nevertheless, the translation into clinical practice is limited, suggesting that personalized approaches to care is inherent, and perhaps necessary for aSAH management.