What is the management of a patient with subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Patients with subarachnoid hemorrhage should be transferred to high-volume centers with neurocritical care and comprehensive stroke center services, with both neuroendovascular and cerebrovascular surgeons for optimal management and improved outcomes. 1

Initial Assessment and Stabilization

• Airway and Hemodynamics:

  • Ensure adequate oxygenation and ventilation
  • Control blood pressure to avoid severe hypotension and hypertension
  • Target systolic BP <160 mmHg to reduce rebleeding risk 1, 2
  • Avoid mean arterial pressure <65 mmHg to prevent cerebral ischemia 1

• Diagnosis and Grading:

  • Non-contrast head CT is the cornerstone of diagnosis with near 100% sensitivity in first 3 days 2
  • If high concern for aneurysm and negative/inconclusive CTA, digital subtraction angiography is indicated 1
  • Use clinical scales (Hunt and Hess, World Federation of Neurological Surgeons) to determine severity and predict outcomes 1

Definitive Management of Aneurysm

• Timing: Secure aneurysm as soon as possible, ideally within 24 hours 2

• Treatment Selection:

  • Ruptured aneurysms should be evaluated by both endovascular and neurosurgical specialists 1
  • For anterior circulation aneurysms suitable for both approaches, primary coiling is recommended over clipping to improve 1-year functional outcomes 1
  • For posterior circulation aneurysms, coiling is strongly preferred over clipping 1, 2
  • Emergency clot evacuation is recommended for salvageable patients with large intraparenchymal hematoma 1
  • For patients >70 years, superiority of coiling or clipping is not well established 1
  • For patients <40 years, clipping might be preferred for durability 1

Prevention and Management of Complications

1. Rebleeding Prevention

• Antifibrinolytics: Routine use is not recommended 1
• Blood Pressure Control: Maintain systolic BP <160 mmHg before aneurysm is secured 1, 2

2. Hydrocephalus Management

• Urgent CSF diversion for acute symptomatic hydrocephalus 1, 2
• Permanent CSF diversion for chronic symptomatic hydrocephalus 1
• Implement bundled protocol for management 1

3. Delayed Cerebral Ischemia (DCI) and Vasospasm

• Nimodipine: Administer 60 mg orally every 4 hours for 21 consecutive days 1, 2, 3
  • If patient cannot swallow, extract contents through needle holes in capsule and administer via nasogastric tube 3
  • Reduce dose to 30 mg every 4 hours in patients with liver cirrhosis 3
• Do NOT use:
  • Prophylactic hemodynamic augmentation 1
  • Routine IV magnesium 1
  • Routine statin therapy 1
  • Endothelin antagonists 1
  • IV nicardipine for DCI prevention 1
• For symptomatic vasospasm/DCI:
  • Induced hypertension and maintenance of euvolemia (not hypervolemia) 1, 2, 4
  • Consider angioplasty and/or selective intra-arterial vasodilator therapy 2

4. Seizure Management

• Avoid phenytoin for seizure prevention (associated with excess morbidity and mortality) 1

5. Medical Complications

• Use standardized ICU care bundles for mechanically ventilated patients 1
• Initiate venous thromboembolism prophylaxis after aneurysm is secured 1
• Avoid induction of hypervolemia (potentially harmful) 1
• Monitor and correct electrolytes, particularly hyponatremia 2

Nursing and Monitoring

• Implement evidence-based protocols and order sets 1
• Perform frequent neurological assessments 1, 2
• Monitor vital signs closely 1
• Use validated dysphagia screening protocols 1
• Monitor for development of arterial vasospasm with transcranial Doppler 2
• Consider perfusion imaging (CT or MRI) to identify regions of potential brain ischemia 2

Pitfalls and Caveats

• Misdiagnosis: Up to 1 in 20 SAH patients are initially misdiagnosed 5. Always consider SAH in patients with sudden severe headache.
• Delayed Treatment: Rebleeding risk is highest in the first 24 hours, making early aneurysm securing critical 4, 6.
• Nimodipine Administration: Never administer nimodipine intravenously as it can cause significant hypotension 3.
• Fluid Management: Maintain euvolemia rather than hypervolemia, which can be harmful 1, 7.
• Blood Pressure Control: Excessive BP reduction may compromise cerebral perfusion and induce ischemia, especially with elevated intracranial pressure 1.

The management of subarachnoid hemorrhage requires a specialized neurocritical care team following evidence-based protocols to reduce mortality and improve functional outcomes.