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Subarachnoid hemorrhage

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Updated 2023 AHA/ASA, 2021 ESO, 2021 ESICM, and 2019 VA/DoD guidelines for the diagnosis and management of subarachnoid hemorrhage.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of subarachnoid hemorrhage are prepared by our editorial team based on guidelines from the American Academy of Family Physicians (AAFP 2023), the American Heart Association (AHA/ASA 2023,2019,2015), the European Society of Hypertension (ESH 2023), the European Society of Intensive Care Medicine (ESICM 2021), the European Stroke Organisation (ESO 2021,2018,2017), the European ...
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Classification and risk stratification

Risk of aneurysm rupture: as per AHA/ASA 2015 guidelines, recognize that:
smoking increases the risk of unruptured intracranial aneurysm formation
B
hypertension may play a role in the growth and rupture of intracranial aneurysms
B
prior history of aneurysmal SAH may be an independent risk factor for future hemorrhage secondary to a different small unruptured aneurysm.
B
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  • Risk assessment

  • Severity assessment

Diagnostic investigations

General principles: as per AHA/ASA 2023 guidelines, obtain prompt diagnostic evaluation to diagnose/exclude aneurysmal SAH and minimize morbidity and mortality in patients with an acute-onset severe headache.
B
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  • CT

  • Digital subtraction angiography

Diagnostic procedures

Lumbar puncture: as per AHA/ASA 2023 guidelines, perform a lumbar puncture to diagnose/exclude aneurysmal SAH in patients with acute-onset severe headache presenting > 6 hours from symptom onset or having a new neurological deficit if CT is negative for aneurysmal SAH.
B
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Respiratory support

Prone positioning/recruitment maneuvers: as per AHA/ASA 2023 guidelines, consider performing rescue maneuvers, such as prone positioning and alveolar recruitment maneuvers with ICP monitoring, to improve oxygenation in patients with aneurysmal SAH developing severe ARDS and life-threatening hypoxemia.
C
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Medical management

Setting of care
As per AHA/ASA 2023 guidelines:
Transfer patients with aneurysmal SAH from hospitals with low-case volume to higher-volume centers with multidisciplinary neurointensive care services, comprehensive stroke center capabilities, and experienced cerebrovascular surgeons/neuroendovascular interventionists in a timely manner to improve outcomes.
B
Provide care to patients with aneurysmal SAH in a dedicated neurocritical care unit by a multidisciplinary team.
B
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  • Anticoagulation reversal

