Subarachnoid hemorrhage

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – stabilization and cardiopulmonary support

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1st line –

stabilization and cardiopulmonary support

Subarachnoid hemorrhage (SAH) requires emergency treatment and early referral to a dedicated neurocritical care unit after resuscitation in the emergency department.[37][96] When patients are evaluated in rural or community settings, strong consideration should be made for expedited referral to high-volume tertiary care centers with multidisciplinary neurointensive care services, comprehensive stroke center capabilities, and experienced cerebrovascular surgeons/neuroendovascular interventionalists.[37]

Consciousness level should be assessed using the Glasgow Coma Scale, and need for endotracheal intubation and mechanical ventilation should be established.

Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

Blood pressure (BP), heart rate, and respiratory function should be closely monitored. In patients with aneurysmal SAH (aSAH) and unsecured aneurysm, frequent BP monitoring and BP control with short-acting antihypertensive drugs is recommended to avoid severe hypotension, hypertension, and BP variability.[37] There is insufficient evidence to recommend a particular BP target.[37] Sudden, profound reduction of BP should be avoided.[37][100]

In patients who are receiving anticoagulants, emergency reversal with appropriate agents should be performed to prevent rebleeding.[37] Reversal strategies should follow current published standards for life-threatening bleeding.[37][101] See Anticoagulation management principles.

Volume status should be closely monitored, with the goal to maintain euvolemia.[37][102][103][104] Induction of hypertension and hypervolemia is potentially harmful because of the association with cerebral edema, hemorrhagic transformation in areas of infarction, reversible leukoencephalopathy, myocardial infarction, and congestive heart failure.[35][37][105][106][107][108] Therefore, prophylactic hemodynamic augmentation should not be performed to reduce iatrogenic patient harm.[37] Electrolyte imbalances (e.g., hyponatremia) are common and should be corrected.[37]

Plus – surgical clipping or coil embolization

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Plus –

surgical clipping or coil embolization

Treatment recommended for ALL patients in selected patient group

Surgical or endovascular treatment of the ruptured aneurysm should be performed as early as feasible after presentation, preferably within 24 hours of onset, to reduce the risk of rebleeding and improve outcome.[37] A neurosurgeon and interventional neuroradiologist should be involved.

Complete obliteration of the ruptured aneurysm is indicated whenever feasible to reduce the risk of rebleeding and retreatment.[37][120][121][122] Treatment should be individualized according to patient-specific factors such as medical comorbidities and prehemorrhage functional status and should incorporate shared decision-making with the patient, if able, and the family or surrogate decision makers if the patient is unable to make decisions.[37]

The American Heart Association/American Stroke Association (AHA/ASA) recommends: in patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH; defined as Hunt and Hess grades 4 and 5 or World Federation of Neurological Surgeons grades 4 and 5), aneurysm treatment is reasonable, after careful discussion of likely prognosis with family members, to optimize patient outcome; in patients with aSAH and advanced age, aneurysm treatment is reasonable, after careful discussion of prognosis with family members, to improve survival and outcome; in patients with aSAH who do not improve after correction of modifiable conditions and have evidence of irreversible neurologic injury, treatment of the aneurysm is not beneficial.[37]

Controversy exists over the choice between clipping and coil embolization. For patients with subarachnoid hemorrhage, the ruptured aneurysm should be evaluated by specialist(s) with endovascular and surgical expertise to determine the relative risks and benefits of surgical or endovascular treatment according to patient (e.g., age, neurologic status on admission, comorbid conditions) and aneurysm (e.g., size and location) characteristics.[37] For asymptomatic patients or patients with mild symptoms from a ruptured aneurysm of the anterior circulation, the AHA/ASA recommends primary coiling in preference to clipping for improved 1-year functional outcome.[37][124][134] However, the guideline notes both treatment options are reasonable in this patient group to achieve a favorable long-term outcome.[37]

For ruptured aneurysms of the posterior circulation that are amenable to coiling, the AHA/ASA recommends coiling over clipping for improved short- and long-term outcomes.[37][134][135][136] Patient age may be a factor in guiding treatment. For aSAH patients age <40 years, clipping of the ruptured aneurysm might be considered the preferred mode of treatment to improve durability of the treatment and outcome. Longer life expectancy and better long-term protection from re-rupture favor consideration of clipping in younger patients.[37][124][137] However, for patients age >70 years, the relative superiority of coiling or clipping for improved outcomes is not well established.[37][124][138] For patients with aSAH deemed operable and with depressed level of consciousness due to large intraparenchymal hematoma, emergency clot evacuation should be performed to reduce mortality.[37]

Complications of clipping include aneurysm rupture, injury to vascular structures, postoperative stroke, and clipping of arterial perforators.

