What is the treatment for subarachnoid hemorrhage?

Treatment of Subarachnoid Hemorrhage

The treatment of subarachnoid hemorrhage requires urgent evaluation and intervention, including early aneurysm repair (clipping or coiling), nimodipine administration, and aggressive management of complications to improve mortality and functional outcomes. 1

Immediate Management

• Diagnosis:

  • Noncontrast head CT is the first diagnostic test; if negative but clinical suspicion remains high, perform lumbar puncture 1
  • Digital subtraction angiography (DSA) with 3D rotational angiography is indicated for aneurysm detection and treatment planning 1

• Initial Stabilization:

  • Secure airway, breathing, and circulation
  • Control blood pressure to balance risk of rebleeding versus maintaining cerebral perfusion pressure 1
  • Avoid sudden, profound BP reduction while treating severe hypertension (>180-200 mmHg) 1

Aneurysm Treatment

• Timing: Perform surgical clipping or endovascular coiling as early as feasible to reduce rebleeding risk 1

• Treatment Selection:

  • For posterior circulation aneurysms: Coiling is preferred over clipping 1
  • For anterior circulation aneurysms in good-grade patients: Primary coiling is recommended over clipping for better 1-year functional outcomes 1
  • For patients >70 years: No clear superiority between coiling or clipping 1
  • For patients <40 years: Clipping might be preferred for better durability 1

• Special Considerations:

  • For wide-neck aneurysms not amenable to standard clipping/coiling: Consider stent-assisted coiling or flow diverters 1
  • For fusiform/blister aneurysms: Flow diverters are reasonable 1
  • Complete aneurysm obliteration should be the goal whenever possible 1

Medical Management

• Nimodipine:

  • Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days 2
  • Start as soon as possible within 96 hours of SAH onset 2
  • If patient cannot swallow, extract contents through needle holes in both ends of capsule and administer via nasogastric tube 2
  • Reduces severity of neurological deficits from vasospasm and improves functional outcomes 2

• Management of Delayed Cerebral Ischemia (DCI):

  • Maintain euvolemia (avoid hypovolemia) 1
  • For symptomatic DCI: Elevate blood pressure and maintain euvolemia 1
  • Avoid prophylactic hypervolemia due to iatrogenic risks 1
  • Do not use routine statin therapy or IV magnesium 1

• Hydrocephalus Management:

  • For acute symptomatic hydrocephalus: Cerebrospinal fluid diversion via external ventricular drain (EVD) or lumbar drainage 1
  • For chronic symptomatic hydrocephalus: Permanent CSF diversion 1

Monitoring and Complications Management

• Invasive Monitoring:

  • Consider for high-grade SAH patients with limited neurological examination 1

• Seizure Management:

  • Prophylactic antiepileptic therapy with phenytoin is generally accepted 3

• Follow-up Imaging:

  • Perform immediate cerebrovascular imaging after aneurysm repair 1
  • Schedule subsequent imaging to monitor for remnants, recurrence, or regrowth 1

Hospital Care Considerations

• Transfer to Specialized Centers:
  • Low-volume hospitals (<10 SAH cases/year) should consider early transfer to high-volume centers (>35 SAH cases/year) 1
  • Multidisciplinary care with neurovascular surgeons, endovascular specialists, and neurointensive care services improves outcomes 1

Rehabilitation and Long-term Care

• Multidisciplinary Approach:
  • Early identification of physical, cognitive, and behavioral deficits using validated screening tools 1
  • Interventions for mood disorders can improve long-term outcomes 1

Common Pitfalls to Avoid

• Delaying aneurysm treatment increases rebleeding risk
• Excessive BP reduction may compromise cerebral perfusion
• Prophylactic hypervolemia provides no benefit and increases complications
• Misdiagnosis of SAH in patients with sudden severe headache (occurs in 1 in 20 emergency presentations) 4
• Overlooking the need for repeat angiography in aneurysmal-pattern SAH with initially negative imaging

By following these evidence-based guidelines, mortality and morbidity from subarachnoid hemorrhage can be significantly reduced, with improved functional outcomes for patients.