What is the treatment for subarachnoid hemorrhage?

Treatment of Subarachnoid Hemorrhage

Nimodipine 60 mg orally every 4 hours for 21 consecutive days and early aneurysm obliteration (preferably by endovascular coiling for amenable aneurysms) are the only treatments with high-level evidence to improve outcomes in subarachnoid hemorrhage. 1

Immediate Stabilization and Transfer

• Transfer patients immediately to high-volume centers with neurovascular teams and dedicated neurocritical care units, as this reduces mortality from 39% to 27%. 2
• Rapidly assess neurological severity using Hunt and Hess or World Federation of Neurological Surgeons grading scales, which are the strongest predictors of outcome. 2, 3
• Obtain non-contrast head CT immediately (98-100% sensitivity within 12 hours, declining to 93% at 24 hours and 57-85% by day 6). 2, 4

Blood Pressure Management Before Aneurysm Securing

• Control blood pressure with short-acting titratable agents to balance rebleeding risk against maintaining cerebral perfusion pressure. 3, 4
• Avoid both severe hypertension (increases rebleeding risk) and hypotension (worsens cerebral perfusion). 4

Aneurysm Obliteration

• Secure the ruptured aneurysm as early as feasible to reduce rebleeding risk, which is 15% within the first 24 hours with high mortality. 2, 3
• For aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping based on superior functional outcomes in randomized trials. 2, 3, 4
• Complete obliteration of the aneurysm should be achieved whenever possible. 3

Medical Management: Nimodipine

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset. 2, 3, 5
• Nimodipine improves neurological outcomes and reduces severe deficits, though it does not prevent angiographic vasospasm. 1, 5
• If the patient cannot swallow, extract capsule contents with an 18-gauge needle into an oral syringe (labeled "Not for IV Use") and administer via nasogastric tube with 30 mL normal saline flush. 5
• Never administer nimodipine intravenously—this can cause fatal hypotension. 5
• Reduce dose to 30 mg every 4 hours in patients with hepatic cirrhosis due to increased bioavailability. 5

Management of Acute Hydrocephalus

• Place external ventricular drainage urgently for acute symptomatic hydrocephalus, a common and life-threatening complication. 2, 3, 4
• Lumbar drainage is an alternative depending on the clinical scenario. 3

Prevention and Treatment of Delayed Cerebral Ischemia

• Maintain euvolemia and normal circulating blood volume through goal-directed fluid management. 2, 3, 4
• Avoid prophylactic hypervolemia—randomized trials show no benefit in preventing vasospasm or improving cerebral blood flow, and it may be harmful. 1, 2
• For symptomatic delayed cerebral ischemia, induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it. 2, 3, 4

Important Caveat on "Triple-H" Therapy

The traditional "triple-H" (hypervolemia, hypertension, hemodilution) therapy has been largely abandoned. 1 Randomized trials by Lennihan et al. and Egge et al. demonstrated that prophylactic hypervolemia provided no benefit over normovolemia in preventing vasospasm or improving outcomes. 1 Only induced hypertension for symptomatic vasospasm has evidence supporting its use. 2

Intensive Care Unit Management

• Provide care in a dedicated neurocritical care unit with continuous monitoring for neurological deterioration. 2, 4
• Avoid systemic insults: maintain normoglycemia, correct electrolyte abnormalities (especially hypomagnesemia, which is associated with vasospasm), prevent hypoxia and hyperthermia, and aggressively manage infections. 1
• Consider magnesium supplementation, as hypomagnesemia is common after SAH and associated with poor outcomes; intravenous magnesium infusion (64 mmol/L/day for 14 days) may reduce delayed cerebral ischemia by 34%. 1

Antifibrinolytic Therapy

• Short-term tranexamic acid or aminocaproic acid is reasonable to reduce early rebleeding risk in patients with significant delay to aneurysm obliteration and no medical contraindications. 2

Additional Supportive Measures

• Initiate venous thromboembolism prophylaxis once the aneurysm is secured. 4
• Emergency reversal of anticoagulation if the patient is anticoagulated. 4
• Avoid prophylactic anticonvulsants beyond the immediate perioperative period, as guidelines recommend against routine long-term use. 1

Follow-up and Monitoring

• Perform immediate post-procedure cerebrovascular imaging to identify aneurysm remnants or recurrence. 3
• Conduct delayed follow-up vascular imaging with strong consideration for retreatment if clinically significant remnants are identified. 2, 3
• Implement multidisciplinary rehabilitation with validated screening tools for physical, cognitive, and behavioral deficits. 4

Key Evidence Gaps

Most SAH management beyond nimodipine and aneurysm repair is empirically based without high-level evidence. 1 Clot removal with intrathecal fibrinolytic agents showed complications that offset benefits. 1 Nicardipine reduced angiographic spasm by 30% but did not improve outcomes. 1 The field requires more multicenter randomized controlled trials using common data elements. 1