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

Acute Management of Subarachnoid Hemorrhage

Secure the ruptured aneurysm within 24 hours of presentation using endovascular coiling (preferred for most cases), start oral nimodipine 60 mg every 4 hours immediately, control systolic blood pressure below 160 mmHg while maintaining MAP ≥65 mmHg, and transfer immediately to a high-volume center with neurocritical care capabilities. 1

Immediate Diagnostic Workup

• Obtain non-contrast head CT immediately—sensitivity is 98-100% within 12 hours but drops to 93% at 24 hours and 57-85% by day 6. 2, 1

• If CT is negative but clinical suspicion remains high (acute severe headache), perform lumbar puncture looking for xanthochromia and elevated bilirubin using spectrophotometric analysis >6 hours after onset (100% sensitivity, 95% specificity). 2, 1

• After confirming SAH, obtain digital subtraction angiography with 3D rotational imaging to identify the aneurysm and plan definitive treatment. 1

• Assess clinical severity immediately using Hunt-Hess or World Federation of Neurological Surgeons (WFNS) scale—this is the single strongest predictor of outcome. 1, 3

Airway and Initial Stabilization

• If intubation is required (decreased consciousness, inability to protect airway), use rapid-sequence intubation with pre-oxygenation, pharmacologic blunting of sympathetic reflexes, and meticulous avoidance of blood pressure swings. 2, 1

• Place nasogastric or orogastric tube immediately after intubation to reduce aspiration risk. 1

• Maintain adequate oxygenation without hyperventilation; monitor with pulse oximetry and periodic arterial blood gases. 2

Blood Pressure Management (Before Aneurysm Secured)

• Target systolic BP <160 mmHg using short-acting titratable IV agents (nicardipine or labetalol) while maintaining MAP ≥65 mmHg. 2, 1

• Never allow MAP to drop below 65 mmHg—hypotension causes cerebral hypoperfusion and worsens outcomes. 1

• Gradual BP reduction is essential; abrupt drops precipitate cerebral ischemia. 1

Nimodipine Administration (Class I, Level A)

• Start oral nimodipine 60 mg every 4 hours within 96 hours of SAH onset and continue for 21 consecutive days. 2, 1, 4

• If the patient cannot swallow, puncture both ends of the capsule with an 18-gauge needle, extract contents into an oral/enteral syringe labeled "Not for IV Use," and administer via nasogastric tube followed by 30 mL normal saline flush. 4

• Nimodipine improves neurological outcomes by 40% and reduces cerebral infarction by 34%, though it does NOT prevent angiographic vasospasm. 3

• Never administer nimodipine intravenously—this causes life-threatening hypotension. 4

Aneurysm Securing (Highest Priority)

Timing

• Secure the aneurysm as early as feasible, ideally within 24 hours, because rebleeding carries 70-80% mortality and 15% of rebleeds occur within the first 24 hours (70% within 2 hours). 2, 1, 5

Treatment Selection

• For anterior circulation aneurysms amenable to both techniques, endovascular coiling is preferred over surgical clipping—it yields superior 1-year functional outcomes (Class I, Level A). 2, 1

• For posterior circulation aneurysms, endovascular coiling is strongly favored—relative risk of death or dependency is 0.41 versus clipping. 2, 1

• For large intraparenchymal hematoma (>50 cm³) with depressed consciousness but retained spontaneous respiration and pain response, perform emergency surgical evacuation plus aneurysm clipping—this reduces mortality from ~80% to ~27%. 2, 1

• For wide-neck aneurysms unsuitable for primary coiling or clipping, stent-assisted coiling or flow-diverter devices are reasonable alternatives. 1

• AVOID stents or flow-diverters for ruptured saccular aneurysms amenable to primary coiling or clipping—they require dual antiplatelet therapy and increase hemorrhagic complications including ventriculostomy-related bleeding. 1

Treatment Goals

• Aim for complete aneurysm obliteration whenever technically possible—incomplete obliteration significantly raises rebleeding risk and need for retreatment. 1, 5

• If complete obliteration cannot be achieved, partial treatment securing the rupture site is acceptable with planned retreatment within 1-3 months. 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 teams. 2, 1

Management of Acute Hydrocephalus

• If acute symptomatic hydrocephalus develops (occurs in 15-87% of patients), perform urgent CSF diversion via external ventricular drainage or lumbar drainage depending on clinical scenario (Class I, Level B). 2, 3

• Do NOT wean EVD over >24 hours—this does not reduce the need for permanent shunting. 2

Prevention of Delayed Cerebral Ischemia (DCI)

• Maintain euvolemia and normal circulating blood volume (Class I, Level B). 2

• AVOID prophylactic hypervolemia and "triple-H" therapy—these lack supporting evidence and may cause harm. 2, 1, 3

Treatment of Symptomatic Delayed Cerebral Ischemia

• If symptomatic DCI develops, induce hypertension while maintaining euvolemia, unless baseline BP is already elevated or cardiac status precludes it (Class I, Level B). 2

• Consider cerebral angioplasty and/or selective intra-arterial vasodilator therapy for symptomatic vasospasm not rapidly responding to hypertensive therapy (Class IIa, Level B). 2

Antifibrinolytic Therapy (Limited Role)

• Short-term antifibrinolytics (<72 hours) with tranexamic acid or aminocaproic acid may be reasonable ONLY when aneurysm securing is unavoidably delayed, rebleeding risk is high, and no contraindications exist (Class IIa, Level B). 2, 1

• The 2023 ULTRA trial showed tranexamic acid does NOT significantly reduce rebleeding or improve outcomes when aneurysms are secured early—therefore, with modern early treatment protocols, antifibrinolytics have minimal role. 1

• Antifibrinolytics increase deep vein thrombosis risk (though not pulmonary embolism). 1

Venous Thromboembolism Prophylaxis

• Initiate pharmacologic VTE prophylaxis once the aneurysm has been secured (Class I, Level B). 1

Post-Treatment Imaging

• Obtain immediate post-treatment vascular imaging to detect residual aneurysm or recurrence requiring further intervention. 1, 3

• Schedule follow-up vascular imaging at 6 months and 18 months; strongly consider retreatment for clinically significant growing remnants. 1, 3

Critical Pitfalls to Avoid

• Do NOT delay aneurysm treatment beyond 24 hours when feasible—early rebleeding risk increases progressively with 70-80% mortality. 1

• Do NOT use prophylactic hypervolemia—it lacks evidence and may be harmful. 1, 3

• Do NOT use stents or flow-diverters for ruptured saccular aneurysms amenable to primary coiling or clipping—higher complication rates. 1

• Do NOT allow hypotension (MAP <65 mmHg)—compromises cerebral perfusion. 1

• Do NOT administer nimodipine intravenously—causes life-threatening hypotension. 4

• Do NOT miss the diagnosis—SAH is misdiagnosed in up to 12% of cases; maintain high suspicion for acute severe headache. 2, 5