Initial Management of Subarachnoid Hemorrhage
Aneurysmal subarachnoid hemorrhage is a medical emergency requiring immediate diagnostic confirmation, urgent blood pressure control, early nimodipine administration, and emergent aneurysm securing to prevent rebleeding and improve neurological outcomes. 1
Immediate Diagnostic Workup
Maintain a high index of suspicion in any patient presenting with acute onset of severe headache, as SAH is frequently misdiagnosed in up to 12% of cases. 1, 2
Obtain noncontrast head CT immediately as the first-line diagnostic test, which has 98-100% sensitivity within the first 12 hours after SAH, declining to 93% at 24 hours. 1, 2
If CT is nondiagnostic, proceed immediately to lumbar puncture looking specifically for xanthochromia and bilirubin in the cerebrospinal fluid. 1, 2
Once SAH is confirmed, perform digital subtraction angiography (DSA) with 3-dimensional rotational angiography to detect and characterize the aneurysm for treatment planning. 1
Initial Clinical Assessment and Stabilization
Rapidly assess clinical severity using validated scales (Hunt and Hess or World Federation of Neurological Surgeons scale), as initial grade is the most useful indicator of outcome. 1, 3
Transfer immediately to a high-volume center (>35 SAH cases per year) with neurocritical care capabilities, experienced cerebrovascular surgeons, and endovascular specialists, as this is associated with lower mortality and better functional outcomes. 1, 3, 4
Admit to a dedicated neurocritical care unit with multidisciplinary team management using evidence-based protocols. 1, 3
Blood Pressure Management
Control blood pressure with a titratable agent between symptom onset and aneurysm obliteration to balance the risk of rebleeding against maintaining adequate cerebral perfusion pressure. 1, 3
The goal is to prevent hypertension-related rebleeding while avoiding hypotension that could worsen cerebral ischemia. 1
Avoid prophylactic hemodynamic augmentation or hypervolemia before aneurysm securing, as this increases iatrogenic risks without proven benefit. 1
Nimodipine Administration
Initiate oral nimodipine 60 mg every 4 hours immediately and continue for 21 consecutive days in all patients with aSAH. 1, 5
Nimodipine improves neurological outcomes and reduces delayed cerebral ischemia, though it does not prevent cerebral vasospasm itself. 1, 5
Do not use intravenous nimodipine or substitute with other calcium channel blockers, as only oral nimodipine has proven efficacy. 1
Do not routinely use statin therapy or intravenous magnesium, as these are not recommended based on current evidence. 1
Aneurysm Securing
Perform surgical clipping or endovascular coiling as early as feasible to reduce the rate of rebleeding, which carries very poor outcomes. 1, 3
The risk of ultraearly rebleeding within 24 hours may be as high as 15%, with 70% occurring within 2 hours of initial SAH. 2
For aneurysms technically amenable to both clipping and coiling, endovascular coiling should be considered as the preferred approach based on better long-term outcomes. 1, 3
Complete obliteration of the aneurysm is the goal whenever technically possible. 1, 3
Evaluation by both neurosurgical and endovascular specialists is necessary to determine the optimal treatment approach. 3, 4
Management of Acute Hydrocephalus
Place external ventricular drainage urgently for acute symptomatic hydrocephalus associated with SAH. 1, 3, 4
Invasive monitoring may also be useful in patients with high-grade aSAH with limited neurological examination. 1
CSF diversion is the cornerstone of managing intraventricular hemorrhage with SAH. 4
Volume and Hemodynamic Management
Maintain euvolemia and normal circulating blood volume to prevent delayed cerebral ischemia. 1, 3
Avoid prophylactic hypervolemia, as it is potentially harmful and associated with excess morbidity. 1, 3
Close monitoring with goal-directed treatment of volume status is essential. 4
Additional Medical Management
Implement aggressive fever control targeting normothermia using standard or advanced temperature modulating systems. 3
Manage glucose carefully with strict avoidance of hypoglycemia. 3
Perform frequent neurological assessments with validated dysphagia screening protocols. 4
Common Pitfalls to Avoid
Do not delay diagnosis in patients with severe headache even if initial presentation is atypical—misdiagnosis significantly increases mortality. 1, 2, 3
Do not use prophylactic triple-H therapy (hypertension, hypervolemia, hemodilution) before aneurysm securing, as hypervolemia increases complications without proven benefit. 1
Do not transfuse red blood cells liberally, as transfusions have been associated with worse outcomes in some series despite potential benefits for anemia. 3
Do not delay aneurysm treatment, as rebleeding risk increases with time (5.7% at 0-3 days to 21.5% at 15-32 days). 2
Post-Treatment Imaging
Obtain immediate cerebrovascular imaging after aneurysm repair to identify remnants or recurrence that may require treatment. 1, 3, 4