ICU Decoded › Library › Ward Pathways › Neurology › Subarachnoid HaemorrhageSubarachnoid HaemorrhageICU / resuscitation
Neurology · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 2 October 2026
Presentation Sudden "worst headache of my life" at peak intensity within a minute, vomiting, neck stiffness; GCS 14; BP 180/100
Red flags Thunderclap onset Falling GCS Focal deficit Seizure Third-nerve palsy (PCOM aneurysm) Differential diagnosis Reversible cerebral vasoconstriction syndrome Cerebral venous thrombosis Pituitary apoplexy Meningitis Migraine (diagnosis of exclusion) Cervical artery dissection When to admit, call ICU or discharge Admit: All SAH — neurosurgical centreICU: WFNS grade III–V, hydrocephalus, after securing for vasospasm monitoringIntubate: GCS ≤8, airway compromise, seizures not controlledKey points Thunderclap headache (peak <1 min) is SAH until proven otherwise; 1 in 3 are initially misdiagnosed. Rebleeding carries ~50% mortality — secure the aneurysm early. Nimodipine improves outcome via neuroprotection, not by reversing vasospasm on angiography. Never Skip the LP when CT is negative beyond 6 h of onset and the story is typical Stop nimodipine early or give it IV routinely Fluid-restrict hyponatraemia after SAH Give prophylactic "triple-H" therapy Common mistakes Labelling it migraine No LP after a late negative CT Hypotension from nimodipine Fluid restriction for low Na⁺ Disposition and follow-up Neurosurgical ICU/HDU; neuro-rehabilitation and aneurysm follow-up imaging.
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