SUBARACHNOID HEMORRHAGE
Management of subarachnoid hemorrhage
David Goldemund M.D.
Updated on 16/08/2024, published on 01/04/2023
Updated on 16/08/2024, published on 01/04/2023
Standard management of SAH focuses on:
- general care of acutely ill patients (incl. strict blood pressure control and maintenance of normovolemia)
- prevention and treatment of vasospasms
- detection and elimination of the aneurysm from the circulation
- prevention and management of complications (intra- and extracerebral)
General management of SAH and rebleeding prevention are discussed here; vasospasms and complications are covered in separate chapters
General therapy and patient monitoring
- patients with SAH should be promptly transferred to a center with a multidisciplinary team available 24/7 (neurologist, neurosurgeon, interventional neuroradiologist, neuro-intensivist, rehabilitation physician, neuropsychologist, and dedicated nursing staff)
- during the first 2 weeks, patients should be managed in an intensive care unit
- the initial management is aimed at stabilizing the patient and selecting individuals who require urgent intervention due to complications (brain shift, hydrocephalus, etc.)
- perform a basic neurological examination, assess the level of consciousness (LOC), airway, breathing, and circulation (ABCs)
- endotracheal intubation should be performed in patients presenting with coma, decreased level of consciousness, inability to protect the airway, or increased intracranial pressure (ICP)
- patients with signs of increased ICP or herniation should be hyperventilated (target pCO2 of 30-35 mm Hg)
- while there are some specifics in the conservative treatment of SAH (see tabs), the principles of general stroke management and management of intracranial hypertension apply
- the patient is admitted to the intensive care unit (ICU)
- initially, order strict bed rest with the head kept elevated at 30° (optimal venous drainage ⇒ ↓ ICP )
- start prevention of constipation (especially in patients with unsecured aneurysms)
- stool softeners should be prescribed routinely – LACTULOSE
- enemas are contraindicated because they markedly increase intra-abdominal pressure
- proper control of fluid balance
- fluid replacement prevents reduction in plasma volume, which may contribute to the development of cerebral ischemia
- there is no sound evidence for the use of volume expansion therapy in patients with aneurysmal SAH
- early rehabilitation, after the ruptured aneurysm is secured, is reasonable to improve functional outcome (AHA/ASA 2023)
- actively search for post-aSAH depression and anxiety; if present, psychotherapy and pharmacotherapy are recommended
- the use of a validated screening tool in the post-acute period is useful for identifying cognitive dysfunction
- perform repeated neurologic examinations, including evaluation of the level of consciousness (LOC)
- monitor hemodynamic and respiratory parameters or initiate extended neuromonitoring
- monitor and treat hyponatremia → see here
- monitor for cardiac complications → see here
- use TCD/TCCD for monitoring vasospasms (see below)
- EEG monitoring in high-risk patients (AHA/ASA guidelines 2023, class 2a)
- detect and treat other SAH complications
- start noninvasive continuous BP monitoring immediately; in severe SAH or fluctuating BP, invasive monitoring is preferred
- BP control in SAH is complex; as there are reasons to both lower BP (to decrease the risk of rebleeding) and raise BP (to decrease the risk of delayed ischemic deficits)
- with an untreated source of bleeding, the aim is to maintain SBP ≤ 130-140 mm Hg
- 150-175 mm Hg postoperatively (⇒ ↑ CPP)
- 150-175 mm Hg postoperatively (⇒ ↑ CPP)
- in the presence of cerebral vasospasms and a secured aneurysm, the target SBP is ~ 180-220 mm Hg to improve cerebral perfusion
- excessive and rapid BP correction may be harmful (may lead to ↓CPP ⇒ risk of ischemia due to vasospasm)
- some surges of high blood pressure can be attenuated by adequate pain management or sedation
- antihypertensive therapy should only be started in patients with extreme elevations of blood pressure and rapidly progressive end-organ deterioration (new retinopathy, left-ventricular failure, nephropathy, etc.)
