Management of Subarachnoid Hemorrhage
Admit the patient immediately to a high-volume neurocritical care unit, secure the aneurysm within 24 hours via endovascular coiling (preferred) or surgical clipping, start oral nimodipine 60 mg every 4 hours for 21 days, maintain euvolemia with goal-directed fluid management, control blood pressure to systolic <160 mmHg pre-treatment and induce hypertension if delayed cerebral ischemia develops, and implement VTE prophylaxis once the aneurysm is secured. 1, 2
Initial Stabilization and Diagnosis
Obtain non-contrast head CT immediately as the first diagnostic step; CT sensitivity is 98-100% within 12 hours but declines to 93% at 24 hours and 57-85% by day 6. 2
If CT is negative but clinical suspicion remains high, proceed directly to lumbar puncture looking for xanthochromia and elevated bilirubin. 2
Assess clinical severity using Hunt and Hess or World Federation of Neurological Surgeons scales immediately, as initial grade is the strongest predictor of outcome and guides treatment intensity. 1, 2
Control blood pressure with titratable agents (such as nicardipine or labetalol) to balance rebleeding risk against maintaining cerebral perfusion pressure; target systolic BP <160 mmHg before aneurysm is secured. 1, 2
Transfer and Specialized Care
Transfer patients from low-volume centers (<10 SAH cases/year) to high-volume centers (>35 SAH cases/year) with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services, as this reduces mortality. 1, 2, 3
Manage all patients in a dedicated neurocritical care unit with multidisciplinary teams including cerebrovascular neurosurgeons, neuroendovascular specialists, and neurointensivists. 3, 4
Definitive Aneurysm Treatment
Perform surgical clipping or endovascular coiling as early as feasible (ideally within 24 hours) to reduce rebleeding risk, which is highest in the first 24 hours at 15% and peaks within 2 hours of initial hemorrhage. 1, 2, 5
For aneurysms amenable to both techniques, prefer endovascular coiling as it is associated with lower long-term seizure rates and better functional outcomes compared to surgical clipping. 1, 2, 5
Achieve complete aneurysm obliteration whenever technically possible to prevent rebleeding. 1, 5
Obtain immediate post-treatment cerebrovascular imaging to identify aneurysm remnants, then perform delayed follow-up imaging at 6 and 18 months. 2
Nimodipine Administration (Critical)
Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days starting within 96 hours of hemorrhage onset; this is the only proven pharmacological therapy to prevent delayed cerebral ischemia and improve functional outcomes (Class I, Level of Evidence A). 1, 2, 6
Nimodipine reduces cerebral infarction by 34% and poor outcomes by 40%, though it does not prevent angiographic vasospasm. 2
If the patient cannot swallow, extract capsule contents using an 18-gauge needle and administer via nasogastric tube or PEG, flushing with 30 mL normal saline; never administer intravenously as this can cause fatal hypotension. 6
In patients with hepatic cirrhosis, reduce dose to 30 mg every 4 hours due to increased bioavailability and risk of hypotension. 6
Fluid and Hemodynamic Management
Maintain euvolemia through close monitoring and goal-directed fluid management using crystalloid or colloid fluids; this is reasonable to prevent delayed cerebral ischemia. 1, 2
Avoid prophylactic hypervolemia and triple-H therapy (hypervolemia, hypertension, hemodilution) as hypervolemia is potentially harmful and associated with excess morbidity without improving outcomes. 1, 2
Monitor volume status using continuous hemodynamic parameters including cardiac output, preload, and stroke volume variability, particularly in high-grade SAH patients. 1
Management of Delayed Cerebral Ischemia
For symptomatic delayed cerebral ischemia presenting as new neurological deficits, induce hypertension as first-line therapy to increase cerebral perfusion pressure unless baseline BP is already elevated or cardiac status precludes it. 1, 2
Elevate blood pressure using vasopressors (phenylephrine, norepinephrine) while maintaining euvolemia, not hypervolemia. 2
Do not use routine statin therapy or intravenous magnesium for vasospasm prophylaxis as they have not shown benefit in rigorous clinical trials. 2, 7
Hydrocephalus Management
Treat acute symptomatic hydrocephalus with external ventricular drainage or lumbar drainage depending on clinical scenario (Class I, Level of Evidence B); acute hydrocephalus occurs in 15-87% of patients. 1, 2
Do not wean external ventricular drainage over >24 hours as this does not reduce the need for permanent shunting. 2
Treat chronic symptomatic hydrocephalus with permanent cerebrospinal fluid diversion (ventriculoperitoneal shunt). 1
Medical Complications Management
Respiratory Management
In patients requiring mechanical ventilation for >24 hours, implement a standardized ICU care bundle to reduce duration of mechanical ventilation and hospital-acquired pneumonia. 1
For severe ARDS with life-threatening hypoxemia, consider rescue maneuvers such as prone positioning and alveolar recruitment maneuvers with ICP monitoring. 1
Electrolyte and Metabolic Management
Use mineralocorticoids (fludrocortisone) to treat natriuresis and hyponatremia as this is reasonable and reduces excess sodium excretion and urine volume. 1
Implement effective glycemic control with strict avoidance of hypoglycemia as both hyperglycemia and hypoglycemia worsen outcomes. 1
Temperature Management
- Aggressively control fever to normothermia using antipyretics as fever independently worsens cognitive outcomes; therapeutic temperature management effectiveness for refractory fever is uncertain. 1
Venous Thromboembolism Prophylaxis
Once the ruptured aneurysm is secured, initiate pharmacological or mechanical VTE prophylaxis to reduce the risk of deep venous thrombosis and pulmonary embolism (Class I recommendation). 1
Screen for heparin-induced thrombocytopenia as early identification and targeted treatment are recommended. 1
Invasive Monitoring
- Implement invasive monitoring (intracranial pressure monitoring, arterial lines) in high-grade SAH patients with limited neurological examination to detect early deterioration. 2
Long-Term Management and Rehabilitation
Refer all survivors for comprehensive multidisciplinary evaluation including cognitive, behavioral, and psychosocial assessments using validated screening tools, as physical, cognitive, and quality of life deficits are common and can persist long-term. 2
Target systolic blood pressure <160 mmHg in the chronic phase to prevent aneurysm recurrence. 2
Common Pitfalls to Avoid
Do not induce prophylactic hypervolemia as this increases complications including pulmonary edema, cardiac strain, and does not prevent vasospasm or improve outcomes. 1, 2
Do not use aspirin, enoxaparin, or tirilazad for vasospasm prophylaxis as they have been shown ineffective. 2, 7
Never administer nimodipine intravenously as this can cause fatal cardiovascular collapse; if inadvertently given IV, provide immediate cardiovascular support with pressors and calcium channel blocker overdose treatments. 6
Avoid large volumes of hypotonic fluids and intravascular volume contraction as these worsen cerebral perfusion. 1
Do not hyperventilate mechanically ventilated patients as this causes vasoconstriction and worsens cerebral ischemia. 1