Complications of coiling include stroke, vessel rupture, and dissection, and incomplete embolization, and recurrences requiring reintervention.[129][130][131][132][133]

Plus – nimodipine

Plus – venous thromboembolism (VTE) prophylaxis

Consider – anticonvulsant

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Consider –

anticonvulsant

Treatment recommended for SOME patients in selected patient group

Prophylactic use of anticonvulsants following subarachnoid hemorrhage (SAH) is controversial.[113][114] US guidelines propose that prophylactic anticonvulsants may be reasonable in patients with SAH and high-seizure-risk features (i.e., ruptured middle cerebral artery aneurysm, high-grade SAH, intracranial hemorrhage, hydrocephalus, and cortical infarction).[37] These guidelines advise that there has not been benefit shown for prophylactic anticonvulsants in patients without high-risk features. In addition, using phenytoin for this purpose is associated with excess morbidity and mortality.[37][87][115]

The risk of seizures is significantly lower after coil embolization than after surgical clipping of aneurysm.[37]

In patients with SAH who present with seizures, treatment with anticonvulsants for ≤7 days is reasonable to reduce seizure-related complications in the perioperative period; treatment >7 days does not reduce future risk of SAH-associated seizure.[35][37][113]

One small prospective study comparing levetiracetam with phenytoin for seizure prophylaxis after neurologic injury (including SAH) found the same outcomes with respect to mortality and seizure control, but levetiracetam-treated patients experienced better long-term functional outcomes than those treated with phenytoin (as evaluated by the Glasgow Outcome Scale-Extended and Disability Rating Scale).[116]

Consult specialist for guidance on choice of a suitable anticonvulsant and doses.

Plus – stool softener

headache

Consider – analgesia

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Consider –

analgesia

Treatment recommended for SOME patients in selected patient group

Analgesia should be provided to conscious patients.

Acetaminophen can be used as a first-line option.[35] For severe pain, opioids such as codeine should be given.[35] If a patient is still in pain, morphine, hydromorphone, or oxycodone may be required.[35] Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided before aneurysm occlusion.[35]

Opioids may cause respiratory depression and have the potential for addiction, abuse, and misuse. Opioids may be used for cough suppression in patients with subarachnoid hemorrhage so it is important to take this into account when considering whether to prescribe opioids.

Mental status also needs to be closely monitored, especially in patients at risk of acute hydrocephalus or vasospasm. Judicious use of analgesia is therefore recommended.

Primary options

acetaminophen: oral: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<50 kg body weight): 15 mg/kg intravenously every 6 hours when required, maximum 75 mg/kg/day; intravenous (≥50 kg body weight): 1000 mg intravenously every 6 hours when required, maximum 4000 mg/day

Secondary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

Tertiary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response; 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required

hydromorphone: 0.2 to 1 mg intravenously every 2-3 hours when required, adjust dose according to response

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required initially, adjust dose according to response

cough

Consider – antitussive

hyponatremia

Consider – sodium replacement

Consider – fludrocortisone

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Consider –

fludrocortisone

Treatment recommended for SOME patients in selected patient group

The American Heart Association states that use of fludrocortisone is reasonable to treat natriuresis and hyponatremia, as supported by several randomized controlled trials.[37] However, although fludrocortisone use reduces excess sodium excretion, urine volume, and intravenous fluid use in patients with subarachnoid hemorrhage, it has not been found to consistently affect outcome.[37][109][110][111][112] Some guidelines state there is insufficient evidence to support its use in maintaining normal serum sodium concentrations or improving functional outcome.[112]

Primary options

fludrocortisone: consult specialist for guidance on dose

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Subarachnoid hemorrhage

Treatment algorithm

all patients

stabilization and cardiopulmonary support

surgical clipping or coil embolization

nimodipine

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

venous thromboembolism (VTE) prophylaxis

anticonvulsant

stool softener

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

headache

analgesia

Primary options

Secondary options

Tertiary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Secondary options

Tertiary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

Secondary options

Tertiary options

cough

antitussive

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options

hyponatremia

sodium replacement

fludrocortisone

Primary options

These drug options and doses relate to a patient with no comorbidities.

Primary options

Drug choice, dose and interactions may be affected by the patient's comorbidities. Check your local drug formulary.

Primary options