What is the management of Subarachnoid Hemorrhage (SAH)?

From the Guidelines

Management of subarachnoid hemorrhage (SAH) requires prompt and comprehensive care to reduce mortality and improve outcomes, with a focus on securing the airway, maintaining adequate oxygenation, and stabilizing hemodynamics, as recommended by the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1.

Initial Management

Initial management includes:

• Securing the airway
• Maintaining adequate oxygenation
• Stabilizing hemodynamics
• Blood pressure control with a target systolic blood pressure of 140-160 mmHg until the aneurysm is secured
• Nimodipine 60 mg orally every 4 hours for 21 days to prevent vasospasm-related ischemic complications, as supported by the 2023 guideline 1 and previous guidelines 1

Aneurysm Treatment

Aneurysm treatment should occur within 24-72 hours, either through:

• Endovascular coiling
• Surgical clipping Depending on aneurysm characteristics and patient factors, as recommended by the 2023 guideline 1 and previous guidelines 1

Complication Management

Patients should be monitored closely in an ICU setting for complications such as:

• Rebleeding
• Hydrocephalus
• Vasospasm
• Delayed cerebral ischemia If vasospasm develops, treatment includes:
• Induced hypertension (systolic BP 180-220 mmHg)
• Hypervolemia
• Consideration of endovascular interventions like balloon angioplasty or intra-arterial vasodilators, as recommended by the 2012 guideline 1 Ventricular drainage may be necessary for hydrocephalus, as supported by the 2015 guideline 1

Quality of Life and Rehabilitation

A multidisciplinary team approach to identify discharge needs and design rehabilitation treatment is recommended, as stated in the 2023 guideline 1 Early identification with validated screening tools can identify deficits, especially in behavioral and cognitive domains Interventions for mood disorders can improve long-term outcomes, and counseling on the higher risk for long-term cognitive dysfunction may be beneficial, as recommended by the 2023 guideline 1

From the FDA Drug Label

In animal experiments, nimodipine had a greater effect on cerebral arteries than on arteries elsewhere in the body perhaps because it is highly lipophilic, allowing it to cross the blood-brain barrier; concentrations of nimodipine as high as 12. 5 ng/mL have been detected in the cerebrospinal fluid of nimodipine-treated subarachnoid hemorrhage (SAH) patients. Nimodipine has been shown, in 4 randomized, double-blind, placebo-controlled trials, to reduce the severity of neurological deficits resulting from vasospasm in patients who have had a recent subarachnoid hemorrhage (SAH). The recommended oral dose is 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days. Oral nimodipine therapy should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage.

The management of Subarachnoid Hemorrhage (SAH) with nimodipine involves:

• Oral administration of 60 mg every 4 hours for 21 consecutive days
• Initiation of therapy as soon as possible within 96 hours of the onset of SAH
• Monitoring for signs of vasospasm and neurological deficits
• Dose adjustment in patients with severely disturbed liver function or those taking strong inhibitors or inducers of CYP3A4 2, 2, 2

From the Research

Management of Subarachnoid Hemorrhage (SAH)

The management of SAH involves several key components, including:

• Admission of patients to high-volume centers under the management of a specialized and multidisciplinary team 3
• Early identification and management of the bleeding source 3, 4
• Evaluation and treatment decision for unsecured aneurysms by a multidisciplinary team made up of cerebrovascular neurosurgeons, endovascular practitioners, and neurointensivists 3
• Management of patients in the neurocritical care unit with oral nimodipine, blood pressure control, euvolemia, and frequent monitoring for neurologic and systemic complications 3, 5

Pharmacologic Management

Pharmacologic management of SAH focuses on preventing delayed cerebral ischemia (DCI), with nimodipine being the only evidence-based medical intervention 5. Other calcium channel blockers, anti-inflammatory drugs, and neuroprotective agents have been evaluated, but their efficacy is inconclusive 5.

Critical Care Management

Critical care management of SAH patients involves a multidisciplinary team and includes:

• Hemodynamic and respiratory stability upon presentation 4
• Prevention of rebleeding and treatment of hydrocephalus 4
• Securing the aneurysm through endovascular or microsurgical methods 4
• Observation for signs and symptoms of vasospasm and prevention of subsequent medical complications 4, 6
• Detection and treatment of delayed cerebral ischemia, which may be limited by disordered consciousness and augmented by monitoring and imaging technology 7

Guidelines and Recommendations

The American Heart Association/American Stroke Association and the Neurocritical Care Society have published guidelines and recommendations for the management of SAH, emphasizing the importance of a multidisciplinary team and evidence-based practices 3, 6, 7. However, gaps in evidence lead to clinical equipoise in some aspects of critical care management, highlighting the need for further research 7.