What is the management plan for an adult patient with Subarachnoid Hemorrhage (SAH) and no known comorbid conditions?

Management of Subarachnoid Hemorrhage

Immediate Stabilization and Airway Management

Secure the ruptured aneurysm within 24 hours via endovascular coiling, initiate oral nimodipine 60 mg every 4 hours immediately, maintain systolic blood pressure <160 mmHg until the aneurysm is secured, and transfer the patient to a high-volume neurocritical care center. 1

Airway and Respiratory Management

• Intubate patients with declining consciousness (typically Hunt-Hess Grade IV-V) using rapid sequence intubation with preoxygenation and pharmacological blunting to prevent blood pressure spikes during laryngoscopy 1, 2
• Maintain adequate oxygenation but avoid hyperventilation, as it causes cerebral vasoconstriction and worsens ischemia 1, 2
• For patients requiring mechanical ventilation >24 hours, implement standardized ICU care bundles to reduce ventilator duration and prevent hospital-acquired pneumonia 1

Blood Pressure Control

• Maintain systolic blood pressure <160 mmHg using titratable intravenous agents (such as nicardipine or labetalol) until the aneurysm is secured 1, 2, 3
• Avoid rapid, large reductions in blood pressure as this may worsen cerebral perfusion in the setting of impaired autoregulation 2
• This blood pressure target balances the 15% risk of rebleeding in the first 24 hours (which carries 70% mortality) against maintaining adequate cerebral perfusion 1, 2

Aneurysm Securing

Timing and Method

• Secure the ruptured aneurysm as early as feasible, ideally within 24 hours, to reduce rebleeding risk which carries 70% case fatality 1, 3
• For good-grade aSAH (Hunt-Hess Grades I-III) from anterior circulation aneurysms equally suitable for both treatments, primary endovascular coiling is recommended over surgical clipping to improve 1-year functional outcome 1
• The ruptured aneurysm should be evaluated by specialists with both endovascular and surgical expertise to determine the relative risks and benefits according to patient and aneurysm characteristics 1, 3

Pharmacological Neuroprotection

Nimodipine Administration

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days to all patients with aSAH, starting as soon as possible within 96 hours of hemorrhage onset 1, 2, 4
• Nimodipine is the only proven pharmacological therapy to improve neurological outcomes, reducing severe deficits and improving functional recovery, though it does not prevent angiographic vasospasm 1, 4
• If the patient cannot swallow, extract capsule contents using an 18-gauge needle into a syringe labeled "Not for IV Use" and administer via nasogastric tube, flushing with 30 mL normal saline 4
• Never administer nimodipine intravenously as this can cause life-threatening hypotension 4

Fluid and Hemodynamic Management

Volume Status

• Maintain euvolemia and normal circulating blood volume using goal-directed fluid management with continuous hemodynamic monitoring 1, 2, 3
• Avoid both hypovolemia and prophylactic hypervolemia (triple-H therapy), as hypervolemia does not improve outcomes and increases complications 1, 2
• Use crystalloid or colloid fluids; avoid large volumes of hypotonic fluids 1, 2

Management of Acute Complications

Hydrocephalus

• Manage acute symptomatic hydrocephalus with cerebrospinal fluid diversion via external ventricular drainage (EVD) or lumbar drainage 1, 2
• Monitor for hydrocephalus development through serial neurological examinations and urgent non-contrast head CT if deterioration occurs 2

Delayed Cerebral Ischemia (DCI)

• For symptomatic DCI presenting as new neurological deficits or decreased consciousness (typically days 4-14 post-hemorrhage), induce hypertension as first-line therapy to increase cerebral perfusion 1, 2
• Elevate blood pressure using vasopressors (such as norepinephrine or phenylephrine) while maintaining euvolemia 1, 2
• Ensure nimodipine is being administered as this is the only proven pharmacological therapy to prevent DCI 2

Rebleeding Prevention

• If aneurysm is not yet secured and rebleeding is suspected (sudden neurological deterioration, new headache), expedite definitive treatment with endovascular coiling or surgical clipping 2
• Rebleeding occurs in 15% of patients within the first 24 hours and carries extremely high mortality 2

Critical Care Monitoring

Neurological Monitoring

• Implement invasive monitoring (ICP monitoring, brain tissue oxygen monitoring) in high-grade SAH patients (Hunt-Hess Grades IV-V) with limited neurological examination 1, 2
• Perform serial neurological examinations to detect early deterioration from rebleeding, DCI, or hydrocephalus 1, 2
• Perform urgent non-contrast head CT to identify new hemorrhage, hydrocephalus, or infarction if neurological deterioration occurs 2

Temperature and Metabolic Management

• Aggressively control fever to normothermia using antipyretics or advanced temperature modulation systems, as fever independently worsens cognitive outcomes 1, 2
• Perform careful glucose management with strict avoidance of hypoglycemia, as both hyperglycemia and hypoglycemia worsen outcomes 2

Transfer and Systems of Care

High-Volume Center Transfer

• Transfer patients from low-volume hospitals (<10 SAH cases/year) to high-volume centers (>35 SAH cases/year) with experienced cerebrovascular surgeons, neuroendovascular specialists, and multidisciplinary neurocritical care services 1, 2, 3
• Management at high-volume centers reduces mortality 1, 2
• Patients should be managed in dedicated neurocritical care units with multidisciplinary teams 1, 2

Common Pitfalls to Avoid

• Do not use prophylactic triple-H therapy (hypervolemia, hypertension, hemodilution) as hypervolemia does not improve outcomes and increases complications 2
• Do not use statins or intravenous magnesium routinely as they are not recommended based on current evidence 2
• Do not delay aneurysm treatment beyond 72 hours unless medically necessary, as rebleeding risk increases progressively 3
• Avoid grapefruit juice during nimodipine administration as it affects drug metabolism 4
• In patients with hepatic cirrhosis, reduce nimodipine dose to 30 mg every 4 hours due to increased bioavailability and monitor blood pressure closely 4