From the Guidelines
The treatment of subarachnoid hemorrhage (SAH) should prioritize prompt medical intervention in a neurocritical care setting, with a focus on securing the aneurysm through endovascular coiling, which is now recommended over surgical clipping to improve 1-year patient outcomes, as supported by the ISAT and BRAT trials 1.
Initial Management
The initial management of SAH includes:
- Securing the airway, maintaining adequate oxygenation, and stabilizing hemodynamics with a target systolic blood pressure below 140-160 mmHg to prevent rebleeing
- Starting nimodipine 60 mg orally every 4 hours for 21 days to reduce vasospasm-related ischemic complications, as recommended by the 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage 1
- Providing seizure prophylaxis with levetiracetam 500-1000 mg twice daily for 7 days
- Implementing strict blood pressure control, typically with labetalol, nicardipine, or clevidipine infusions
Definitive Treatment
Definitive treatment involves:
- Securing the aneurysm through endovascular coiling or surgical clipping within 24-72 hours of presentation
- Considering a multidisciplinary discussion for patients with wide-neck aneurysms or ruptured fusiform or blister aneurysms, where stent-assisted coiling or flow diversion may be recommended 1
- Aneurysm obliteration within 24 hours of aSAH is likely superior to delayed treatment, particularly >3 days
Supportive Measures
Supportive measures include:
- Vasospism prevention by maintaining euvolemia and avoiding hyponatremia
- Induced hypertension with vasopressors and balloon angioplasty if vasospasm develops
- Pain control, deep vein thrombosis prophylaxis, stress ulcer prevention, and glycemic control
- External ventricular drainage may be required for hydrocephalus
Long-term Care
Long-term care involves:
- A multidisciplinary team approach to identify discharge needs and design rehabilitation treatment
- Early identification of physical, cognitive, behavioral, and quality of life deficits using validated screening tools
- Interventions for mood disorders and counseling on the higher risk for long-term cognitive dysfunction may be beneficial 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 treatment for subarachnoid hemorrhage (SAH) with nimodipine is:
- Oral administration of 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days.
- Therapy should commence as soon as possible within 96 hours of the onset of SAH.
- The goal of treatment is to reduce the severity of neurological deficits resulting from vasospasm.
- Dosing should be adjusted in patients with severely disturbed liver function or those taking CYP3A4 inhibitors or inducers 2 2.
From the Research
Treatment for Subarachnoid Hemorrhage (SAH)
The treatment for SAH involves a comprehensive approach, including:
- Stabilization of the patient
- Surgical intervention
- Continued intensive care treatment of medical and neurologic complications 3
- Blood pressure control
- Surgical evacuation of clot in selected cases 3
Medical Management
Medical management in the intensive care unit is vital, with careful attention to:
- Fluid and electrolyte balance
- Nutrition
- Cardiopulmonary monitoring
- Close observation for changes in the neurologic exam 3
- Use of antifibrinolytics, timing of aneurysm securement, recognition of cerebral edema, and detection and prevention of delayed cerebral ischemia 4
Pharmacological Treatment
Pharmacological treatment includes:
- Nimodipine, a calcium-channel blocker, to treat arterial spasm in SAH 5, 6, 7
- Prophylactic antiepileptic therapy with phenytoin sodium to prevent seizures 6
- Intravenous nicardipine to treat delayed cerebral ischemia 6
Surgical Treatment
Surgical treatment includes:
- Clipping or coiling of the aneurysm to prevent rebleeding
- Insertion of a drain to treat hydrocephalus 6
- Endovascular coiling to treat aneurysmal SAH 7
Complications Management
Complications of SAH, such as rebleeding, hydrocephalus, delayed cerebral ischemia, and seizures, are managed by: