What are the management strategies for Subarachnoid Hemorrhage (SAH)?

Management of Subarachnoid Hemorrhage

Aneurysmal SAH requires immediate transfer to a high-volume center (>35 cases/year), early aneurysm securement via endovascular coiling (preferred when technically feasible), enteral nimodipine 60 mg every 4 hours for 21 days, euvolemia maintenance, and induced hypertension for symptomatic delayed cerebral ischemia. 1

Initial Assessment and Stabilization

Diagnosis

• Maintain high clinical suspicion in any patient with acute onset severe headache, as misdiagnosis occurs in up to 12% of cases 2
• Perform noncontrast head CT immediately (98-100% sensitivity within 12 hours, declining to 93% at 24 hours and 57-85% by day 6) 2
• If CT is nondiagnostic, proceed to lumbar puncture looking specifically for xanthochromia and bilirubin in cerebrospinal fluid 2

Severity Grading

• Rapidly determine clinical severity using validated scales (Hunt and Hess or World Federation of Neurological Surgeons scale), as this is the most useful outcome predictor 2, 3
• Invasive monitoring may be useful in high-grade SAH patients with limited neurological examination 1

Blood Pressure Management

• Control blood pressure with titratable agents between symptom onset and aneurysm obliteration to balance rebleeding risk against maintaining cerebral perfusion pressure 2, 3
• Avoid both hypertension-related rebleeding and hypotension-induced cerebral ischemia 2

Definitive Aneurysm Treatment

Timing and Modality

• Perform surgical clipping or endovascular coiling as early as feasible to reduce rebleeding risk (ultraearly rebleeding within 24 hours occurs in 15% of cases, with 70% occurring within 2 hours) 2, 3
• For aneurysms amenable to both techniques, endovascular coiling should be considered as the preferred approach 2, 3
• Complete obliteration of the aneurysm is recommended whenever technically possible 2, 3

Transfer Considerations

• Urgent transfer to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services is essential 3, 4

Prevention of Delayed Cerebral Ischemia

Nimodipine Administration

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days starting as soon as possible within 96 hours of SAH onset 1, 5
• This improves neurological outcomes and functional recovery, though it does not prevent angiographic vasospasm 1, 5
• If the patient cannot swallow, extract capsule contents with an 18-gauge needle and administer via nasogastric tube with 30 mL normal saline flush 5
• Never administer nimodipine intravenously as this causes life-threatening hypotension 5
• Avoid grapefruit juice as it interferes with nimodipine metabolism 5

Hemodynamic Management

• Maintain euvolemia and normal circulating blood volume to prevent delayed cerebral ischemia 1, 3
• Do not perform prophylactic hemodynamic augmentation or hypervolemia, as this increases iatrogenic complications without benefit 1

Treatment of Symptomatic Delayed Cerebral Ischemia

• Elevate blood pressure (induced hypertension) in patients with symptomatic delayed cerebral ischemia unless baseline blood pressure is already elevated or cardiac status precludes it 1, 3
• This reduces progression and severity of delayed cerebral ischemia 1

Medications NOT Recommended

• Do not routinely use statin therapy for delayed cerebral ischemia prevention 1
• Do not routinely use intravenous magnesium for delayed cerebral ischemia prevention 1

Management of Complications

Hydrocephalus

• Manage acute symptomatic hydrocephalus with cerebrospinal fluid diversion via external ventricular drainage or lumbar drainage depending on clinical scenario 2, 3
• Chronic symptomatic hydrocephalus requires permanent CSF diversion 2

Medical Complications

• Aggressively control fever to normothermia using standard or advanced temperature modulating systems 3
• Carefully manage glucose with strict avoidance of hypoglycemia 3
• Consider packed red blood cell transfusion in patients at risk of cerebral ischemia, though transfusions have been associated with worse outcomes in some series 3
• Implement standardized ICU care bundles in patients requiring mechanical ventilation >24 hours to reduce ventilator duration and hospital-acquired pneumonia 3
• Early identification and targeted treatment of heparin-induced thrombocytopenia and deep venous thrombosis 3

Seizure Management

• Only 6-18% of SAH patients experience seizures, with most occurring before medical evaluation 6
• Prophylactic anticonvulsants may be considered immediately post-hemorrhage but are not routinely recommended long-term unless specific risk factors exist 6

Follow-Up Imaging and Monitoring

Immediate Post-Treatment

• Perform immediate cerebrovascular imaging after aneurysm repair to identify remnants or recurrence requiring treatment 1, 2

Long-Term Surveillance

• Delayed follow-up vascular imaging is recommended after coiling or clipping, with consideration for retreatment if clinically significant remnant exists 1, 2
• Imaging monitoring for de novo aneurysms is important in younger patients with multiple aneurysms or ≥2 first-degree relatives with SAH 1

Rehabilitation and Long-Term Care

Multidisciplinary Approach

• A multidisciplinary team approach to identify discharge needs and design rehabilitation treatment is recommended 1
• Physical, cognitive, behavioral, and quality of life deficits are common and can persist among SAH survivors 1

Screening and Intervention

• Early identification with validated screening tools can identify deficits, especially in behavioral and cognitive domains 1
• Interventions for mood disorders can improve long-term outcomes 1
• Counseling on higher risk for long-term cognitive dysfunction may be beneficial 1

Critical Pitfalls to Avoid

• Never administer nimodipine intravenously - this is a fatal error causing severe hypotension 5
• Avoid hypervolemia - it increases morbidity without proven benefit 1, 3
• Do not delay aneurysm securement - rebleeding risk is highest in first 24 hours with 70% occurring within 2 hours 2
• Do not apply aneurysmal SAH protocols to traumatic SAH - the pathophysiology and treatment priorities differ substantially 6
• Maintain high suspicion for delayed diagnosis - misdiagnosis is common and significantly increases mortality and morbidity 3