Treatment for Small Subarachnoid Hemorrhage (SAH)

Initial Management

The American Heart Association recommends rapid assessment of clinical severity using validated scales as it is the most useful indicator of outcome 3, 4
Urgent transfer to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services is recommended, as outcomes are better at institutions that treat high volumes of SAH patients 3, 4
Blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure 3

The American Stroke Association recommends surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible to reduce the rate of rebleeding 3
For patients with ruptured aneurysms amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered as the first option 3, 5
Complete obliteration of the aneurysm is recommended whenever possible 3

Oral nimodipine should be administered at a dose of 60 mg every 4 hours for 21 consecutive days, starting within 96 hours of hemorrhage onset 1
Nimodipine has been shown to improve neurological outcomes but not cerebral vasospasm itself 2
Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI 1, 2
Prophylactic hypervolemia and triple-H therapy are not recommended as they can increase complications 6, 7

Acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion (external ventricular drainage or lumbar drainage, depending on the clinical scenario) 1, 2
Chronic symptomatic hydrocephalus should be treated with permanent cerebrospinal fluid diversion 2
Weaning external ventricular drainage over >24 hours does not appear to be effective in reducing the need for ventricular shunting 2

Routine prophylactic anticonvulsants are not recommended for all patients with SAH 2
Patients treated with endovascular coiling have a lower incidence of seizures compared to those treated with surgical clipping 2

Cerebrovascular imaging after treatment and subsequent imaging monitoring are important to identify remnants, recurrence, or regrowth of the treated aneurysm 1
Transcranial Doppler ultrasonography can be used to monitor for vasospasm development 5
Early identification with validated screening tools can identify deficits, especially in behavioral and cognitive domains 1

Misdiagnosis is common in SAH, and high suspicion should be maintained with acute severe headache 3
Hypervolemia is potentially harmful and associated with excess morbidity; euvolemia should be the target 3, 6