What is the management of Subarachnoid Hemorrhage (SAH)?

Management of Subarachnoid Hemorrhage (SAH)

The management of aneurysmal subarachnoid hemorrhage (aSAH) requires urgent evaluation and treatment at a high-volume center with a multidisciplinary team to reduce mortality and improve outcomes. 1

Initial Management

• aSAH is a medical emergency that is frequently misdiagnosed. Maintain high suspicion in patients with acute onset of severe headache 1
• Rapid assessment of clinical severity using validated scales (Hunt and Hess, World Federation of Neurological Surgeons) is essential as it is the most useful indicator of outcome 1
• Urgent transfer to high-volume centers (>35 aSAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services is recommended 1
• Between symptom onset and aneurysm obliteration, blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 1

Aneurysm Management

• Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible to reduce the rate of rebleeding 1
• For patients with ruptured aneurysms amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered 1
• Complete obliteration of the aneurysm is recommended whenever possible 1
• After any aneurysm repair, immediate cerebrovascular imaging is recommended to identify remnants or recurrence that may require treatment 1

Prevention and Management of Complications

Vasospasm and Delayed Cerebral Ischemia (DCI)

• Oral nimodipine should be administered to all patients with aSAH at a dose of 60 mg every 4 hours for 21 consecutive days 1, 2
  • Nimodipine has been shown to improve neurological outcomes but not cerebral vasospasm itself 1, 2
  • If the patient cannot swallow, the capsule contents can be extracted and administered via nasogastric tube 2
• Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI 1
• Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it 1
• Administration of large volumes of hypotonic fluids and intravascular volume contraction is not recommended 1
• Monitoring volume status by some combination of central venous pressure, pulmonary wedge pressure, and fluid balance is reasonable 1

Hydrocephalus

• aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drain or lumbar drainage, depending on the clinical scenario) 1

Seizure Management

• The use of prophylactic anticonvulsants may be considered in the immediate posthemorrhagic period 1
• Routine long-term use of anticonvulsants is not recommended but may be considered for patients with known risk factors for delayed seizure disorder 1

Medical Complications

• Aggressive control of fever to a target of normothermia using standard or advanced temperature modulating systems is reasonable 1
• Careful glucose management with strict avoidance of hypoglycemia may be considered 1
• The use of packed red blood cell transfusion to treat anemia might be reasonable in patients at risk of cerebral ischemia 1
• The use of fludrocortisone acetate and hypertonic saline solution is reasonable for preventing and correcting hyponatremia 1
• Early identification and targeted treatment of heparin-induced thrombocytopenia and deep venous thrombosis are recommended 1
• In patients requiring mechanical ventilation for >24 hours, implementation of a standardized ICU care bundle is recommended to reduce duration of mechanical ventilation and hospital-acquired pneumonia 1

Pitfalls and Caveats

• Misdiagnosis is common in aSAH. Always maintain high suspicion with acute severe headache 1
• Delayed diagnosis and treatment significantly increase mortality and morbidity 1
• Hypervolemia is potentially harmful and associated with excess morbidity 1
• Red blood cell transfusions have been associated with worse outcomes in some series, despite their potential benefit in treating anemia 1
• Nimodipine should never be administered intravenously as it can cause significant hypotension 2
• Grapefruit juice should be avoided during nimodipine therapy due to drug interactions 2
• Patients with severely disturbed liver function may require reduced nimodipine dosing (30 mg every 4 hours) due to increased bioavailability 2