What are the acute management steps for a patient with Subarachnoid Hemorrhage (SAH)?

Acute Management of Subarachnoid Hemorrhage

Immediate Diagnosis and Stabilization

Obtain noncontrast head CT immediately upon clinical suspicion; if negative and suspicion remains high, proceed directly to lumbar puncture looking for xanthochromia and elevated bilirubin. 1

• CT sensitivity is 98-100% within 12 hours but declines to 93% at 24 hours and 57-85% by day 6, making early imaging critical 1
• Rapidly assess clinical severity using Hunt and Hess or World Federation of Neurological Surgeons scales, as initial grade is the strongest predictor of outcome 1

Blood Pressure Management

Control blood pressure with titratable agents (nicardipine, labetalol, or clevidipine) to maintain systolic BP <160 mmHg between symptom onset and aneurysm obliteration. 1, 2

• This balances rebleeding risk against maintaining adequate cerebral perfusion pressure 1
• Avoid hypervolemia during blood pressure management, as this increases complications without improving outcomes 2

Definitive Aneurysm Treatment

Perform endovascular coiling or surgical clipping as early as feasible, with endovascular coiling preferred when both techniques are feasible. 1

• Rebleeding risk is highest in the first 24 hours (15% "ultraearly rebleeding"), with 70% occurring within 2 hours of initial hemorrhage 1
• Complete aneurysm obliteration should be achieved whenever technically possible 1
• Endovascular coiling is associated with lower long-term seizure rates compared to surgical clipping 1

Nimodipine Administration

Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days starting within 96 hours of hemorrhage onset. 3, 1, 4

• This is a Class I, Level of Evidence A recommendation that reduces cerebral infarction by 34% and poor outcomes by 40% 1, 4
• Nimodipine improves neurological outcomes but does not prevent angiographic vasospasm 3, 4
• 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 with 30 mL normal saline flush 4
• DO NOT administer nimodipine intravenously—this can cause life-threatening hypotension 4
• Reduce dose to 30 mg every 4 hours in patients with hepatic cirrhosis due to increased bioavailability 4

Fluid and Volume Management

Maintain euvolemia through close monitoring and goal-directed treatment of volume status; avoid prophylactic hypervolemia. 3, 1

• Induction of hypervolemia is potentially harmful (Class III: Harm recommendation) because of association with excess morbidity 3
• Monitor volume status using central venous pressure, pulmonary wedge pressure, and fluid balance in select patients 3
• Prophylactic triple-H therapy (hypervolemia, hypertension, hemodilution) should not be performed 1

Management of Delayed Cerebral Ischemia

For symptomatic delayed cerebral ischemia, elevate blood pressure (induced hypertension) and maintain euvolemia. 1

• This approach reduces progression and severity of delayed cerebral ischemia 1
• Consider endovascular intervention (balloon angioplasty or vasodilator infusion) for patients who do not improve with hemodynamic augmentation 3

Acute Hydrocephalus Management

Treat acute symptomatic hydrocephalus with external ventricular drainage or lumbar drainage depending on clinical scenario. 3, 1

• This is a Class I, Level of Evidence B recommendation 3
• Acute hydrocephalus occurs in 15-87% of patients 3
• Do not wean external ventricular drainage over >24 hours, as this does not reduce need for permanent shunting 3

Electrolyte Management

Use mineralocorticoids (fludrocortisone) and hypertonic saline to prevent and correct hyponatremia. 3

• This is a Class IIa, Level of Evidence B recommendation 3
• Hyponatremia is common and may be due to cerebral salt wasting or syndrome of inappropriate antidiuretic hormone 3

Glycemic Control

Implement effective glycemic control with strict hyperglycemia management while avoiding hypoglycemia. 3

• This is reasonable to improve outcomes (Class IIa, Level of Evidence B-NR) 3
• Even glucose levels within normal range may be associated with brain energy metabolic crisis in poor-grade SAH 3

Mechanical Ventilation Management

For patients requiring mechanical ventilation >24 hours, implement a standardized ICU care bundle to reduce duration of mechanical ventilation and hospital-acquired pneumonia. 3

• This is a Class I, Level of Evidence B-NR recommendation 3
• For severe ARDS with life-threatening hypoxemia, rescue maneuvers such as prone positioning and alveolar recruitment with ICP monitoring may be reasonable 3

Venous Thromboembolism Prophylaxis

Once the ruptured aneurysm is secured, initiate pharmacological or mechanical VTE prophylaxis. 3

• This is a Class I, Level of Evidence C-LD recommendation 3
• Early identification and targeted treatment of deep venous thrombosis and heparin-induced thrombocytopenia are critical 3

Fever Management

Aggressively control fever to target normothermia using antipyretic medications. 3

• For fever refractory to antipyretics, therapeutic temperature management effectiveness is uncertain (Class IIb, Level of Evidence C-LD) 3
• Fever may result from infectious or noninfectious causes including central fever and systemic inflammatory syndrome 3

Invasive Monitoring

Use invasive monitoring (intracranial pressure monitoring, arterial lines) in high-grade SAH patients with limited neurological examination. 1

• This allows for close monitoring and goal-directed treatment to optimize hemodynamic parameters 3

Medications to Avoid

Do not use routine statin therapy or intravenous magnesium for vasospasm prophylaxis. 1

• Aspirin, enoxaparin, and tirilazad have been shown ineffective 1
• These interventions failed to show benefit in large trials 5

Pain Management

Administer oral acetaminophen as the foundation of headache management; minimize opioid use as efficacy is poor (median pain reduction only -1 point on numeric rating scale). 2

• Avoid medication overuse headache by counseling patients about risks of using simple analgesics >15 days/month or opioids >10 days/month for >3 months 2

Critical Care Setting

Admit patients to high-volume centers (>35 SAH admissions per year) under management of a multidisciplinary specialized team in a neurocritical care unit. 6

• Management by cerebrovascular neurosurgeons, neuroendovascular specialists, and neurointensivists improves outcomes 6
• Over the past 30 years, discharge mortality has considerably decreased due to improved care in specialized neurocritical care units 6