What is the management and treatment approach for a patient with a suspected subarachnoid (subarachnoid space) haemorrhage (bleeding)?

Management of Subarachnoid Hemorrhage

Subarachnoid hemorrhage is a medical emergency requiring immediate CT imaging, rapid transfer to a specialized neurovascular center, urgent aneurysm securing within 24 hours, and administration of oral nimodipine 60 mg every 4 hours for 21 days. 1, 2

Immediate Diagnosis

Clinical Recognition

• Maintain high suspicion in any patient presenting with acute onset of severe headache ("worst headache of my life"), which occurs in 80% of patients who can provide history 1
• The misdiagnosis rate remains 12%, and misdiagnosis increases mortality and disability nearly 4-fold 1
• Associated symptoms include nausea/vomiting (77%), loss of consciousness (53%), and nuchal rigidity (35%) 1
• Warning or sentinel headaches occur in 20% of patients before major rupture 1

Diagnostic Workup

• Obtain non-contrast head CT immediately as first-line test 1, 2
• CT sensitivity is 98-100% within 12 hours but declines to 93% at 24 hours and 57-85% by day 6 2, 3
• If CT is negative and clinical suspicion remains high, perform lumbar puncture for CSF analysis looking specifically for xanthochromia and bilirubin 1, 3
• Spectrophotometric analysis of CSF reliably distinguishes traumatic tap from SAH and remains sensitive even 4 weeks after bleeding 4

Vascular Imaging

• Perform selective cerebral angiography (digital subtraction angiography with 3D reconstruction) once SAH is confirmed to identify the bleeding source and plan treatment 1, 5
• CTA or MRA may be considered when conventional angiography cannot be performed timely, though they are less definitive 1
• Approximately 20-25% of initial angiograms show no bleeding source; repeat angiography after 1 week identifies an additional 1-2% of aneurysms 1

Initial Stabilization and Transfer

Neurological Assessment

• Rapidly grade clinical severity using validated scales (Hunt and Hess or World Federation of Neurological Surgeons Scale), as initial clinical severity is the strongest predictor of outcome 1, 3
• Document Glasgow Coma Scale score on admission 1

Airway and Hemodynamic Management

• Ensure adequate airway, breathing, and circulation; perform rapid sequence intubation if Glasgow Coma Scale deteriorates, airway protection is compromised, or respiratory failure develops 1
• Use preoxygenation and pharmacological blunting of reflex responses during intubation to avoid blood pressure fluctuations 1
• Place nasogastric or orogastric tube after intubation to reduce aspiration risk 1

Blood Pressure Control

• Control blood pressure with short-acting titratable intravenous agents (nicardipine, labetalol, or esmolol) to balance rebleeding risk against maintaining cerebral perfusion 1, 3, 5
• Target systolic blood pressure <160 mm Hg, as retrospective data suggest rebleeding is more common with systolic BP >150-160 mm Hg 1
• Avoid hypotension, which can worsen cerebral perfusion 5

Transfer to Specialized Center

• Transfer immediately to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and dedicated neurocritical care units, as this reduces mortality from 39% to 27% 2, 5

Aneurysm Securing

Timing

• Perform early aneurysm treatment (within 24 hours when feasible) to reduce rebleeding risk, which is 15% in the first 24 hours with 70% occurring within 2 hours of initial hemorrhage 2, 3, 5
• The risk of rebleeding is 3-4% in the first 24 hours, then 1-2% per day for the first month, and 3% per year long-term if untreated 1

Treatment Modality Selection

• For aneurysms amenable to both surgical clipping and endovascular coiling, endovascular coiling is preferred based on superior functional outcomes in randomized trials 1, 2, 3
• For good-grade SAH patients (Hunt and Hess I-III) with anterior circulation aneurysms, coiling improves 1-year functional outcomes 5
• For posterior circulation aneurysms amenable to coiling, endovascular treatment is preferred over clipping 5
• Aim for complete aneurysm obliteration whenever technically possible 3

