How to manage Subarachnoid Intracranial Hemorrhage (SIDH)?

Management of Subarachnoid Intracranial Hemorrhage (SIDH)

The management of subarachnoid hemorrhage requires immediate transfer to a high-volume center with multidisciplinary capabilities including neurosurgeons, neuroendovascular specialists, and neurointensivists for optimal outcomes. 1

Initial Assessment and Diagnosis

• Acute diagnostic workup should include noncontrast head CT, which if nondiagnostic, should be followed by lumbar puncture 2
• CT sensitivity is highest (98-100%) within the first 12 hours after SAH, declining to 93% at 24 hours and 57-85% by day 6 2
• The initial clinical severity of SAH should be rapidly determined using validated scales (e.g., Hunt and Hess, World Federation of Neurological Surgeons) as it is the most useful indicator of outcome 2

Immediate Management

• Blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 2
• Urgent cerebrospinal fluid (CSF) diversion should be performed if acute symptomatic hydrocephalus develops 1
• Emergency reversal of anticoagulants should be performed if the patient is on them 1
• Care should be provided in a neurocritical care unit by a specialized team using evidence-based protocols 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 2
• For patients with ruptured aneurysms technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered 2, 1
• Complete obliteration of the aneurysm is recommended whenever possible 2
• Timing of surgery after SAH is significantly related to the likelihood of preoperative rebleeding, with rates increasing as time passes (0-3 days: 5.7%; 4-6 days: 9.4%; 7-10 days: 12.7%; 11-14 days: 13.9%; 15-32 days: 21.5%) 3

Prevention and Management of Complications

Vasospasm and Delayed Cerebral Ischemia

• Oral nimodipine (60 mg every 4 hours for 21 consecutive days) should be administered to all patients with SAH to improve neurological outcomes 2, 4
• Nimodipine therapy should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage 4
• Maintenance of euvolemia and normal circulating blood volume is recommended to prevent delayed cerebral ischemia (DCI) 2, 1
• Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it 2
• Transcranial Doppler (TCD) should be used to monitor for vasospasm, though its sensitivity and specificity are variable 1

Hydrocephalus

• SAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario) 2
• Small or asymptomatic subdural hematomas should be managed conservatively while treating the CSF leak 3
• Symptomatic hematomas with significant mass effect may need burr hole drainage 3

Seizures

• Prophylactic antiepileptic therapy is generally accepted, though phenytoin should be avoided as it is associated with excess morbidity and mortality 1, 5

Rebleeding Prevention

• The risk of "ultraearly rebleeding" (within 24 hours of initial SAH) may be 15%, which is considerably higher than previously recognized, with high mortality rates 3
• 70% of ultraearly rebleeds occur within 2 hours of initial SAH 3
• In patients with ventriculostomy, early treatment of the ruptured aneurysm should follow to minimize rebleeding risk 3

Long-term Management

• After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment 2
• In the absence of contraindications, patients who undergo coiling or clipping should have delayed follow-up vascular imaging 2
• A multidisciplinary team approach should be implemented to identify discharge needs and design rehabilitation treatment 1
• Validated screening tools should be used to identify physical, cognitive, and behavioral deficits 1

Special Considerations

• For patients with cerebral venous thrombosis in the context of SAH, epidural blood patch should be prioritized as initial treatment, with consideration of anticoagulation on an individual basis 3
• For patients with superficial siderosis, MRI of the brain and spine with blood-sensitive sequences should be performed 3
• Patients with SAH who develop ataxia, hearing loss, or myelopathic features should be evaluated for superficial siderosis 3

Common Pitfalls to Avoid

• Delaying transfer to a specialized center, which can negatively impact outcomes 1
• Inducing hypervolemia prophylactically, which has not been shown to improve outcomes and may be harmful 1
• Using statins, intravenous magnesium, and endothelin antagonists routinely, as they have not been shown to improve outcomes 1
• Administering nimodipine intravenously, which can cause clinically significant hypotension 4
• Delaying aneurysm treatment, which increases the risk of rebleeding 3, 2