  • Prevention of thrombosis

  • Antifibrinolytic agents

  • Prevention of delayed cerebral ischemia

  • Management of delayed cerebral ischemia

  • Prevention of seizures

  • Management of seizures

  • Management of hydrocephalus

  • Management of volume status

  • Management of BP

  • Management of body temperature

  • Management of glucose levels

Inpatient care

Neurological monitoring
As per AHA/ASA 2023 guidelines:
Obtain frequent neurological assessment with a neurological assessment tool, such as the GCS or the NIHSS, to monitor delayed cerebral ischemia and other secondary complications in patients with aneurysmal SAH.
B
Obtain frequent vital sign and neurological monitoring for the detection of neurological change and prevention of secondary cerebral insults and poor outcomes in patients with aneurysmal SAH.
B
NIH Stroke Scale (NIHSS)
Level of consciousness
Alert, keenly responsive
Arousable by minor stimulation to obey, answer, or respond
Requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped)
Responds only with reflex motor or autonomic effects, or totally unresponsive, flaccid, and areflexic
Ask month and age
Answers both questions correctly
Answers one question correctly
Answers neither question correctly
1C: 'Blink eyes' and 'squeeze hands' tasks
Performs both tasks correctly
Performs one task correctly
Performs neither task correctly
Horizontal extraocular movements
Normal
Partial gaze palsy; gaze is abnormal in one or both eyes, but forced deviation or total gaze paresis is not present
Forced deviation, or total gaze paresis is not overcome by the oculocephalic maneuver
Visual fields
No visual loss
Partial hemianopia
Complete hemianopia
Bilateral hemianopia (blind including cortical blindness)
Facial palsy
Normal symmetry
Minor paralysis (flattened nasolabial fold, asymmetry on smiling)
Partial paralysis (total or near-total paralysis of lower face)
Complete paralysis of one or both sides (absence of facial movement in the upper and lower face)
Left arm motor drift
No drift; limb holds 90 (or 45) degrees for full 10 seconds
Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
No effort against gravity; limb falls
No movement
Amputation/joint fusion
Right arm motor drift
No drift; limb holds 90 (or 45) degrees for full 10 seconds
Drift; limb holds 90 (or 45) degrees, but drifts down before full 10 seconds; does not hit bed or other support
Some effort against gravity; limb cannot get to or maintain (if cued) 90 (or 45) degrees, drifts down to bed, but has some effort against gravity
No effort against gravity; limb falls
No movement
Amputation/joint fusion
Left leg motor drift
No drift; leg holds 30-degree position for full 5 seconds
Drift; leg falls by the end of the 5- second period but does not hit the bed
Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity
No effort against gravity; leg falls to bed immediately
No movement
Amputation/joint fusion
Right leg motor drift
No drift; leg holds 30-degree position for full 5 seconds
Drift; leg falls by the end of the 5- second period but does not hit the bed
Some effort against gravity; leg falls to bed by 5 seconds but has some effort against gravity
No effort against gravity; leg falls to bed immediately
No movement
Amputation/joint fusion
7: Limb ataxia
Absent
Ataxia in one limb
Ataxia in two limbs
Amputation/joint fusion
Sensation
Normal
Mild-to-moderate sensory loss; patient feels pinprick is less sharp or is dull on the affected side; or there is a loss of superficial pain with pinprick, but patient is aware of being touched
Severe or total sensory loss; patient is not aware of being touched in the face, arm, and leg
Language/aphasia
Normal
Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression (reduction of speech and/or comprehension, however, makes conversation about provided materials difficult or impossible; for example, in conversation about provided materials, examiner can identify picture or naming card content from patient's response)
Severe aphasia; all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener (range of information that can be exchanged is limited; listener carries burden of communication; examiner cannot identify materials provided from patient response)
Mute, global aphasia; no usable speech or auditory comprehension
Dysarthria
Normal
Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty
Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia, or is mute/anarthric
Intubated/unable to test
Extinction/inattention
No abnormality
Visual, tactile, auditory, spatial, or personal inattention, or extinction to bilateral simultaneous stimulation in one of the sensory modalities
Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space
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  • Monitoring for delayed cerebral ischemia

  • Monitoring for seizures

Therapeutic procedures

Indications for treatment: as per AHA/ASA 2023 guidelines, consider offering aneurysm treatment to optimize outcomes in patients with high-grade aneurysmal SAH after carefully discussing the likely prognosis with family members.
C
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  • Timing for treatment

  • Goals of treatment

  • Choice of treatment modality (general principles)

  • Choice of treatment modality (endovascular coiling versus microsurgical clipping)

  • Choice of treatment modality (endovascular adjuncts)

  • RBC transfusion

Perioperative care

General anesthesia: as per AHA/ASA 2023 guidelines, include minimizing postprocedural pain, nausea, and vomiting in anesthetic goals in patients with aneurysmal SAH.
B
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  • Intraoperative neuromonitoring

  • Intraoperative induced hypothermia

  • Intraoperative adenosine administration

  • Management of intraoperative BP

  • Management of intraoperative glucose levels

  • Management of intraoperative intracranial hypertension

  • Postoperative imaging

Preventative measures

Primary prevention
As per AHA/ASA 2015 guidelines:
Advise smoking cessation in patients with unruptured intracranial aneurysms.
B
Monitor BP and treat hypertension in patients with unruptured intracranial aneurysms.
B
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Follow-up and surveillance

Discharge from hospital: as per AHA/ASA 2023 guidelines, use validated grading scores or patient-reported outcome measures before hospital discharge to screen for physical, cognitive, behavioral, and quality-of-life deficits in patients with aneurysmal SAH.
B
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  • Rehabilitation (approach and timing)

  • Rehabilitation (neurostimulants)

  • Rehabilitation (motor therapy)

  • Rehabilitation (evaluation for cognitive dysfunction)

  • Rehabilitation (cognitive, speech, and sensory therapy)

  • Rehabilitation (evaluation for dysphagia)

  • Rehabilitation (dysphagia therapy, nutritional support)

  • Rehabilitation (dysphagia therapy, exercises)

  • Rehabilitation (dysphagia therapy, oral hygiene)

  • Rehabilitation (dysphagia therapy, pharmacotherapy)

  • Rehabilitation (dysphagia therapy, electrical stimulation)

  • Rehabilitation (dysphagia therapy, acupuncture)

  • Rehabilitation (evaluation for depression and anxiety)

  • Rehabilitation (management of depression and anxiety)

  • Rehabilitation (return to work)

  • Surveillance imaging

Quality improvement

Care protocols: as per AHA/ASA 2023 guidelines, implement evidence-based protocols and order sets to improve standardization of care in patients with aneurysmal SAH.
B
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