Standard management of SAH focuses on:

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 or medium care unit
  • the initial management is directed toward 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
Treatment Regimen
  • admission to the intensive care unit (ICU)
  • initially, strict bed rest with the head kept elevated at 30° (optimal venous drainage ⇒ ↓ ICP )
  • start prevention of constipation (especially in patients with unsecured aneurysms)
  • 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
Blood pressure
  • 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 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)
  • 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)
  • avoid nitrates if possible, as they may increase intracranial pressure (ICP)
Analgesics, anxiolytics
  • analgesics, often opioids, are needed to contain severe headache
  • 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
Thromboembolism prevention
  • intermittent pneumatic compression (IPC)   Intermittent pneumatic compresion (Venaflow) used in prevention of venous thromboembolism (VTE)
  • use LMWH only after securing the ruptured aneurysm

→ see here

  • 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
  • fever is expected in the first days after SAH (due to neurogenic dysregulation, the presence of blood in the cerebrospinal fluid)
  • infectious complications are common in the later phase
    • monitor CRP and procalcitonin levels
  • treatment is focused on maintaining normothermia
Epileptic seizures
  • seizures increase intracranial hypertension and the risk of rebleeding
  • patients presenting with epileptic seizure – start anticonvulsant medication for ≤ 7 days (if seizure-free)  (AHA/ASA guidelines 2023, class 2a)
    • onset seizure
    • early seizures (≤ 7 days) and late seizures (> 7 days) require prolonged administration of ASM  
  • no seizures – prophylactic administration of anticonvulsant medication 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)

→ Acute symptomatic seizures

  • 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, cardiac troponin
    • to exclude possible myocardial ischemia
    • predictor of pulmonary and cardiac complications
    • a correlation was 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
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
Aneurysm clipping
Aneurysm clipping, artifact from the clip on CT scan
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)  Stent and balloon assissted coiling
Aneurysm coiling
Aneurysm coiling
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)


  • 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
  • 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

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Management of subarachnoid hemorrhage