What is the management of subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Immediate Stabilization and Transfer

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

• Rapidly assess neurological status using validated grading scales (Hunt and Hess or World Federation of Neurological Surgeons), as clinical severity at presentation is the strongest predictor of outcome 1, 2
• Control blood pressure with titratable agents before aneurysm obliteration to balance rebleeding risk against maintaining cerebral perfusion pressure 2
• Provide care in a dedicated neurocritical care unit with continuous monitoring for neurological deterioration, intracranial pressure changes, and systemic complications 1, 3

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 1, 2
• If CT is nondiagnostic, proceed to lumbar puncture looking specifically for xanthochromia and bilirubin 2
• Once SAH is confirmed, proceed immediately to cerebrovascular imaging (CT angiography or catheter angiography) to identify the bleeding source 1, 2

Aneurysm Securing

Early aneurysm treatment should be performed as soon as feasible 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, 2
• Time from SAH to treatment is shorter with endovascular coiling (mean 1.1 days) versus surgery (mean 1.8 days), resulting in fewer preoperative hemorrhages 4
• Evaluation by both endovascular and neurosurgical specialists is necessary to determine the optimal treatment approach 3
• Complete obliteration of the aneurysm is recommended whenever possible 2
• Immediate post-treatment cerebrovascular imaging is recommended to identify aneurysm remnants or recurrence 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. 1, 3, 2, 5

• Nimodipine reduces the severity of neurological deficits resulting from vasospasm, though it does not prevent vasospasm itself 5
• If the patient cannot swallow, extract capsule contents with an 18-gauge needle into a syringe labeled "Not for IV Use" and administer via nasogastric tube, followed by 30 mL normal saline flush 5
• Never administer nimodipine intravenously or by other parenteral routes, as this can cause life-threatening hypotension. 5
• Avoid grapefruit juice, as it interferes with nimodipine metabolism 5
• In patients with hepatic cirrhosis, reduce dose to 30 mg every 4 hours due to increased bioavailability 5

Management of Hydrocephalus

Place external ventricular drainage urgently for acute symptomatic hydrocephalus, which is a common and life-threatening complication. 1, 3, 2

• Early aneurysm securing should follow ventriculostomy placement to minimize rebleeding risk through the external ventricular drain 2
• Lumbar drainage may be considered depending on the clinical scenario 2

Prevention and Management 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, 3, 2

• For symptomatic delayed cerebral ischemia, induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it. 1, 3, 2
• Prophylactic hemodynamic augmentation should be avoided in patients at risk for delayed cerebral ischemia 3
• Consider endovascular therapies for symptomatic vasospasm refractory to induced hypertension 6, 7

Antifibrinolytic Therapy

• Short-term tranexamic acid or aminocaproic acid is reasonable to reduce early rebleeding risk in patients with significant delay to aneurysm obliteration and no medical contraindications 1
• This addresses the 15% ultraearly rebleeding risk within 24 hours, with 70% occurring within 2 hours of initial SAH 2

Monitoring and Follow-up

• Implement frequent neurological assessments and vital sign monitoring with validated dysphagia screening protocols 3
• Perform delayed follow-up vascular imaging with strong consideration for retreatment if clinically significant remnants are identified 1, 3, 2
• Monitor for systemic complications including cardiopulmonary complications from increased sympathetic activity, fever, dysnatremia, and dysglycemia 8

Special Considerations for Timing

• Preoperative rebleeding rates increase significantly with delayed treatment: 5.7% at 0-3 days, 9.4% at 4-6 days, 12.7% at 7-10 days, 13.9% at 11-14 days, and 21.5% at 15-32 days 4, 2
• Early surgery facilitates aggressive therapy of vasospasm 4
• Postoperative rebleeding occurs at 1.6% overall and does not differ among time intervals 4