What is the management of subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

The management of subarachnoid hemorrhage (SAH) requires urgent evaluation and treatment with early aneurysm obliteration, blood pressure control, oral nimodipine administration, and vigilant monitoring for complications to reduce mortality and improve neurological outcomes. 1, 2

Initial Assessment and Diagnosis

• Clinical Presentation: Sudden severe headache ("worst headache of life"), often accompanied by nausea, vomiting, neck stiffness, photophobia, and altered mental status 2
• Severity Assessment: Use validated scales (Hunt and Hess, World Federation of Neurological Surgeons) to determine initial clinical severity 1
• Diagnostic Workup:
  • Noncontrast head CT (sensitivity approaches 100% in first 12 hours) 2
  • If CT is negative but clinical suspicion remains high, perform lumbar puncture 1
  • Vascular imaging with CTA or DSA with 3D rotational angiography to identify aneurysm location 2

Immediate Management (First 24 Hours)

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 maintain systolic BP <160 mmHg to reduce rebleeding risk while maintaining cerebral perfusion 1, 2

3. Aneurysm Obliteration:

   • Secure the aneurysm as early as possible (ideally within 24 hours) 2
   • Treatment options include endovascular coiling and surgical clipping 1
   • Decision between approaches should be multidisciplinary 2

4. Medication:

   • Nimodipine: Administer 60 mg orally every 4 hours for 21 days to improve neurological outcomes 1, 3
     • If patient cannot swallow, extract contents from capsule and administer via nasogastric tube 3
     • Reduce dose to 30 mg every 4 hours in patients with liver cirrhosis 3

Management of Complications

1. Rebleeding Prevention

• Early aneurysm obliteration is the definitive treatment 1, 2
• Consider tranexamic acid in the ultra-early period before aneurysm obliteration 4

2. Hydrocephalus Management

• Monitor for signs of acute hydrocephalus 2
• Place external ventricular drain (EVD) if symptomatic 2

3. Delayed Cerebral Ischemia (DCI) and Vasospasm

• Maintain euvolemia (avoid hypovolemia/hypervolemia) 2
• For confirmed DCI:
  • Induced hypertension therapy 2
  • Consider endovascular interventions (angioplasty) for refractory cases 2

4. Electrolyte Management

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

5. Seizure Management

• Prophylactic antiepileptic therapy may be considered, particularly in high-risk patients 5

Ongoing Monitoring

• Continuous neurological assessment to detect deterioration 2
• Transcranial Doppler to monitor for vasospasm 2
• Regular electrolyte monitoring, particularly sodium levels 2
• Once aneurysm is secured, initiate venous thromboembolism prophylaxis 2

Prognosis

• Case fatality rate after aneurysmal hemorrhage is approximately 50% 2
• Outcomes have improved over time with early intervention and aggressive management 2
• Hunt and Hess grade is a strong predictor of outcome:
  • Grade I-III patients have better outcomes
  • Grade IV-V patients have higher mortality and disability rates 1, 2

Special Considerations

• Transfer to high-volume centers (>35 SAH patients/year) with specialized multidisciplinary teams improves outcomes 6
• Patients with sentinel headaches (minor hemorrhage preceding major SAH) should be evaluated urgently, as they have 10-fold higher risk of early rebleeding 2
• Misdiagnosis is associated with nearly 4-fold higher likelihood of death or disability at 1 year 2

The management of SAH has evolved significantly, with improved outcomes resulting from rapid diagnosis, early aneurysm obliteration, and aggressive prevention and treatment of complications in specialized neurocritical care units.