Management of Subarachnoid Hemorrhage

Immediate Stabilization and Transfer

• Patients with subarachnoid hemorrhage should be transferred immediately to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and dedicated neurocritical care units, as this significantly reduces mortality from 39% to 27% 1, 2, 3
• Rapidly assess neurological status using validated grading scales, as clinical severity at presentation is the strongest predictor of outcome 1, 4

Diagnostic Workup

• Obtain non-contrast head CT immediately, which has 98-100% sensitivity within 12 hours but declines to 93% at 24 hours and 57-85% by day 6 5
• Proceed to cerebrovascular imaging once SAH is confirmed to identify the bleeding source 1, 2

Aneurysm Securing

• Early aneurysm treatment should be performed to reduce rebleeding risk, which is 15% within the first 24 hours and carries high mortality 1, 3, 5
• For aneurysms amenable to both surgical clipping and endovascular coiling, endovascular coiling should be considered as the preferred approach based on superior outcomes in randomized trials 1, 2, 3

Medical Management

• Administer oral nimodipine 60 mg every 4 hours for 21 consecutive days starting within 96 hours of hemorrhage onset to improve neurological outcomes 1, 2, 5

Prevention of Delayed Cerebral Ischemia

• Maintain euvolemia and normal circulating blood volume through goal-directed fluid management; avoid prophylactic hypervolemia as it does not improve outcomes and may be harmful 1, 2, 5, 6
• For symptomatic DCI, induce hypertension as first-line therapy unless baseline blood pressure is already elevated or cardiac status precludes it 1, 2, 5, 6

Management of Hydrocephalus

• Place external ventricular drainage urgently for acute symptomatic hydrocephalus, which is a common and life-threatening complication 1, 2, 5, 6

Antifibrinolytic Therapy

• Short-term tranexamic acid or aminocaproic acid is reasonable to reduce early rebleeding risk in patients with significant delay to aneurysm obliteration and no medical contraindications 1

Monitoring and Follow-up

• Provide care in a dedicated neurocritical care unit with continuous monitoring for neurological deterioration, intracranial pressure changes, and systemic complications 5, 6
• Perform delayed follow-up vascular imaging with strong consideration for retreatment if clinically significant remnants are identified 2, 5