Appendix: Survey questionnaire
Appendix to “Intensive care of aneurysmal subarachnoid hemorrhage: an international
survey” by Stevens RD et al.
I. Respondent
1) What is your age?
A <30 years
B 30-40 years
C 41-50 years
D 51-60 years
E >60 years
2) Where do you practice?
A USA or Canada
B Europe
C Other
3) What is your primary specialty?
A Internal medicine
B Surgery
C Anesthesiology
D Neurosurgery
E Neurology
F Other
4)
Have you received subspecialty or fellowship training in one of these fields?
A Critical care medicine
B Neurologic critical care
C Cerebrovascular surgery
D Cerebrovascular medicine (stroke)
E Other
5) What professional society are you affiliated with?
A Society for Critical Care Medicine
B European Society for Critical Care Medicine
C Both A and B
D Neither A nor B
II. Institutional characteristics
6) Which hospital setting do you practice in?
A University-affiliated teaching hospital
B Other
7) How many patients with SAH are treated in your institution annually?
A < 20
B 20-40
2
C
D
E
F
41-60
61-80
81-100
>100
8) In your institution, what type of hospital unit are patients with SAH usually admitted to?
A Medical ICU
B Surgical ICU
C Multi-disciplinary ICU
D Neurological / neurosurgical ICU
E Neurosurgical ICU
F Intermediate /stepdown unit
G Other
9) What proportion of patients with SAH admitted to your institution in the last year was
initially treated with endovascular coiling?
A 100%
B 81-99%
C 61-80 %
D 41-60%
E 21-40%
F <20%
10) What proportion of patients with SAH admitted to your institution in the last year was
initially treated with surgical clipping?
A 100%
B 81-99%
C 61-80 %
D 41-60%
E 21-40%
F <20%
11) What proportion of patients with SAH admitted to your institution in the last year
received neither coiling nor clipping?
A 100%
B 81-99%
C 61-80 %
D 41-60%
E 21-40%
F <20%
III. Management of SAH
12) Which statement do you agree with regarding outcomes (mortality, functional status)
following SAH ?
A Outcomes following SAH are largely determined by factors which are independent of
intensive care management
B Outcomes following SAH are significantly influenced by intensive care management
C There are insufficient data regarding the influence of intensive care management on
outcomes following SAH
3
13) For the detection of aneurysm(s) in patients with SAH, which initial vascular diagnostic
modality is most commonly used in your institution?
A Digital subtraction angiography
B CT angiography
14) At your institution, prior to surgical or endovascular aneurysm coiling or clipping, which
measures do you usually implement?
A Control of elevated blood pressure
B Administration of antifibrinolytics (e.g., aminocaproic acid)
C Both A and B
D Neither A nor B
15) Prior to aneurysm clipping or coiling, what is the optimal blood pressure target?
A Blood pressure reduction is not indicated
B Systolic blood pressure < 180 mmHg
C Systolic blood pressure < 160 mmHg
D Systolic blood pressure < 140 mmHg
E Mean arterial pressure < 120 mmHg
F Mean arterial pressure < 100 mmHg
G Mean arterial pressure < 80 mmHg
16) Prior to aneurysm coiling or clipping, which of the following intravenous agents would
be your first choice to control blood pressure?
A Calcium channel blocker (eg., nicardipine, nifedipine)
B Beta blocker (e.g., labetalol, metoprolol, esmolol)
C Hydralazine
D Enalaprilat
E Sodium nitroprusside
F Nitroglycerin
G None of the above
17) In your institution, what is the usual time interval between onset of SAH and surgical or
endovascular therapy ?
A <24 hrs
B 24 –48 hrs
C 48-72 hrs
D >72 hrs
18) Which treatment modality is preferable for SAH patients with a Glasgow Coma Scale of
15 who have a ruptured aneurysm that is narrow-necked, <10 mm in diameter, and
located in the anterior circulation ?
