Treatment of Subarachnoid Hemorrhage
For patients with aneurysmal subarachnoid hemorrhage, secure the ruptured aneurysm as early as feasible using either endovascular coiling (preferred when technically feasible) or neurosurgical clipping, combined with nimodipine 60 mg every 4 hours for 21 days, while maintaining systolic blood pressure <160 mmHg before aneurysm treatment and mean arterial pressure >90 mmHg afterward. 1, 2
Immediate Aneurysm Securing
Treatment Modality Selection
Endovascular coiling should be considered first for ruptured aneurysms judged technically amenable to both coiling and clipping, as it provides superior functional outcomes with a 7% absolute risk reduction in poor outcomes at 1 year 1, 3
Long-term follow-up at 10 years demonstrates that patients treated with endovascular coiling have higher rates of independent survival (82% vs 78%) and are more likely to be alive and independent compared to surgical clipping 4
Surgical clipping may receive increased consideration in specific scenarios: patients with large intraparenchymal hematomas (>50 mL), middle cerebral artery aneurysms, or when endovascular access is not feasible 1
The decision between coiling and clipping should be made by a multidisciplinary team including both experienced cerebrovascular surgeons and endovascular specialists, based on aneurysm characteristics and patient factors 1
Timing of Intervention
Early aneurysm treatment (within 96 hours of hemorrhage onset) is recommended in the majority of cases to reduce the risk of rebleeding, which carries a mortality rate of 20-30% 1, 5
Surgical clipping reduces the absolute risk of poor outcomes by approximately 9.7%, meaning surgery must be performed in 10 patients to prevent one poor outcome 6
Pharmacological Management
Nimodipine Administration
All patients with subarachnoid hemorrhage should receive oral nimodipine 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset 2
Nimodipine reduces the severity of neurological deficits from vasospasm, with particular benefit in patients with Hunt and Hess Grades IV-V (good recovery rate 25.3% vs 10.9% with placebo) 2
For patients who cannot swallow, extract capsule contents using an 18-gauge needle and administer via nasogastric tube, followed by 30 mL normal saline flush 2
Critical warning: Never administer nimodipine intravenously—this can cause fatal cardiovascular collapse 2
Blood Pressure Management
Pre-Aneurysm Securing Phase
Maintain systolic blood pressure <160 mmHg using short-acting, titratable agents (nicardipine or clevidipine preferred) to reduce rebleeding risk while avoiding hypotension 1, 7
Arterial line placement is strongly recommended for continuous beat-to-beat monitoring, as blood pressure targets change dramatically based on treatment phase 7
Avoid mean arterial pressure <65 mmHg at all times, as hypotension compromises cerebral perfusion and increases ischemia risk 7
Avoid rapid blood pressure fluctuations and sudden reductions >70 mmHg in 1 hour, which are associated with increased rebleeding risk 7
Post-Aneurysm Securing Phase
After aneurysm securing, maintain mean arterial pressure >90 mmHg to prevent delayed cerebral ischemia, which typically occurs 4-12 days after hemorrhage 1, 7
For symptomatic vasospasm after aneurysm treatment, induced hypertension should be used as first-line treatment in the absence of cardiac contraindications 7
Maintain euvolemia rather than hypervolemia for vasospasm prevention 7
Monitoring and Complications
Delayed Cerebral Ischemia
Transcranial Doppler monitoring is reasonable to detect arterial vasospasm 7
Perfusion imaging with CT or MRI can identify regions of potential brain ischemia 7
Close neurological examination is essential during blood pressure adjustments to detect early signs of cerebral ischemia 7
Rebleeding Prevention
Complete aneurysm obliteration is recommended whenever possible, as incompletely treated aneurysms have increased rehemorrhage risk 1
Patients with coiled aneurysms require delayed follow-up vascular imaging, with strong consideration for retreatment if clinically significant remnants develop 1
Short-term antifibrinolytic therapy (tranexamic acid or aminocaproic acid for <72 hours) is reasonable only for patients with unavoidable delays in aneurysm obliteration 7
Systems of Care Considerations
Patients should be managed in high-volume centers (>35 SAH patients annually) with both neurosurgical and endovascular capabilities, as these centers demonstrate significantly lower 30-day mortality (27% vs 39% in low-volume centers) 1
Urban teaching hospitals with larger size are associated with better outcomes and lower mortality rates despite longer stays 1
Common Pitfalls to Avoid
Never use prophylactic hyperdynamic therapy or balloon angioplasty for vasospasm prevention—these interventions are not recommended 7
Do not routinely use antifibrinolytic therapy beyond 72 hours, as it does not improve functional outcomes 7
For patients with hepatic cirrhosis, reduce nimodipine dose to 30 mg every 4 hours due to doubled bioavailability from decreased first-pass metabolism 2
Avoid grapefruit juice during nimodipine therapy, as it interferes with CYP3A4 metabolism 2
Do not coadminister strong CYP3A4 inhibitors with nimodipine, as this is contraindicated 2