- preferably use labetalol, nimodipine, enalaprilat, esmolol, or urapidil
- avoid nitrates if possible, as they may increase intracranial pressure (ICP)
- analgesics, often paracetamol combined with opioids, are needed to contain severe headache
- opioids may cause hypotension and constipation
- corticosteroids can be used successfully in the treatment of aseptic meningitis (e.g., SOLUMEDROL 250-500mg + 500 mL of NS once daily for several days)
- consider the use of anxiolytics
- a short-acting benzodiazepine (such as midazolam) and opioids should be administered before every invasive procedure
- DVT is not as common after SAH as after ischemic stroke (younger patients, often with no significant paralysis)
- intermittent pneumatic compression (IPC)
- use LMWH only after securing the ruptured aneurysm
- antifibrinolytics and hemostyptics reduce the incidence of bleeding but increase the risk of ischemia due to thrombosis
- they should only be used in proven hypocoagulable states
etamsylate (DICYNONE) 500 mg IV every 6-8 hours
- mild fever (≤ 38.5 °C) is usually expected in the first days after SAH (due to neurogenic dysregulation, inflammatory reaction to the presence of blood in the cerebrospinal fluid)
- infectious complications are common in the later phase
- monitor CRP and procalcitonin levels
- pulse rate is elevated
- monitor CRP and procalcitonin levels
- treatment is focused on maintaining normothermia
- seizures increase intracranial hypertension and the risk of rebleeding, but the prophylactic use of antiseizure medication (ASM) is controversial
- intracranial hematoma and intracranial surgery probably increase the risk
- patients with symptomatic epileptic seizure – administer ASM for ≤ 7 days (if seizure-free) (AHA/ASA guidelines 2023, class 2a)
- onset seizure (~ 0-24h)
- early seizures (≤ 7 days) and late seizures (> 7 days) require prolonged administration of ASM
- prophylactic administration of ASM can be considered in the acute phase in high-risk patients, at least until the aneurysm is secured
- high-risk patients = MCA aneurysm, extensive SAH, ICH, cortical ischemia
- avoid phenytoin! (AHA/ASA guidelines 2023, class 3)
- Hb < 90 g/L (< 100 g/L for vasospasms) is a predictor of a poor outcome
- however, since transfusion can also worsen prognosis, individual assessment is essential
Laboratory studies and other methods
- serum chemistry panel – a baseline for detecting future complications
- natremia should be checked repeatedly
- CBC – evaluates potential infection or hematologic abnormalities
- prothrombin time (PT) and activated partial thromboplastin time (aPTT) to rule out coagulopathy
- blood typing/screening – to be ready for potential transfusion
- cardiac enzymes and troponin
- to exclude possible myocardial ischemia
- predictor of pulmonary and cardiac complications
- a correlation was has been found between troponin levels and neurological complications and outcome
- arterial blood gas (ABG) – required in respiratory-compromised patients
- a baseline chest X-ray
- ECG + ECG monitoring, transthoracic echocardiogram
- differentiate myocardial ischemia from common benign changes
- patients with SAH can experience myocardial ischemia due to the increased level of circulating catecholamines or autonomic stimulation from the brain
- nonspecific ST and T wave changes
- decreased PR intervals
- prolonged QRS intervals
- prolonged QT intervals
- presence of U waves
- arrhythmias – premature ventricular contractions (PVCs), supraventricular tachycardia (SVT), and bradyarrhythmias
Prevention and treatment of vasospasms
Rebleeding prevention – timing
- rebleeding prevention is essential in SAH management – the risk is highest in the first few days (4% within the first 24 h) and decreases over time
- risk factors for rebleeding:
- decompensated hypertension
- aneurysm size and shape
- the severity of initial bleeding, incl. ICH or IVH
- seizures
- the most effective prevention is to treat the source ASAP (acute procedure, ideally within 24 hours) if the clinical condition of the patient permits
- thanks to vasospasm monitoring by TCD/TCCD, surgery can be performed even after 72 hours in the absence of spasm
- endovascular treatment is possible even in the presence of vasospasm (and can be combined with PTA/vasodilatation)
- early intervention allows subsequent full conservative therapy to prevent cerebral vasospasms
- indication for urgent neurosurgery:
- acute hydrocephalus requiring EVD
- life-threatening ICH (hematoma evacuation + aneurysm clipping)
- deferred management (elective procedures) should be chosen in the following cases:
- presence of vasospasms when clipping is indicated
- severe patient condition (Hunt-Hess IV-V, severe comorbidities)
- difficult, complex aneurysm
- incomplete endovascular team (e.g., at night)
- aneurysms where parent artery occlusion is considered
- it is optimal to verify collateral circulation by balloon occlusion test (BTO). However, due to heparin use, it is not suitable for the acute stage of bleeding
| Hunt-Hess score | |
| I-III | indication for acute intervention |
| IV-V | the procedure is indicated in the presence of an expanding hematoma; otherwise, the indication is uncertain (the outcome of acutely operated and non-operated patients does not differ significantly) |
Rebleeding prevention – methods
- a multidisciplinary team should be involved in decision-making (neurosurgeon, neuroradiologist, neurologist, and anesthesiologist)
- treatment method is always individualized and depends on many factors, such as:
- age and comorbidities
- Hunt and Hess (H+H) score
- the time interval since the SAH
- aneurysm size, shape, and location
- condition of the extra- and intracranial cerebral vessels (access route)
- presence of an expanding hematoma
- in general, for aneurysms that can be treated by either method, coiling is often the appropriate solution (AHA/ASA 2009 I/B)
- indications for endovascular procedure
- posterior circulation aneurysms
- anterior circulation aneurysms in elderly patients (aged > 65 years)