A Endovascular coiling
B Surgical clipping
C Both options are equally suitable
19) Following are some variables which assist in deciding between endovascular aneurysm
coiling versus surgical clipping in patients with SAH. Which in your opinion are the 4
most important factors in favor of endovascular coiling ?
A Poor neurological condition (Hunt and Hess grades IV and V)
B Good neurological condition (Hunt and Hess grades I, II and III)
C Anterior circulation aneurysm
4
D
E
F
G
H
I
J
Posterior circulation aneurysm
Aneurysm diameter
Aneurysm morphology
Age > 70 yrs
Age < 70 yrs
Associated single or multiple organ failure
Availability of qualified personnel (e.g., interventional radiologist)
20) What is your practice regarding the administration of glucocorticoids in patients with
SAH?
A Glucocorticoids are administered to all patients with SAH
B Glucocorticoids are administered to selected patients with SAH
C We do not administer glucocorticoids for SAH
21) What is your practice regarding nimodipine therapy in patients with SAH?
A Nimodipine is administered to all patients with SAH
B Nimodipine is administered to selected patients with SAH
C We do not administer nimodipine for SAH
22) What, in your view, is the rationale for administering nimodipine in SAH?
A Nimodipine has been associated with improved neurological outcomes
B Nimodipine reduces the incidence and severity of vaospasm
C There is no good rationale for nimodipine
23) What is your practice regarding the administration of anticonvulsants in SAH?
A Prophylactic anticonvulsants are administered to all SAH patients
B Prophylactic anticonvulsants are administered in selected SAH patients at higher risk
of seizures
C Anticonvulsants are only administered when there is clinical or
electroencephalographic evidence of seizures
24) What anticonvulsant do you use most commonly in patients with SAH?
A Phenytoin
B Valproic acid
C Phenobarbital
D Carbamazepine
E Other
25) What is your practice regarding unfractionated heparin or low molecular weight heparin
prophylaxis of venous thromboembolism in patients with SAH?
A Heparin prophylaxis is initiated only after the aneurysm has been secured by clipping
or coiling
B Heparin prophylaxis is initiated on admission, regardless of whether the aneurysm
has been secured
C Heparin prophylaxis is held
26) Which of the following glycemic control strategies best matches your clinical practice in
patients with SAH?
A Administer insulin for a target blood glucose of 80 – 110 mg/dL
B Administer insulin for a target blood glucose of 111 – 150 mg/dL
C Administer insulin for a target blood glucose of 151 – 200 mg/dL
D Administer insulin for a target blood glucose of 201 – 250 mg/dL
5
E
Administer insulin only if blood glucose is > 250 mg/dL
27) What is you current practice regarding temperature management in patients with SAH?
A Institute cooling measures for hyperthermia (T > 38.0 degrees Celsius)
B Therapeutic hypothermia (T < 36.0 degrees Celsius) for patients with vasospasm
C A and B
D Neither nor B
28) When do you most commonly use continuous EEG monitoring in patients with SAH?
A To detect episodes of clinically inapparent seizure activity, e.g. non-convulsive status
epilepticus
B To titrate pharmacological coma in patients with refractory intracranial hypertension
or status epilepticus
C To monitor for ischemia
D We do not use continuous EEG
29) Which of the following technique(s) do you use on a routine basis to evaluate cerebral
perfusion in patients with SAH (you may select more than one) ?
A Trancranial Doppler ultrasound
B CT perfusion
C MR perfusion
D PET
E SPECT
F None
30) Which of the following technique(s) do you use on a routine basis to monitor for cerebral
ischemia in patients with SAH (you may select more than one) ?
A Jugular venous oximetry
B Continuous EEG
C Cerebral microdialysis
D Brain tissue oxygen
E Near infrared spectroscopy
F None
31) Which hemodynamic monitor do you most commonly use in patients with SAH?
A Pulmonary artery catheter
B Central venous catheter
C Transpulmonary thermodilution (e.g., PICCO ®)
D Lithium dilution cardiac output (e.g.LIDCO ®)
E Esophageal Doppler
F Other
32) In which of the following patients with SAH would you be most likely to place a
pulmonary artery catheter?
