What is the management for a patient with a subarachnoid (below the arachnoid membrane) hemorrhage?

Management of Subarachnoid Hemorrhage

Secure the ruptured aneurysm as soon as feasible—this is the only proven intervention to prevent rebleeding and reduce mortality. 1

Immediate Diagnostic Workup

• Obtain non-contrast head CT immediately; if non-diagnostic but clinical suspicion remains high, proceed to lumbar puncture 2
• Perform digital subtraction angiography (DSA) with 3D reconstruction to identify the aneurysm and plan treatment 2
• Rapidly assess clinical severity using Hunt and Hess or World Federation of Neurological Societies scale—this is the strongest predictor of outcome 2

Aneurysm Obliteration Strategy

The ruptured aneurysm must be evaluated by both endovascular and neurosurgical specialists to determine the optimal treatment approach based on aneurysm characteristics and patient factors. 1

Treatment Selection Algorithm:

• For good-grade anterior circulation aneurysms amenable to both techniques: Primary endovascular coiling is recommended over clipping to improve 1-year functional outcomes 1, 2
• For posterior circulation aneurysms amenable to coiling: Coiling is indicated in preference to clipping 1, 2
• For patients with large intraparenchymal hematoma and depressed consciousness: Emergency surgical clot evacuation should be performed to reduce mortality 1
• For wide-neck aneurysms not amenable to clipping or primary coiling: Stent-assisted coiling or flow diverters are reasonable 1
• For fusiform/blister aneurysms: Flow diverters are reasonable to reduce mortality 1

Important Caveats:

• For patients >70 years old, superiority of coiling versus clipping is not well established 1
• For patients <40 years old, clipping might be preferred for improved durability 1
• Do NOT use stents or flow diverters for ruptured saccular aneurysms amenable to primary coiling or clipping—this increases complication risk 1

Medical Management

Nimodipine (Mandatory):

• Administer oral nimodipine 60 mg every 4 hours within 96 hours of hemorrhage onset and continue for 21 consecutive days 2, 3
• If patient cannot swallow, extract capsule contents with 18-gauge needle into oral syringe (labeled "Not for IV Use"), administer via nasogastric tube, and flush with 30 mL normal saline 3
• NEVER administer nimodipine intravenously—this can cause life-threatening hypotension 3
• For patients with hepatic cirrhosis, reduce dose to 30 mg every 4 hours due to increased bioavailability 3

Blood Pressure Management:

• Control blood pressure with short-acting titratable agents to balance stroke risk, rebleeding risk, and cerebral perfusion pressure maintenance 2
• When severely hypertensive (>180-200 mmHg), implement gradual reduction 2
• Strictly avoid hypotension (mean arterial pressure <65 mmHg) 4

Volume Status:

• Maintain euvolemia through close monitoring and goal-directed treatment 1, 2
• Do NOT induce prophylactic hypervolemia or "triple-H therapy" 4

Complication Management

Hydrocephalus:

• Acute symptomatic hydrocephalus: Manage with cerebrospinal fluid diversion (external ventricular drain or lumbar drainage) 1, 2
• Chronic symptomatic hydrocephalus: Treat with permanent CSF diversion 1, 2

Delayed Cerebral Ischemia:

• Induce hypertension for patients with DCI unless baseline blood pressure is already elevated or cardiac status precludes it 1

What NOT to Do:

• Do NOT use routine antifibrinolytic therapy—it does not improve outcomes 2, 4
• Do NOT use routine statin therapy for outcome improvement 2

Care Setting and Transfer

• Low-volume hospitals (<10 SAH cases/year) should transfer patients early to high-volume centers (>35 SAH cases/year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care 1, 2, 4
• Provide care in a neurocritical care unit with frequent neurological assessments and multimodality monitoring 4, 5

Follow-Up Imaging

• Obtain immediate cerebrovascular imaging after aneurysm repair to identify remnants or recurrence requiring treatment 1, 2
• Schedule delayed follow-up vascular imaging (timing and modality individualized), with strong consideration for retreatment if clinically significant remnant exists 1, 2

Additional Monitoring

• Screen for and treat heparin-induced thrombocytopenia and deep venous thrombosis early 1, 2
• Implement validated dysphagia screening protocols 4
• Use transcranial Doppler for vasospasm monitoring 6