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

Acute Management of Subarachnoid Hemorrhage

Immediately secure the airway if needed, obtain non-contrast head CT within minutes, perform lumbar puncture if CT is negative beyond 6 hours, control systolic blood pressure below 160 mmHg with titratable IV agents, start nimodipine 60 mg every 4 hours, and secure the aneurysm within 24 hours—preferably by endovascular coiling for anterior circulation aneurysms. 1

Initial Stabilization and Airway Management

• Ensure adequate airway, breathing, and circulation immediately upon presentation; airway surveillance is paramount because neurological deterioration can occur rapidly. 2
• If endotracheal intubation is required due to decreased consciousness, inability to protect the airway, or respiratory compromise, use rapid-sequence intubation with meticulous pre-oxygenation, pharmacologic blunting of reflex dysrhythmia, and strict avoidance of blood pressure fluctuations. 2, 3
• Place a nasogastric or orogastric tube immediately after intubation to reduce aspiration risk. 2
• Maintain appropriate oxygenation without hyperventilation; monitor with pulse oximetry and arterial blood gas analysis. 2

Diagnostic Workup

Imaging

• Perform non-contrast head CT immediately for any patient with suspected SAH; CT sensitivity is 98–100% within 12 hours of onset but declines to 93% at 24 hours and 57–85% by day 6. 1, 4
• If the CT is negative but clinical suspicion remains high (especially if presentation is beyond 6 hours), proceed directly to lumbar puncture looking for xanthochromia and elevated bilirubin; spectrophotometric analysis performed >6 hours after onset has 100% sensitivity and 95.2% specificity. 2, 1

Vascular Imaging

• Once SAH is confirmed, obtain digital subtraction angiography with three-dimensional rotational imaging immediately to identify the aneurysm and guide definitive treatment planning. 1
• CTA may be considered when conventional angiography cannot be performed in a timely fashion, but selective catheter cerebral angiography remains the standard for diagnosing cerebral aneurysms. 2

Clinical Severity Assessment

• Document the clinical grade on presentation using Hunt-Hess, World Federation of Neurological Surgeons (WFNS), Fisher, or Glasgow Coma Scale; the initial grade is the single most powerful predictor of functional outcome. 1, 4

Blood Pressure Management (Prior to Aneurysm Securing)

• Target systolic blood pressure <160 mmHg using short-acting, titratable intravenous agents (nicardipine, labetalol, or clevidipine) to minimize rebleeding risk while preserving cerebral perfusion. 1, 4
• Never permit mean arterial pressure to fall below 65 mmHg, as hypotension worsens cerebral perfusion and outcomes. 1
• Avoid sudden, profound drops in blood pressure, which may precipitate cerebral ischemia. 1

Pharmacologic Neuroprotection

Nimodipine (Class I Recommendation)

• Administer oral nimodipine 60 mg every 4 hours for 21 days, starting as soon as possible (ideally within 96 hours of SAH onset); nimodipine improves neurological outcomes but does NOT prevent angiographic vasospasm. 1, 4
• If the patient cannot swallow, administer nimodipine via enteral tube (≈80 mg daily) or rectal suppository (≈325 mg daily). 1

Antifibrinolytic Therapy (Limited Role)

• Do NOT routinely use antifibrinolytic therapy; the 2023 ULTRA trial showed that tranexamic acid does not significantly reduce rebleeding rates or improve functional outcomes when aneurysms are secured early. 1
• Short-term antifibrinolytics (<72 hours) may be considered ONLY when aneurysm securing is unavoidably delayed, rebleeding risk is high, and no contraindications exist. 1

Antiplatelet Agents

• Withhold aspirin and other antiplatelet agents until after the aneurysm has been secured. 1

Timing of Aneurysm Securing

Secure the ruptured aneurysm as early as feasible, ideally within 24 hours of presentation, because early rebleeding carries a mortality of 70–80% and early treatment is the only proven intervention to reduce this catastrophic risk. 1, 4

• Rebleeding risk is greatest in the first 2–12 hours, with 4–13.6% occurring within 24 hours and >33% within the first 3 hours. 1

Selection of Definitive Treatment Modality

Anterior Circulation Aneurysms

• For anterior circulation aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping because it yields superior 1-year functional outcomes (Class I, Level A recommendation). 1, 4
• In patients younger than 40 years, surgical clipping may be considered to enhance long-term durability. 1