A All patients
B Patients with cerebral vasospasm
C Patients with associated organ dysfunction
D No patients
33) What is your practice regarding hypervolemia, hypertension, hemodilution (triple-H)
therapy in patients with SAH?
6
A Initiate triple-H therapy on admission to the hospital, before and after aneurysm
coiling or clipping
B Initiate triple-H therapy immediately after aneurysm coiling or clipping, to prevent
cerebral vasospasm
C Initiate triple-H therapy after aneurysm coiling or clipping, but only in the presence
of symptomatic cerebral vasospasm
D Do not use triple-H therapy
34) Which of the following is sufficient to prompt triple-H therapy in patients with SAH?
A Neurological deficits consistent with vasospasm
B Transcranial Doppler evidence of vasospasm
C Angiographic evidence of vasospasm
D A and B
E A and C
35) Which of the following is most likely to reverse the effects of cerebral vasospasm in
patients with SAH?
A Increase in central venous pressure
B Increase in pulmonary artery occlusion (“wedge”) pressure
C Increase in mean arterial pressure
D Increase in systolic blood pressure
E Increase in cardiac output
F Net positive fluid balance
G Other
36) In patients with symptomatic vasospasm, what duration of triple-H therapy without
reversal of in neurological deficits would convince you that this therapy has failed?
A >1 hr
B >2 hrs
C >4 hrs
D >8 hrs
E >12hrs
F >24 hrs
37) Which intravenous fluid do you most frequently administer for intravascular volume
expansion in patients with SAH?
A Normal saline
B Lactacted Ringer’s
C Hypertonic saline
D Hetastarch
E Albumin
F Other
38) What is the optimal serum hematocrit in patients with SAH ?
A > 40%
B 36 – 40%
C 31 – 35%
D 26 – 30%
E
< 25%
7
39) In your institution, what is the practice regarding endovascular techniques (cerebral
angioplasty or selective intra-arterial vasodilator injection) for treating patients with
symptomatic vasospasm?
A Endovascular techniques are first line therapies for cerebral vasospasm
B Endovascular techniques are second line therapies, used when triple-H therapy fails
to reverse symptomatic vasospasm
C Endovascular therapies are not used for vasospasm
40) Which of the following agents is most commonly used as a selective intra-arterial
vasodilator in your institution?
A Papaverine
B Verapamil
C Nimodipine
D Nicardipine
E None
41) A subset of patients with SAH is noted to develop severe hypoxemic respiratory failure
associated with pulmonary edema. In your experience, which is the most likely
diagnosis?
A Acute lung injury / acute respiratory distress syndrome
B Cardiogenic pulmonary edema
C Neurogenic pulmonary edema
D None of the above
42) What is your view regarding mechanical ventilation in patients with concurrent SAH and
acute lung injury?
A Lung-protective ventilation (decreased tidal volumes and plateau pressures) should
be instituted in all patients meeting criteria for acute lung injury
B Lung protective ventilation is contraindicated
C Lung protective ventilation is acceptable provided that intracranial pressure and/or
cerebral perfusion pressure are not adversely affected
43) What is your approach regarding the use of positive end-expiratory pressure (PEEP)
patients with concurrent SAH and acute lung injury?
A PEEP should be titrated to whatever level will maximize oxygenation
B PEEP is contraindicated
C Higher levels of PEEP (>10 cmH2O) are acceptable provided that intracranial
pressure and/or cerebral perfusion pressure are not adversely affected
44) A subset of patients with SAH is noted to have increased serum troponin levels, ECG
abnormalities, and left ventricular dysfunction. In your experience, which is the most
likely diagnosis?
A Acute coronary syndrome
B Neurogenic cardiac injury
C None of the above
45) A subset of patients with SAH are noted to develop hypoosmolar hyponatremia. In your
experience, which is the most likely diagnosis?
A Syndrome of inappropriate antidiuretic hormone (SIADH)
B Cerebral salt wasting syndrome
C Adrenal insufficiency
D None of the above