What is the management of subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Immediate Stabilization and Transfer

Patients with subarachnoid hemorrhage should be transferred immediately to high-volume centers (>35 SAH cases per year) with experienced cerebrovascular surgeons, endovascular specialists, and dedicated neurocritical care units, as this significantly reduces mortality from 39% to 27%. 1

• Rapidly assess neurological status using validated grading scales (Hunt and Hess or World Federation of Neurological Surgeons Scale), as clinical severity at presentation is the strongest predictor of outcome 1, 2
• Secure the airway using rapid sequence intubation if Glasgow Coma Scale ≤8, inability to protect airway, or respiratory compromise, with careful attention to avoiding blood pressure fluctuations during the procedure 1
• Maintain adequate oxygenation without hyperventilation; monitor with pulse oximetry and arterial blood gases 1

Blood Pressure Management

• Control blood pressure with titratable agents (nicardipine or labetalol) to balance rebleeding risk against maintaining cerebral perfusion pressure 2
• Target systolic blood pressure <160 mmHg prior to aneurysm securing, though optimal targets remain controversial 1, 2
• Avoid rapid, large reductions in blood pressure that may compromise cerebral perfusion 2

Diagnostic Workup

• Obtain non-contrast head CT immediately, which has 98-100% sensitivity within 12 hours but declines to 93% at 24 hours and 57-85% by day 6 2
• If CT is negative but clinical suspicion remains high, perform lumbar puncture looking specifically for xanthochromia and elevated bilirubin 2
• Proceed to cerebrovascular imaging (CT angiography or digital subtraction angiography) once SAH is confirmed to identify the bleeding source 1

Aneurysm Securing

Early aneurysm treatment (within 24-72 hours) should be performed to reduce rebleeding risk, which is 15% within the first 24 hours and carries high mortality. 1, 2

• For aneurysms amenable to both surgical clipping and endovascular coiling, endovascular coiling should be considered as the preferred approach based on superior outcomes in randomized trials. 1
• Treatment decisions must be made by a multidisciplinary team including experienced cerebrovascular neurosurgeons and endovascular specialists, considering both patient and aneurysm characteristics 1
• Complete obliteration of the aneurysm is mandatory whenever technically feasible, as incomplete treatment significantly increases rebleeding risk 1
• Obtain immediate post-treatment cerebrovascular imaging to identify aneurysm remnants requiring retreatment 1, 2

Medical Management

Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days starting within 96 hours of hemorrhage onset to improve neurological outcomes, though it does not prevent vasospasm. 1, 2, 3

• If the patient cannot swallow, extract capsule contents using an 18-gauge needle into an oral syringe labeled "Not for IV Use" and administer via nasogastric tube with 30 mL saline flush 3
• Never administer nimodipine intravenously, as this causes life-threatening hypotension and has resulted in deaths 3
• Reduce nimodipine dose to 30 mg every 4 hours in patients with hepatic cirrhosis due to increased bioavailability 3
• Avoid grapefruit juice, which increases nimodipine levels through CYP3A4 inhibition 3

Prevention of Delayed Cerebral Ischemia

• Maintain euvolemia and normal circulating blood volume through goal-directed fluid management; avoid prophylactic hypervolemia as it does not improve outcomes and may be harmful 1, 4, 2
• Monitor for delayed cerebral ischemia (DCI) with frequent neurological assessments and transcranial Doppler sonography 4, 2
• For symptomatic DCI, induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it 1, 4, 2
• Consider cerebral angioplasty and/or selective intra-arterial vasodilator therapy for patients with symptomatic vasospasm not rapidly responding to hypertensive therapy 1

Management of Hydrocephalus

• Place external ventricular drainage urgently for acute symptomatic hydrocephalus, which is a common and life-threatening complication 1, 4, 2
• Use lumbar drainage as an alternative in select clinical scenarios without obstructive hydrocephalus 1
• Treat chronic symptomatic hydrocephalus with permanent cerebrospinal fluid diversion (ventriculoperitoneal shunt) 1

Antifibrinolytic Therapy

• Short-term tranexamic acid or aminocaproic acid (<72 hours) is reasonable to reduce early rebleeding risk in patients with significant delay to aneurysm obliteration and no medical contraindications 1
• Prolonged antifibrinolytic therapy beyond 72 hours is not recommended due to increased risk of delayed cerebral ischemia 1

Monitoring and Follow-up

• Provide care in a dedicated neurocritical care unit with continuous monitoring for neurological deterioration, intracranial pressure changes, and systemic complications 4, 2
• Implement validated dysphagia screening protocols before oral intake 4
• Perform delayed follow-up vascular imaging (timing and modality individualized) with strong consideration for retreatment if clinically significant remnants are identified 1, 2
• Refer patients for comprehensive cognitive, behavioral, and psychosocial assessments after discharge, as neuropsychological sequelae are common 1

Common Pitfalls

• Do not confuse traumatic SAH with aneurysmal SAH; traumatic SAH requires different management focused on intracranial pressure control rather than aneurysm repair and nimodipine 5
• Avoid prophylactic "triple-H" therapy (hypertension, hypervolemia, hemodilution) as hypervolemia has not been shown to prevent DCI and may cause harm 4, 2
• Do not delay aneurysm treatment beyond 72 hours, as rebleeding risk increases progressively (5.7% days 0-3,9.4% days 4-6,12.7% days 7-10,21.5% days 15-32) 2
• Recognize that up to 12% of SAH cases are initially misdiagnosed; maintain high clinical suspicion in patients with sudden severe headache even if initial presentation seems benign 2