Treatment of Traumatic Subarachnoid Hemorrhage (tSAH)
Oral nimodipine should be administered to all patients with traumatic subarachnoid hemorrhage as the cornerstone of management to improve neurological outcomes. 1
Initial Assessment and Management
Severity Assessment:
Immediate Stabilization:
Pharmacological Management
Nimodipine Administration:
- Dosage: 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days 1
- Start as soon as possible within 96 hours of onset 1
- If patient cannot swallow, extract contents through holes made in both ends of capsule with 18-gauge needle and administer via nasogastric tube 1
- Nimodipine improves neurological outcomes by 55% in tSAH patients when protocol is followed 4
Blood Pressure Management:
Management of Complications
1. Hydrocephalus
- Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage) 3
- Chronic symptomatic hydrocephalus requires permanent CSF diversion 3
- Weaning external ventricular drainage over >24 hours is not effective in reducing need for ventricular shunting 3
2. Seizures
- Short-term prophylactic anticonvulsants may be considered in the immediate post-hemorrhagic period 3
- Routine long-term use of anticonvulsants is not recommended 3
- Consider long-term anticonvulsants only for patients with risk factors for delayed seizures (prior seizure, intracerebral hematoma, intractable hypertension, infarction) 3
3. Delayed Cerebral Ischemia (DCI)
- Monitor closely with frequent neurological assessments using tools like GCS or NIHSS 3
- For patients with DCI, induced hypertension is recommended 3
- Consider endovascular options including intra-arterial vasodilators and balloon angioplasty for accessible lesions 2
4. Respiratory Management
- For patients requiring mechanical ventilation >24 hours, implement standardized ICU care bundles to reduce duration of ventilation and hospital-acquired pneumonia 3
- For severe ARDS with life-threatening hypoxemia, consider rescue maneuvers such as prone positioning with ICP monitoring 3
Monitoring and Follow-up
- Frequent vital sign and neurological monitoring for detection of neurological changes 3
- Implement validated dysphagia screening before initiating oral intake 3
- After aneurysm repair (if applicable), immediate cerebrovascular imaging is recommended to identify remnants requiring treatment 3
- For isolated tSAH with mild TBI (GCS 13-15), repeat CT scanning within 24 hours has utility as it may identify new lesions or deterioration 5
Special Considerations
- Patients with severe liver dysfunction require dose reduction to 30 mg every 4 hours with close monitoring of blood pressure 1
- Avoid grapefruit juice during nimodipine treatment due to drug interactions 1
- Consider transfer to high-volume centers (>35 SAH cases per year) for optimal management 2
Pitfalls and Caveats
- Nimodipine should NEVER be administered intravenously as it can cause significant hypotension 1
- Misdiagnosis occurs in approximately 12% of SAH cases and is associated with a nearly 4-fold higher likelihood of death or disability 2
- Induction of hypervolemia is potentially harmful due to association with excess morbidity 3
- Routine fenestration of the lamina terminalis is not useful for reducing the rate of shunt-dependent hydrocephalus 3
Early implementation of this treatment protocol, with particular emphasis on nimodipine administration, can significantly improve outcomes in patients with traumatic subarachnoid hemorrhage.