What is the management of subarachnoid hemorrhage (SAH)?

From the Guidelines

Management of subarachnoid hemorrhage requires prompt and comprehensive care, with aneurysm securing via endovascular coiling or surgical clipping within 24-48 hours, as recommended by the 2023 American Heart Association/American Stroke Association guideline 1. The initial management includes stabilization of airway, breathing, and circulation, followed by neurological assessment using validated scales such as the Glasgow Coma Scale and Hunt and Hess classification. Patients should be admitted to an intensive care unit for close monitoring. Key interventions include:

• Nimodipine administration at the usual dosing schedule for 14 to 21 days to prevent vasospasm, as supported by Evidence Level A 1
• Blood pressure control with a target systolic pressure below 140-160 mmHg
• Seizure prophylaxis with levetiracetam may be considered for 7 days
• Vasospism prevention includes maintaining euvolemia with isotonic fluids and monitoring for delayed cerebral ischemia between days 3-14
• External ventricular drainage may be required for hydrocephalus management
• Complications to monitor include rebleeding, hydrocephalus, hyponatremia, and cardiac dysfunction
• Rehabilitation should begin early with physical, occupational, and speech therapy as appropriate for the patient's condition. It is crucial to note that decisions regarding modality of treatment should be based on patient-specific characteristics, which include consideration of patient age, clinical grade, size, location, as recommended by the Canadian Stroke Best Practice Recommendations 1. The most recent guideline from the American Heart Association/American Stroke Association, published in 2023, provides updated recommendations based on current evidence for the treatment of patients with aneurysmal subarachnoid hemorrhage 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.

Management of Subarachnoid Hemorrhage:

• The drug of choice is nimodipine.
• The recommended dose is 60 mg every 4 hours for 21 consecutive days.
• Therapy should commence as soon as possible within 96 hours of the onset of subarachnoid hemorrhage.
• Close monitoring of blood pressure and heart rate is necessary, especially in patients with severely disturbed liver function.
• Dose reduction may be necessary in patients with liver cirrhosis or those taking strong inhibitors of CYP3A4 2, 2.

From the Research

Management of Subarachnoid Hemorrhage

• The management of subarachnoid hemorrhage (SAH) involves several key components, including early identification and management of the bleeding source, evaluation and treatment decision for unsecured aneurysms, and management of patients in the neurocritical care unit 3.
• Patients with SAH are at risk for several significant neurologic complications, including hydrocephalus, cerebral edema, delayed cerebral ischemia, rebleeding, seizures, and neuroendocrine abnormalities 3.
• The use of nimodipine, a calcium channel antagonist, has been shown to be effective in reducing the incidence of cerebral vasospasm after SAH 4, 5, 6.
• Continuous selective intra-arterial application of nimodipine has been recommended as a low-risk treatment for refractory cerebral vasospasm after SAH 4.
• Oral nimodipine has been associated with a high rate of hypotension requiring intervention or dose modification in children with SAH 5.
• The acute effects of nimodipine on cerebral vasculature and brain metabolism in high-grade SAH patients have been observed to include decreases in mean arterial pressure (MAP) and cerebral perfusion pressure (CPP) 6.

Diagnosis and Risk Stratification

• A computed tomography (CT) of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure for SAH 7.
• If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered, keeping risks and limitations in mind 7.
• Risk tools can be used to assess the complications for which the patient is at greatest risk 7.

Treatment and Outcomes

• Initiating timely treatment is essential following diagnosis to help mitigate future complications 7.
• The publication of consensus guidelines by the American Heart Association/American Stroke Association and the Neurocritical Care Society has provided clarification on best practices for patients with SAH 3.
• Management of patients with SAH should adhere to currently available treatment guidelines, and several aspects of SAH management remain controversial and need further studies to clarify their role in improving patient outcome 3.