What is the management approach for a patient with suspected subarachnoid hemorrhage?

Management of Subarachnoid Hemorrhage

Immediate Diagnosis and Stabilization

For any patient with suspected subarachnoid hemorrhage, obtain an immediate noncontrast head CT, and if negative but clinical suspicion remains high, proceed directly to lumbar puncture looking for xanthochromia and elevated bilirubin. 1

Diagnostic Approach

• CT sensitivity is time-dependent: 98-100% within 12 hours, declining to 93% at 24 hours and 57-85% by day 6, making early imaging critical 1
• Lumbar puncture must be performed with proper technique when CT is nondiagnostic, specifically analyzing CSF for xanthochromia and bilirubin 1
• Misdiagnosis occurs in up to 12% of cases, so maintain high clinical suspicion for acute severe headache 1

Initial Severity Assessment

• Rapidly grade clinical severity using Hunt and Hess or World Federation of Neurological Surgeons scales—this is the single most useful predictor of outcome 1
• Transfer immediately to a high-volume center (>35 SAH admissions annually) with neurosurgeons, neuroendovascular specialists, and neurointensivists 2

Blood Pressure Management

Control blood pressure with short-acting titratable agents, avoiding both severe hypertension (>180-200 mmHg) and hypotension (MAP <65 mmHg) until the aneurysm is secured. 1, 3

• Gradual BP reduction is necessary when severely hypertensive, but hypotension must be strictly avoided as it worsens cerebral perfusion 3
• Blood pressure variability itself is harmful and should be minimized 2

Nimodipine Administration

Start oral nimodipine 60 mg every 4 hours within 96 hours of hemorrhage onset and continue for 21 consecutive days—this is the only proven pharmacologic intervention to improve neurological outcomes. 1, 4

Administration Details

• Nimodipine improves outcomes but does NOT prevent vasospasm 1
• Never administer intravenously—this can cause life-threatening hypotension requiring pressors 4
• If patient cannot swallow: puncture both ends of capsule with 18-gauge needle, extract contents with parenteral syringe, transfer to oral syringe labeled "Not for IV Use," and administer via nasogastric tube followed by 30 mL normal saline flush 4
• Avoid grapefruit juice during treatment 4

Aneurysm Obliteration

Secure the ruptured aneurysm as early as feasible—this is the only proven method to reduce rebleeding risk and must not be delayed. 3

Treatment Selection

• For anterior circulation aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping to improve 1-year functional outcomes 1, 2
• Posterior circulation aneurysms should be coiled rather than clipped 2
• Both neurosurgical and endovascular specialists must evaluate the aneurysm together to determine optimal approach 2, 3
• Complete obliteration is the goal, but partial treatment to secure the rupture site followed by delayed definitive treatment is acceptable if complete obliteration isn't immediately feasible 2

Timing Considerations

• Ultraearly rebleeding risk is 15% within 24 hours, with 70% occurring within 2 hours of initial SAH—this drives the urgency for early treatment 1
• Preoperative rebleeding rates increase with delayed surgery: 5.7% at 0-3 days, 9.4% at 4-6 days, 12.7% at 7-10 days, 13.9% at 11-14 days, and 21.5% at 15-32 days 1

Acute Hydrocephalus Management

Perform urgent CSF diversion via external ventricular drainage or lumbar drainage if acute symptomatic hydrocephalus develops. 1, 2

• Choice between EVD and lumbar drainage depends on clinical scenario 1
• In patients requiring ventriculostomy, secure the aneurysm early to minimize rebleeding risk 1

Neurocritical Care Unit Management

Admit to a specialized neurocritical care unit with evidence-based protocols and frequent neurological assessments. 2

Fluid Management

• Maintain euvolemia, NOT hypervolemia—prophylactic hypervolemia has not improved outcomes and may be harmful 2
• Avoid prophylactic triple-H therapy (hypertension, hypervolemia, hemodilution) for vasospasm prevention 2, 3
• Goal-directed volume management based on close monitoring 3

Monitoring Strategy

• Implement frequent neurological assessments and vital sign monitoring 3
• Use validated dysphagia screening protocols 2, 3
• Transcranial Doppler monitoring can identify severe vasospasm, though sensitivity and specificity vary by vessel 5, 2
• Lindegaard ratios of 5-6 indicate severe spasm requiring treatment based on clinical situation 5, 2

Delayed Cerebral Ischemia Management

If delayed cerebral ischemia develops, induce hypertension while maintaining euvolemia unless baseline BP is already elevated or cardiac status precludes it. 1, 2

Recognition

• New focal deficits unexplained by hydrocephalus or rebleeding suggest symptomatic vasospasm 5
• Unexplained increases in mean arterial pressure may indicate autoregulatory attempts to prevent ischemia 5
• Maintain higher suspicion in comatose patients where subtle examination changes may be the only sign 5

Treatment Approach

• Elevating blood pressure while maintaining euvolemia benefits patients with symptomatic DCI 2
• Consider endovascular therapies once vasospasm is confirmed 6
• Despite maximal therapy, 15-20% of patients still suffer stroke or die from vasospasm, which accounts for nearly 50% of deaths in patients surviving to treatment 5

What NOT to Do

• Do not use routine antifibrinolytic therapy—it does not improve functional outcomes 3
• Do not routinely use statins, IV magnesium, or endothelin antagonists—they have not shown outcome benefit 2
• Avoid phenytoin for seizure prophylaxis—it is associated with excess morbidity and mortality 2
• Do not delay aneurysm treatment for cardiac workup if troponin is elevated—this represents neurogenic stunned myocardium from catecholamine surge, not primary coronary disease 3

Additional Supportive Care

• Initiate venous thromboembolism prophylaxis once the aneurysm is secured 2
• Use standardized ICU care bundles for mechanical ventilation when required 2
• Emergency reversal of anticoagulants if patient is anticoagulated 2

Follow-up Imaging

Perform immediate post-treatment cerebrovascular imaging to identify aneurysm remnants or recurrence, with delayed follow-up imaging to assess for clinically significant remnants requiring retreatment. 1

Long-term Rehabilitation

• Implement multidisciplinary team approach to identify discharge needs and design rehabilitation 2
• Use validated screening tools for physical, cognitive, and behavioral deficits 2
• Provide interventions for mood disorders to improve long-term outcomes 2