How to manage a 26-year-old with subarachnoid hemorrhage, hypertension, and left hemiplegia?

Management of Subarachnoid Hemorrhage with Left Hemiplegia in a 26-Year-Old

The immediate management of this 26-year-old patient with subarachnoid hemorrhage (SAH) and left hemiplegia should focus on securing the airway, controlling blood pressure with titratable agents to maintain systolic BP <160 mmHg, and urgent neurosurgical evaluation for definitive treatment of the aneurysm within 24 hours.

Initial Assessment and Stabilization

• Assess level of consciousness using Glasgow Coma Scale (GCS)
• If GCS ≤8, secure airway immediately 1
• Document neurological deficits, particularly the left hemiplegia
• Grade severity using World Federation of Neurological Surgeons Scale:
  • Grade depends on GCS and presence of motor deficit (left hemiplegia indicates Grade III or higher) 1

Diagnostic Workup

• Non-contrast head CT has already confirmed subarachnoid hemorrhage 2
• CT Angiography (CTA) should be performed immediately to identify aneurysm location 1
• If CTA is negative or inconclusive, proceed to Digital Subtraction Angiography (DSA) with 3D rotational angiography 2
• Repeat CT at 6 and 24 hours to evaluate for hematoma expansion 1

Blood Pressure Management

• Control blood pressure with titratable agents to balance risk of rebleeding against maintaining cerebral perfusion 2
• Target systolic BP <160 mmHg to reduce risk of rebleeding 2, 1
• Avoid excessive BP reduction which may compromise cerebral perfusion 2
• Use short-acting medications for BP control until aneurysm is secured 2
• Avoid sudden, profound BP reduction 2

Definitive Treatment

• Urgent neurosurgical consultation for aneurysm treatment
• Secure the aneurysm as early as possible (ideally within 24 hours) to reduce rebleeding risk 1
• Treatment options include:
  1. Endovascular coiling - preferred for posterior circulation aneurysms 2
  2. Surgical clipping - may be preferred for certain aneurysm morphologies
  • Decision should be made by a multidisciplinary team based on patient and aneurysm characteristics 2

Management of Hemiplegia

• If hemiplegia is due to large intraparenchymal hematoma, emergency clot evacuation should be performed 2
• Monitor for worsening of hemiplegia which may indicate:
  • Rebleeding
  • Developing hydrocephalus
  • Cerebral vasospasm (typically occurs 3-14 days after initial bleed)

Prevention and Management of Complications

Hydrocephalus

• Monitor for signs of acute hydrocephalus (declining consciousness, worsening headache)
• If symptomatic, place external ventricular drain (EVD) 2

Vasospasm and Delayed Cerebral Ischemia

• Administer nimodipine 60 mg orally every 4 hours for 21 days 3
  • If unable to swallow, extract contents of capsule and administer via nasogastric tube 3
  • Nimodipine reduces severity of neurological deficits from vasospasm 3
• Maintain euvolemia to prevent delayed cerebral ischemia (DCI) 2
• Monitor for signs of vasospasm (new or worsening neurological deficits) between days 3-14
• If vasospasm develops:
  • Induced hypertension may be used for DCI treatment 2
  • However, recent evidence suggests limited long-term benefit of hypertension induction 4

Seizure Prevention

• Avoid phenytoin due to association with increased morbidity and mortality 1

Electrolyte Management

• Monitor serum sodium levels regularly
• Hyponatremia occurs in 10-30% of SAH patients 1
• Consider fludrocortisone acetate or 3% hypertonic saline for correction 1

Pitfalls to Avoid

• Delaying aneurysm treatment (highest rebleeding risk is in first hours) 1
• Excessive BP reduction causing cerebral hypoperfusion 1
• Hyperventilation causing cerebral vasoconstriction 1
• Failing to recognize developing hydrocephalus
• Missing signs of delayed cerebral ischemia (3-14 days post-bleed)
• Using hypotonic fluids which may worsen cerebral edema

Monitoring and Follow-up

• Continuous neurological assessment to detect deterioration
• Transcranial Doppler to monitor for vasospasm
• Regular electrolyte monitoring, particularly sodium levels
• Maintain euvolemia and avoid hypovolemia/hypervolemia

This young patient with SAH and hemiplegia requires urgent, specialized neurocritical care management with focus on preventing rebleeding, managing complications, and preserving neurological function.