What is the management of subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) requires immediate, aggressive management at high-volume centers with multidisciplinary expertise to significantly reduce morbidity and mortality. 1

Initial Assessment and Management

• SAH is a medical emergency that is frequently misdiagnosed; maintain high suspicion in patients with acute onset of severe headache 1
• Rapidly assess clinical severity using validated scales (Hunt-Hess, World Federation of Neurological Surgeons, or Glasgow Coma Scale) as it strongly predicts outcome 1, 2
• Urgent transfer to high-volume centers (>35 SAH patients/year) with experienced cerebrovascular surgeons, endovascular specialists, and neurocritical care services 1, 3
• Control blood pressure with titratable agents to balance risk of rebleeding against maintaining cerebral perfusion 1, 2
• Maintain airway protection and adequate oxygenation; intubate if decreased level of consciousness or respiratory compromise using rapid sequence intubation protocols 2

Aneurysm Management

• Secure the aneurysm as early as feasible (within 24-72 hours) to reduce rebleeding risk 1, 2
• Multidisciplinary decision-making involving both cerebrovascular surgeons and endovascular specialists to determine optimal treatment approach 4
• For aneurysms amenable to both techniques, endovascular coiling is generally preferred over surgical clipping, especially in:
  • Elderly patients (>70 years) 4
  • Poor-grade SAH (WFNS IV/V) 4
  • Posterior circulation aneurysms 4
• Surgical clipping may be preferable for:
  • Large intraparenchymal hematomas (>50 mL) 4
  • Middle cerebral artery aneurysms 4
• Complete obliteration of the aneurysm should be achieved whenever possible 1, 4

Prevention and Management of Complications

Rebleeding Prevention

• Maintain strict bed rest until aneurysm is secured 2
• Control blood pressure to reduce rebleeding risk while maintaining cerebral perfusion 2, 1
• Avoid hypervolemia as it is potentially harmful 1

Vasospasm and Delayed Cerebral Ischemia (DCI)

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days to all SAH patients 1, 5
• If patient cannot swallow, puncture both ends of nimodipine capsule with 18-gauge needle, extract contents into oral syringe (labeled "Not for IV Use"), and administer via nasogastric tube 5
• Maintain euvolemia through careful fluid management 1, 6
• Monitor for vasospasm using transcranial Doppler and clinical examination 4
• For patients with DCI, induce hypertension unless contraindicated by cardiac status or baseline hypertension 1, 4
• Consider perfusion imaging (CT or MRI) to identify regions of potential brain ischemia 4

Hydrocephalus Management

• Treat acute symptomatic hydrocephalus with cerebrospinal fluid diversion (external ventricular drain or lumbar drain) 1, 2
• Monitor for development of chronic hydrocephalus requiring permanent CSF diversion 2

Seizure Management

• Routine prophylactic anticonvulsants are not recommended 2
• Treat clinical seizures with appropriate anticonvulsants 2

Management of Medical Complications

• Fever control: Aggressively treat fever to achieve normothermia 6, 1
  • Use acetaminophen as first-line antipyretic 6
  • Investigate for infectious causes (pneumonia, UTI, line infections) 6
• Glucose management: Implement strict glycemic control while avoiding hypoglycemia 1, 6
• Anemia: Consider packed red blood cell transfusion for patients at risk of cerebral ischemia, though transfusions have been associated with worse outcomes in some cases 1
• Thrombocytopenia: Early identification and treatment of heparin-induced thrombocytopenia 1
• Deep venous thrombosis: Implement prophylaxis after aneurysm is secured 1
• Hyponatremia: Monitor and manage with mineralocorticoids if needed 6
• Ventilator-associated pneumonia: Implement standardized ICU care bundles for patients requiring mechanical ventilation 1, 6

Pitfalls to Avoid

• Misdiagnosis is common in SAH; maintain high suspicion with acute severe headache 1
• Delayed diagnosis and treatment significantly increase mortality and morbidity 1
• Never administer nimodipine intravenously (can cause severe hypotension) 5
• Avoid hypervolemia as it is associated with excess morbidity 1
• Avoid administration of large volumes of hypotonic fluids 6
• Do not ignore fever as it may be an early sign of developing complications 6
• Avoid grapefruit juice during nimodipine therapy due to drug interactions 5