What is the recommended acute management for a patient with suspected or confirmed subarachnoid hemorrhage?

Acute Management of Subarachnoid Hemorrhage

Patients with suspected or confirmed subarachnoid hemorrhage require immediate emergency treatment including rapid diagnostic confirmation, urgent transfer to a specialized neurocritical care center, early aneurysm securing (ideally within 24 hours), blood pressure control with titratable agents, and oral nimodipine 60 mg every 4 hours for 21 consecutive days. 1, 2

Immediate Diagnostic Workup

For patients presenting with acute severe headache, obtain a noncontrast head CT immediately to confirm or exclude SAH. 1

• If the patient presents <6 hours from symptom onset without neurological deficit, a high-quality CT interpreted by a board-certified neuroradiologist may be sufficient to exclude SAH (sensitivity 95-100% within 12 hours). 1

• If the patient presents >6 hours from symptom onset or has any neurological deficit, perform lumbar puncture for xanthochromia analysis if the CT is negative, as CT sensitivity declines to 93% at 24 hours and 57-85% by day 6. 1, 3

• Spectrophotometric analysis for xanthochromia has 100% sensitivity and 95.2% specificity when performed >6 hours after symptom onset. 1

• Once SAH is confirmed, perform digital subtraction angiography (DSA) to identify the aneurysm source and determine optimal treatment strategy. 1

Emergency Stabilization and Transfer

Immediately transfer the patient to a high-volume center (>35 SAH cases/year) with neurosurgical, neuroendovascular, and neurocritical care expertise. 2, 3

• Ensure airway protection—if intubation is required, use rapid sequence protocols with attention to preoxygenation and avoiding blood pressure fluctuations. 1

• Document Hunt and Hess grade or World Federation of Neurological Surgeons scale immediately, as initial clinical grade is the strongest predictor of outcome. 1, 4

• Admit to a dedicated neurocritical care unit with multidisciplinary protocols and frequent neurological assessments. 2, 5

Blood Pressure Management

Control blood pressure with short-acting, titratable intravenous agents (such as nicardipine or labetalol) to maintain systolic BP <160 mm Hg while avoiding hypotension (maintain MAP ≥65 mm Hg). 1, 2, 4

• In severely hypertensive patients (systolic >180-200 mm Hg), reduce BP gradually to balance rebleeding risk against cerebral perfusion. 2

• Hypotension is absolutely contraindicated as it compromises cerebral perfusion and worsens outcomes. 2

• Continue strict BP control until the aneurysm is secured. 2, 4

Nimodipine Administration

Start oral nimodipine 60 mg (two 30 mg capsules) every 4 hours immediately and continue for 21 consecutive days to prevent delayed cerebral ischemia. 2, 6

• Therapy should commence within 96 hours of SAH onset. 6

• If the patient cannot swallow, extract capsule contents with an 18-gauge needle and administer via nasogastric tube followed by 30 mL normal saline flush, or use rectal suppository (325 mg daily). 1, 2, 6

• Never administer nimodipine intravenously—this can cause life-threatening hypotension. 6

Aneurysm Securing

Secure the ruptured aneurysm as early as feasible, ideally within 24 hours, to prevent rebleeding (which carries 70-80% mortality). 1, 2

• For anterior circulation aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping to achieve better 1-year functional outcomes. 1, 2

• For posterior circulation aneurysms, strongly favor endovascular coiling (relative risk 0.41 for death or dependency versus clipping). 2

• For patients with large intraparenchymal hematoma and depressed consciousness, perform emergency surgical clot evacuation combined with aneurysm clipping—this reduces mortality from approximately 80% to 27%. 2

• For wide-neck aneurysms not amenable to primary coiling or clipping, stent-assisted coiling or flow-diverter devices are reasonable options. 2

• Avoid stents or flow diverters for ruptured saccular aneurysms that can be treated with primary coiling or clipping, as they increase complication rates. 2

• Evaluation by both neurosurgical and endovascular specialists is necessary to determine optimal treatment approach. 5

Management of Acute Hydrocephalus

If acute symptomatic hydrocephalus develops, perform urgent cerebrospinal fluid diversion via external ventricular drain (EVD) or lumbar drain. 2, 5

• Use standardized EVD bundle protocols addressing all aspects of management. 1

• This is particularly critical in patients with intraventricular hemorrhage. 5

Fluid Management

Maintain euvolemia with goal-directed volume management—do NOT use prophylactic hypervolemia ("triple-H therapy"). 2, 4

• Prophylactic hypervolemia does not prevent delayed cerebral ischemia and may cause harm. 2, 4

• Monitor volume status closely and treat deviations promptly. 5

Antiplatelet and Anticoagulant Management

Withhold aspirin and other antiplatelet agents until after the aneurysm is secured. 2

• If the patient is anticoagulated, perform emergency reversal of anticoagulation. 2

• After aneurysm securing, initiate venous thromboembolism prophylaxis. 2

Critical Pitfalls to Avoid

• Do not delay aneurysm treatment beyond 24 hours when feasible—early rebleeding carries 70-80% mortality and risk increases progressively. 1, 2

• Do not use prophylactic hypervolemia, which lacks supporting evidence and may be detrimental. 2, 4

• Do not allow hypotension (MAP <65 mm Hg), as it compromises cerebral perfusion. 2

• Do not use stents or flow diverters for ruptured saccular aneurysms amenable to primary coiling or clipping. 2

• Do not administer nimodipine intravenously—this is potentially fatal. 6

• Do not miss the diagnosis—SAH is misdiagnosed in up to 12% of cases, and failure to identify a sentinel bleed before catastrophic rupture can be fatal. 1, 3

Monitoring for Complications

Implement frequent neurological assessments with validated dysphagia screening protocols. 5

• Monitor specifically for rebleeding, hydrocephalus, delayed cerebral ischemia, seizures, and systemic complications. 4

• Avoid systemic insults including hyperglycemia, acidosis, electrolyte abnormalities, hypoxia, and hyperthermia—all worsen outcomes. 4

• If delayed cerebral ischemia develops after aneurysm securing, induce hypertension while maintaining euvolemia (unless baseline BP is already elevated or cardiac status precludes it). 2, 5