Subarachnoid Hemorrhage

• Thunderclap headache: non-contrast CT (97% sensitive <6 h), LP if negative; CTA/DSA finds the aneurysm.
• Secure the aneurysm within 24–72 h by coiling or clipping, holding SBP <160 until it is secured.
• 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

• Subarachnoid hemorrhage: sudden worst headache of life ± LOC · noncontrast head CT with hyperdensity (blood) in basal cisterns, Sylvian fissure, and sulci; blood may also fill the ventricles · lumbar puncture shows xanthochromia when head CT is negative
• Admit to intensive care unit, ideally a specialized neuro-ICU · bed rest, airway protection, keep MAP <110 mm Hg, consider antifibrinolytic agent to prevent rebleeding, frequent neurological examinations, EKG · use antiseizure medication selectively (e.g., seizures, cortical involvement, intraparenchymal hematoma, or other high-risk features) rather than routine prophylaxis, laxatives, pain and anxiety control · order cerebral angiography · place EVD for signs of hydrocephalus (drowsiness, large ventricles on head CT)
• Aneurysm or other vascular malformation identified?
• 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)
• Early vasospasm prevention: keep euvolemia · permissive hypertension (hold antihypertensives) · nimodipine 60 mg orally or enterally every 4 hours
• 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
• 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?
• 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?
• Treat as vasospasm: maintain euvolemia (prophylactic hypervolemia is harmful) · raise MAP 15% above patient's baseline, vasopressors if needed · consider hemodynamic monitoring with heart failure or pulmonary edema to optimize hemodynamics · assess response to intervention · arrange angiography (urgent if no response in 2–3 hours) · treat fever aggressively · exclude seizures (consider EEG)
• Endovascular therapy for angiographic vasospasm: intra-arterial verapamil, nimodipine, nicardipine, or milrinone · balloon angioplasty (proximal intracranial vessel segments)
• Start immediate ICP management (elevate head, mannitol, etc.) → head CT
• 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?
• Immediate neurosurgical management: consider reclipping or re-coiling · treat other aneurysms
• Hydrocephalus?
• Place external ventricular drain
• Continue evaluation and ICP management