Management of Aneurysmal Subarachnoid Hemorrhage

Initial Management

The American Heart Association recommends that aSAH is a medical emergency that is frequently misdiagnosed, and high suspicion should be maintained in patients with acute onset of severe headache 3
Rapid assessment of clinical severity using validated scales is essential as it is the most useful indicator of outcome, according to the American Heart Association 3, 4
Urgent transfer to high-volume centers with experienced cerebrovascular surgeons, endovascular specialists, and multidisciplinary neurocritical care services is recommended by the American Heart Association 3
Blood pressure should be controlled with a titratable agent to balance the risk of stroke, hypertension-related rebleeding, and maintenance of cerebral perfusion pressure, as suggested by the American Heart Association 3

Surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible to reduce the rate of rebleeding, according to the American Heart Association 3
For patients with ruptured aneurysms amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered by the American Heart Association 3
Complete obliteration of the aneurysm is recommended whenever possible by the American Heart Association 3

Oral nimodipine should be administered to all patients with aSAH at a dose of 60 mg every 4 hours for 21 consecutive days, as recommended by the American Heart Association 5, 3
Maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI by the American Heart Association 3, 1
Induction of hypertension is recommended for patients with DCI unless blood pressure is elevated at baseline or cardiac status precludes it, according to the American Heart Association 3

aSAH-associated acute symptomatic hydrocephalus should be managed by cerebrospinal fluid diversion, as recommended by the American Heart Association 3

Aggressive control of fever to a target of normothermia using standard or advanced temperature modulating systems is reasonable, according to the American Heart Association 5
Careful glucose management with strict avoidance of hypoglycemia may be considered by the American Heart Association 5
The use of packed red blood cell transfusion to treat anemia might be reasonable in patients at risk of cerebral ischemia, as suggested by the American Heart Association 5
Early identification and targeted treatment of heparin-induced thrombocytopenia and deep venous thrombosis are recommended by the American Heart Association 5
In patients requiring mechanical ventilation for >24 hours, implementation of a standardized ICU care bundle is recommended to reduce duration of mechanical ventilation and hospital-acquired pneumonia, according to the American Heart Association 1

Misdiagnosis is common in aSAH, and high suspicion should be maintained with acute severe headache, as warned by the American Heart Association 3
Delayed diagnosis and treatment significantly increase mortality and morbidity, according to the American Heart Association 3
Hypervolemia is potentially harmful and associated with excess morbidity, as noted by the American Heart Association 1
Red blood cell transfusions have been associated with worse outcomes in some series, despite their potential benefit in treating anemia, as reported by the American Heart Association 5