- patients in poor clinical condition with high surgical risk and/or cerebral edema
- patients with a high risk of vasospasms or with already developed vasospasm(s)
- cases involving multiple aneurysms where it is unclear which aneurysm is the source of bleeding and clipping would require a bilateral craniotomy
- patients with moyamoya
- patients who have failed neurosurgical treatment
- indications for neurosurgery:
- aneurysms in the middle cerebral artery (MCA) territory
- wide-neck aneurysms
- patients indicated for concurrent ICH evacuation
- case where endovascular treatment is not available or has failed
- aneurysms in the middle cerebral artery (MCA) territory
Craniotomy and aneurysm clipping |
- the advantage of clipping is the immediate and permanent removal of the aneurysm from the circulation
- some aneurysms are not treatable due to their shape/location
Endovascular procedures |
- in acute SAH, coiling alone should be performed (the use of stents and diverters requires antiplatelet therapy)
- the aneurysm sac is usually filled with detachable platinum coils that induce local thrombosis
- it takes some time for the aneurysm to be completely removed from the circulation; partial filling of the sac may occur, and repeated embolization is sometimes necessary (perform a control vascular imaging after the procedure)
- rebleeding rate is slightly higher than with clipping
- this method is preferred for aneurysms with a narrow neck (ideally < 5 mm) in the posterior circulation and for patients with more severe neurological deficits, cerebral edema, or older age with comorbidities
- the use of flow diverters, stents, or balloon-assisted coiling extends the indications for endovascular management to aneurysms with wider necks (mostly in elective procedures)
Deconstructive procedures |
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Other surgical procedures
- management of acute hydrocephalus
- external ventricular drainage (EVD) for obstructive hydrocephalus + ICP monitoring
- lumbar CSF drainage for hyporesorptive hydrocephalus, typically for 5-7 days, with the evacuation of 100-200mL of CSF per 24h
- routine fenestration of the lamina terminalis is not indicated for reducing the rate of shunt-dependency
- management of chronic hydrocephalus (VP shunt)
- trepanation and insertion of a micro-sensor for ICP (ventricular, parenchymal) and/or tissue monitoring
- ICH evacuation (combined with clipping)
- decompressive craniectomy
- only few studies are available on decompressive surgery for the treatment of refractory increased intracranial pressure in SAH, demonstrating heterogeneous results
Predictors of shunt-dependency
- rebleeding
- vasospasms
- aneurysm in the posterior circulation or at the AComA
- IVH
- increased age
- high Fisher grade
- meningitis
- prolonged EDV
Therapy results
- effectiveness of aneurysm treatment is measured by the rebleeding rate and clinical outcome
- ISAT (The International Subarachnoid Aneurysm Trial) was a prospective randomized trial comparing endovascular treatment with surgical clipping
- only patients eligible for both treatments were enrolled at centers performing both treatments (n=2143)
- the primary endpoint was the prevention of disability (mRS 3-5) and death from SAH within one year after treatment
- coiling was more likely to result in independent survival at 1 year than neurosurgical clipping; the survival benefit continued for at least 7 years
- dependency or death: 23% (endovascular) vs. 30.6% (clipping), the benefit continues > 7 years
- risk of rebleeding was relatively low but more common after coiling compared to clipping – 1.6% (coiling) vs. 0.7% (clipping)
- in both groups, rebleeding occurred most frequently during the first 30 days after aneurysm treatment, and rebleeding was associated with up to 50% mortality in both groups
- CARAT (Cerebral Aneurysm Rerupture After Treatment)
- the rebleeding rate was higher in the embolized patients (3.4% vs. 1.3%)
- rebleeding in coiled patients was mostly seen in angiographically incompletely filled aneurysms
- factors leading to incomplete aneurysm occlusion are:
- larger aneurysms (> 10 mm)
- wide neck (> 4 mm)
Management of rebleeding
- sudden apnoea in a patient with SAH usually signifies rebleeding
- with full resuscitative measures, spontaneous respiration will rapidly return in ~ 50% of the cases; if spontaneous respiration does not return, then organ donation should be considered
- in patients who regain consciousness consider emergency clipping or coiling of the aneurysm and evacuation of possible large hematoma
Follow-up
- long-term follow-up is recommended (especially in patients with incomplete occlusion) → increased risk of recurrence or regrowth of the treated aneurysm or development of de novo aneurysm(s)
- in the ISAT trial, the risk of recurrent aSAH from the target aneurysms in the endovascularly treated and surgically treated groups in the first 30 days after treatment was 1.9% and 0.6%, respectively
- In the ISAT trial, the risk of recurrent SAH from the target aneurysms in the endovascularly treated and surgically treated groups at 30 days to 1 year was 0.6% and 0.4%, at 1-5 years was 0% and 0%, and at >5 years was 0.5% and 0.3%, respectively
- in the ISAT trial, the risk of recurrent aSAH from the target aneurysms in the endovascularly treated and surgically treated groups in the first 30 days after treatment was 1.9% and 0.6%, respectively
- incomplete aneurysm occlusion
- associated with a higher risk of rerupture (however, even completely obliterated aneurysms carry a risk of rerupture in the long term)
- a higher rate of incomplete occlusion is associated with coiling compared to clipping
- imaging (perioperative and long-term) is recommended to evaluate for remnants or recurrence that may require treatment
- de novo aneurysm formation
- risk is ~ 0.3% at 1-5 years, and 0.3% at >5 years
- risk factors: younger age, family history, and multiple aneurysms
- risk factors for growth and rupture of de novo aneurysms: female sex, shorter interval to formation of the de novo aneurysm, multiple aneurysms, and larger size
