Subarachnoid Hemorrhage

• Thunderclap headache: urgent noncontrast CT. If negative and presentation is >6 h or there is a new deficit, do an LP when safe. Within 6 h, a high-quality CT read by an expert can exclude SAH in a neurologically intact patient. CTA or DSA finds the aneurysm.
• Secure a ruptured aneurysm as early as you can, preferably within 24 h, by coiling or clipping. Until then, avoid severe hypertension, hypotension and BP swings with short-acting drugs; SBP <160 is a local target, not a universal 2023 guideline one.
• Give nimodipine 60 mg q4h ×21 d to every patient; delayed cerebral ischemia peaks on day 4–14, so track TCDs and exams.
• Maintain euvolemia — avoid prophylactic hypervolemia; watch Na⁺, seizures, fever, and hydrocephalus (EVD).

Initial Workup and Management of Subarachnoid Hemorrhage

• Sudden severe headache ± loss of consciousness: suspect SAH and get a noncontrast CT now. If CT is negative, do an LP (when safe) if presentation is >6 h or there is a new deficit. Within 6 h, a high-quality CT read by an expert may be enough in a neurologically intact patient.
• Admit to a neuro-ICU: protect the airway; monitor neuro status, BP and ECG closely; control pain; avoid severe hypertension, hypotension and BP swings. No routine antifibrinolytics. Get vascular imaging. Symptomatic hydrocephalus needs urgent CSF diversion. Treat seizures; reserve prophylaxis for selected high-risk patients. Start enteral nimodipine early.
• Aneurysm or other vascular malformation identified?
• Yes
• Secure aneurysm/vascular malformation to prevent rebleeding: neurosurgery plus neurointerventionalist consults to pick optimal plan (clipping vs. coiling of aneurysms, embolization vs. resection of AVM) · aneurysm treatment within 24 hours strongly recommended · evacuate hematoma if focal deficits with herniation or increased ICP
• Aneurysm secured (successfully clipped or coiled)
• Continue enteral nimodipine 60 mg every 4 h (usually 21 days) and keep euvolaemic. Do not raise BP to prevent vasospasm; consider BP augmentation only for symptomatic delayed cerebral ischaemia after assessment.
• Watch for common complications: frequent neurologic examination · ICP monitoring if appropriate · frequent checks of vitals, heart rhythm, electrolytes · Foley catheter for close input/output tracking · → Pathway 26.2
• No
• Digital subtraction angiography if CTA or MRA used initially · consider other cause (trauma, PMSAH) · repeat angiography in 1–3 weeks

Managing Complications After Subarachnoid Hemorrhage

• Altered mental status or new neurologic deficit after SAH
• Timing since initial event?
• Yes
• 4–21 days after the initial event — vasospasm suspected? Fluctuating mental status · new focal neurologic deficit · Fisher grade ≥3 on initial head CT · increased flow velocities on TCD
• Vasospasm strongly suspected?
• Yes
• Suspected symptomatic DCI: first exclude rebleeding, hydrocephalus, seizures and metabolic causes; keep euvolaemic. Once the aneurysm is secured, a trial of raised BP may be reasonable, judged by neurological response and cardiac tolerance. Persistent deterioration needs urgent neurovascular review. There is no fixed MAP percentage or set waiting time.
• Endovascular therapy for angiographic vasospasm: intra-arterial verapamil, nimodipine, nicardipine, or milrinone · balloon angioplasty (proximal intracranial vessel segments)
• No
• Start immediate ICP management (elevate head, mannitol, etc.) → head CT
• No
• 0–3 days after the initial event: if needed intubate for airway protection · begin immediate ICP management (elevate head, mannitol, etc.)
• Head CT
• New SAH/rebleeding?
• Yes
• Immediate neurosurgical management: consider reclipping or re-coiling · treat other aneurysms
• No
• Hydrocephalus?
• Yes
• Place external ventricular drain
• No
• Continue evaluation and ICP management