What is the management of a patient with a subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

The management of subarachnoid hemorrhage (SAH) requires urgent evaluation and treatment, with early aneurysm obliteration (within 24 hours when feasible), blood pressure control, nimodipine administration, and vigilant monitoring for complications to improve mortality and neurological outcomes.

Initial Diagnostic Approach

• Rapid clinical assessment:

  • Document level of consciousness using Glasgow Coma Scale (GCS)
  • Assess using validated scales (Hunt and Hess, World Federation of Neurological Surgeons) 1, 2
  • Document symptoms: sudden onset severe headache, nausea, vomiting, neck pain/stiffness, photophobia 2

• Immediate imaging:

  • Non-contrast head CT (sensitivity approaches 100% within first 12 hours) 2
  • If CT negative but clinical suspicion remains high, perform lumbar puncture 2
  • Vascular imaging with CTA or DSA with 3D rotational angiography to identify aneurysm location 1, 2

Acute Management

1. Airway management:

   • Secure airway if GCS ≤8 or deteriorating neurological status 2
   • Maintain appropriate oxygenation without hyperventilation 2

2. Blood pressure control:

   • Use titratable agents to balance risk of rebleeding against maintaining cerebral perfusion 1, 2
   • Target systolic BP <160 mmHg to reduce rebleeding risk 2
   • Avoid excessive BP reduction which may compromise cerebral perfusion 1, 2

3. Aneurysm obliteration:

   • Secure aneurysm as early as possible (ideally within 24 hours) 1, 2
   • Treatment options:
     • Endovascular coiling: Preferred for posterior circulation aneurysms and in patients with good-grade SAH from anterior circulation aneurysms 1, 2
     • Surgical clipping: May be preferred for patients <40 years of age and certain aneurysm morphologies 1, 2
     • Decision between approaches should be made by a multidisciplinary team based on patient and aneurysm characteristics 1, 2

4. Pharmacological treatment:

   • Nimodipine: 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of onset 1, 2, 3
     • Only pharmacological treatment shown to improve neurological outcomes 2, 3
     • If unable to swallow, extract contents through holes made in both ends of capsule and administer via nasogastric tube 3
     • Reduce dose to 30 mg every 4 hours in patients with liver cirrhosis 3

Complication Management

1. Hydrocephalus:

   • Monitor for signs (declining consciousness, worsening headache)
   • Place external ventricular drain (EVD) if symptomatic 2

2. Delayed cerebral ischemia (DCI) and vasospasm:

   • Monitor for new or worsening neurological deficits between days 3-14 2
   • Management of symptomatic vasospasm:
     • Induced hypertension and maintenance of euvolemia 1, 2
     • Consider angioplasty and/or selective intra-arterial vasodilator therapy 2

3. Electrolyte management:

   • Monitor serum sodium levels regularly (hyponatremia occurs in 10-30% of SAH patients)
   • Consider fludrocortisone acetate or 3% hypertonic saline for correction 2
   • Avoid hypotonic fluids which may worsen cerebral edema 2

4. Venous thromboembolism prophylaxis:

   • Initiate once the aneurysm is secured 2

Monitoring Protocol

• Continuous neurological assessment to detect deterioration
• Transcranial Doppler to monitor for vasospasm
• Regular electrolyte monitoring, particularly sodium levels 2
• Repeat CT at 6 and 24 hours to evaluate for hematoma expansion 2

Prognosis

• Case fatality rate after aneurysmal hemorrhage is approximately 50%, with one in eight patients dying outside the hospital 2
• Outcome has improved over time with early intervention and aggressive management 2
• Hunt and Hess Grade at presentation is a strong predictor of outcome 2, 3

Common Pitfalls to Avoid

1. Delayed diagnosis - SAH is frequently misdiagnosed; maintain high suspicion with acute onset severe headache 1
2. Delayed aneurysm treatment - increasing risk of rebleeding
3. Excessive BP reduction - may compromise cerebral perfusion
4. Failure to administer nimodipine - only proven pharmacological treatment
5. Volume overload or depletion - maintain euvolemia
6. Missing early signs of complications - requires vigilant monitoring

The management of SAH requires a coordinated approach with rapid diagnosis, early aneurysm obliteration, appropriate medical management, and vigilant monitoring for complications to optimize outcomes and reduce mortality and morbidity.