What is the management of aneurysmal subarachnoid hemorrhage?

Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) requires urgent evaluation and treatment with surgical clipping or endovascular coiling as early as feasible to reduce the high risk of rebleeding and mortality. 1

Initial Diagnosis and Assessment

• aSAH is a medical emergency that is frequently misdiagnosed; maintain high suspicion in patients with acute onset of severe headache 1
• Initial diagnostic workup must include:
  • Non-contrast head CT, followed by lumbar puncture if CT is negative 1
  • Rapid clinical severity assessment using validated scales (Hunt and Hess, World Federation of Neurological Surgeons) as these are the strongest prognostic indicators 1
• Digital subtraction angiography (DSA) with 3D rotational angiography is indicated for aneurysm detection and treatment planning 1, 2

Aneurysm Management

• Urgent treatment is essential as early rebleeding risk is high and associated with poor outcomes 1
• Treatment options include:
  • Surgical clipping or endovascular coiling should be performed as early as feasible to reduce rebleeding risk 1
  • For aneurysms amenable to both techniques, endovascular coiling should be considered first 1
  • Complete obliteration of the aneurysm should be achieved whenever possible 1
• Treatment decisions should be made by a multidisciplinary team including experienced cerebrovascular surgeons and endovascular specialists 1
• Microsurgical clipping may be preferred for patients with large (>50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms 1

Medical Management

• Blood pressure control:

  • Between symptom onset and aneurysm obliteration, blood pressure should be controlled with titratable agents to balance stroke risk, rebleeding risk, and cerebral perfusion pressure 1, 3
  • Gradual reduction of blood pressure in severely hypertensive patients, strictly avoiding hypotension 2

• Calcium channel blocker therapy:

  • Oral nimodipine must be administered to all patients at a dose of 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of onset 1, 3
  • Note: Nimodipine improves neurological outcomes but does not prevent cerebral vasospasm 1, 3

• Volume status:

  • Maintain euvolemia and normal circulating blood volume to prevent delayed cerebral ischemia (DCI) 1
  • Hypertension induction is recommended for patients with DCI unless baseline blood pressure is elevated or cardiac status precludes it 1

Management of Complications

• Hydrocephalus management:

  • Acute symptomatic hydrocephalus requires cerebrospinal fluid diversion via external ventricular drainage or lumbar drainage 1
  • Chronic symptomatic hydrocephalus should be treated with permanent CSF diversion 1

• Cerebral vasospasm management:

  • Monitor for development of vasospasm, which typically occurs 3-14 days after hemorrhage 4
  • For symptomatic vasospasm not responding to hypertensive therapy, cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable 1

• Other complications requiring monitoring and management:

  • Seizures, hyponatremia, pulmonary edema, cardiac arrhythmias, fever, anemia, infection, hyperglycemia, and venous thromboembolism 5
  • Early identification and targeted treatment of heparin-induced thrombocytopenia and deep venous thrombosis 1

Hospital Care Considerations

• Low-volume hospitals (<10 aSAH cases per year) should consider early transfer to high-volume centers (>35 aSAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neuro-intensive care services 1
• Care should be provided in a dedicated neurointensive care unit by a multidisciplinary team 2, 4

Follow-up Care

• Immediate cerebrovascular imaging after aneurysm repair is recommended to identify remnants or recurrence requiring treatment 1
• Delayed follow-up vascular imaging should be performed for patients who undergo coiling or clipping, with consideration for retreatment if clinically significant remnants are found 1

Common Pitfalls and Caveats

• Misdiagnosis is common with aSAH; maintain high suspicion for any sudden severe headache 1, 2
• Nimodipine should never be administered intravenously as it can cause significant hypotension 3
• Antifibrinolytic therapy is not recommended for routine use 2
• Routine statin therapy is not recommended to improve outcomes 2
• Avoid grapefruit juice during nimodipine therapy due to drug interactions 3