Posterior Circulation Aneurysms

• For posterior circulation aneurysms, endovascular coiling is strongly favored; the relative risk of death or dependency is 0.41 (95% CI 0.19–0.92) compared with clipping. 1, 4

Large Intraparenchymal Hematoma with Depressed Consciousness

• In patients with a large intraparenchymal hematoma (≈50 cm³) causing markedly decreased consciousness but who retain spontaneous respiration and pain response, perform emergency surgical clot evacuation combined with immediate aneurysm clipping without delay. 1, 4
• This combined approach reduces mortality from approximately 80% to 27% and raises the proportion achieving independent functional status from about 20% to 53%. 1

Wide-Neck or Complex Aneurysms

• For wide-neck aneurysms not amenable to primary coiling or clipping, stent-assisted coiling or flow-diverter devices are reasonable options. 1
• For ruptured fusiform or blister aneurysms, flow-diverter devices are reasonable to reduce mortality. 1

Critical Caveat: Avoid Stents/Flow-Diverters in Ruptured Saccular Aneurysms

• Do NOT use stent-assisted coiling or flow-diverter devices for ruptured saccular aneurysms that are suitable for primary coiling or clipping, because they require dual antiplatelet therapy and increase hemorrhagic complication rates (including ventriculostomy-related bleeding). 1

Treatment Goals

• Aim for complete aneurysm obliteration whenever technically feasible; incomplete obliteration markedly increases the risk of rebleeding and need for retreatment. 1
• If complete obliteration cannot be achieved, partial treatment that secures the rupture site is acceptable acutely, with planned retreatment within 1–3 months. 1

Multidisciplinary Decision-Making

• Treatment modality (coiling vs. clipping) should be decided by a multidisciplinary team comprising cerebrovascular neurosurgeons, endovascular specialists, and neurointensivists. 1

Transfer to Specialized Centers

• Immediately transfer patients from low-volume hospitals (<10 SAH cases/year) to high-volume centers (>35 cases/year) with experienced cerebrovascular surgeons, endovascular specialists, and dedicated neurocritical care services. 1, 4, 5

Management of Acute Hydrocephalus

• Treat acute symptomatic hydrocephalus urgently with cerebrospinal fluid diversion via external ventricular drain (EVD) or lumbar drain using a standardized EVD bundle protocol. 1, 4
• Chronic symptomatic hydrocephalus should be treated with permanent CSF shunting. 1

Fluid and Hemodynamic Management

• Maintain euvolemia; do NOT employ prophylactic hypervolemia ("triple-H" therapy), which lacks supporting evidence and may cause harm. 1

Management of Delayed Cerebral Ischemia (DCI)

• If symptomatic DCI develops, induce hypertension while maintaining euvolemia, unless baseline blood pressure is already elevated or cardiac status precludes it. 1
• Consider cerebral angioplasty and/or selective intra-arterial vasodilator therapy for symptomatic vasospasm that fails to respond promptly to hypertensive therapy. 1

Venous Thromboembolism Prophylaxis

• Initiate pharmacologic VTE prophylaxis once the aneurysm has been secured. 1, 4

Vascular Imaging Follow-Up

• Obtain immediate post-treatment vascular imaging to detect residual aneurysm filling or recurrence. 1
• Schedule follow-up vascular imaging at 6 months and 18 months; retreatment (re-coiling or repeat clipping) should be strongly considered for clinically significant growing remnants. 1

Common Pitfalls to Avoid

• Do NOT delay aneurysm treatment beyond 24 hours when feasible; early rebleeding risk rises progressively and mortality remains 70–80%. 1
• Do NOT use prophylactic hypervolemia, which has not improved outcomes and may be harmful. 1
• Do NOT use stents or flow-diverters for ruptured saccular aneurysms amenable to primary coiling or clipping due to higher complication risk. 1
• Do NOT allow hypotension (MAP <65 mmHg) during blood pressure management, as it compromises cerebral perfusion. 1
• SAH is frequently misdiagnosed; maintain a high level of suspicion in patients with acute onset of severe headache. 2, 3

Evidence Base

Nimodipine therapy and endovascular aneurysm repair are the only two interventions with strong supporting evidence for improving outcomes after subarachnoid hemorrhage; many intensive-care strategies lack robust randomized trial data. 1