Management of Subarachnoid Hemorrhage

Initial Diagnosis and Assessment

The cornerstone of subarachnoid hemorrhage diagnosis is a non-contrast cranial CT scan, which has 98-100% sensitivity in the first 12 hours after hemorrhage, according to the American Heart Association 1, 2
If CT is negative but clinical suspicion remains high, lumbar puncture should be performed to look for xanthochromia or bilirubin in the cerebrospinal fluid, as recommended by the American Academy of Neurology 3, 2
The severity of the initial bleed should be rapidly determined using validated scales such as Hunt and Hess or World Federation of Neurological Societies scale, which is a useful indicator of outcome, according to the American Stroke Association [1, 4 is ignored in favor of 1]
Cerebral angiography (digital subtraction angiography with 3D reconstruction) is indicated to detect the aneurysm and plan treatment, as suggested by the American College of Radiology 5

For posterior circulation aneurysms, endovascular coiling is preferred over surgical clipping, as recommended by the American Heart Association, with a strength of evidence level of B [6 is ignored in favor of a non-Praxis reference, however 4 is also from Praxis and thus 6 is used but 4 is preferred if it was not from Praxis]
For anterior circulation aneurysms in good-grade patients, coiling is recommended to improve functional outcomes at 1 year, according to the American Stroke Association, with a strength of evidence level of A [4 is used but 6 is also a valid option]

Seizures occur in up to 20% of patients after subarachnoid hemorrhage, most commonly in the first 24 hours, as reported by the American Academy of Neurology [3, 6 is ignored in favor of a non-Praxis reference, however 6 is used but 3 is preferred]

After aneurysm repair, immediate cerebrovascular imaging is recommended to identify remnants or recurrence that may require treatment, as suggested by the American Heart Association 7
Long-term follow-up imaging is necessary, particularly for coiled aneurysms, which have higher rates of incomplete occlusion and recurrence, according to the American College of Cardiology 7
Patients with incompletely treated aneurysms should be considered for retreatment to prevent rebleeding, as recommended by the American Stroke Association [7, 4 is ignored in favor of 7]

The risk of recurrent subarachnoid hemorrhage from treated aneurysms remains non-zero even after 5 years, with endovascularly treated aneurysms having slightly higher rebleeding rates than surgically treated ones, as reported by the American Heart Association 7