Post-Treatment Imaging

• Perform immediate post-procedure cerebrovascular imaging to identify remnants or incomplete occlusion requiring retreatment 1, 3, 5

Medical Management

Nimodipine Administration

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset 1, 2, 3, 6
• Nimodipine improves neurological outcomes and reduces poor outcomes, though it does not prevent vasospasm itself 3, 6, 4
• If patient cannot swallow, extract capsule contents with 18-gauge needle into oral/NG syringe (never IV syringe), administer via nasogastric tube, and flush with 30 mL normal saline 6
• Never administer nimodipine intravenously—this can cause fatal hypotension 6
• Reduce dose to 30 mg every 4 hours in patients with hepatic cirrhosis due to increased bioavailability 6

Therapies NOT Recommended

• Do not use routine statin therapy—it does not improve outcomes 1, 5
• Do not use intravenous magnesium routinely 1
• Do not use routine antifibrinolytic therapy (tranexamic acid or aminocaproic acid) unless significant delay to aneurysm obliteration exists and no contraindications are present 2, 5

Management of Complications

Hydrocephalus

• Place external ventricular drainage urgently for acute symptomatic hydrocephalus, which is common and life-threatening 1, 2, 3, 5
• For chronic symptomatic hydrocephalus, place permanent CSF shunt 5
• Lumbar drainage may be considered depending on the site of CSF obstruction 7

Delayed Cerebral Ischemia (DCI)

• Maintain euvolemia and normal circulating blood volume through goal-directed fluid management 1, 2, 3, 5
• Do not perform prophylactic hypervolemia or prophylactic hemodynamic augmentation—these do not improve outcomes and may cause harm 1, 2, 3
• For symptomatic DCI, induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it 1, 2, 3
• Consider endovascular intervention for refractory vasospasm 8

Intracranial Pressure Management

• Invasive ICP monitoring may be useful in high-grade SAH patients with limited neurological examination 1
• Control intracranial hypertension and optimize cerebral perfusion pressure 9

Seizure Management

• Identify and treat seizures, though prophylactic anticonvulsants are not routinely recommended in current guidelines 1

Neurocritical Care

ICU Monitoring

• Provide care in dedicated neurocritical care unit with continuous monitoring for neurological deterioration, intracranial pressure changes, and systemic complications 2, 9, 10
• Consider multimodality monitoring including continuous EEG, brain tissue oxygen monitoring, and microdialysis to detect secondary brain injury in potentially reversible states 9
• Monitor for and treat medical complications including electrolyte abnormalities, cardiac dysfunction, respiratory complications, and venous thromboembolism 1, 9, 10

Vasospasm Monitoring

• Use transcranial Doppler ultrasonography for diagnosing and monitoring vasospasm 8
• CTA can detect severe vasospasm but is less accurate for mild-moderate vasospasm 1

Follow-Up Care

Vascular Imaging Surveillance

• Perform delayed follow-up vascular imaging with strong consideration for retreatment if clinically significant remnants are identified 1, 2, 3, 5
• Consider long-term imaging surveillance for de novo aneurysm development, especially in younger patients with multiple aneurysms or ≥2 first-degree relatives with SAH 1

Rehabilitation

• Implement multidisciplinary team approach to identify discharge needs and design rehabilitation treatment 1
• Physical, cognitive, behavioral, and quality of life deficits are common and can persist long-term 1
• Assess whether patients can return to previous occupation, which is a meaningful measure of functional recovery 1

Special Considerations for Poor-Grade SAH

• Patients with Hunt and Hess Grades IV-V have high mortality but potential for meaningful recovery with aggressive treatment 9
• Early aggressive resuscitation, aneurysm repair, and intensive monitoring have improved outcomes even in poor-grade patients 9
• Global cerebral edema, acute ischemic injury on diffusion-weighted imaging, and early vasospasm require particular attention in poor-grade patients 9