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Subarachnoid hemorrhage

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 Heart Association (AHA/ASA 2023; 2019; 2015), the American Academy of Family Physicians (AAFP 2023), the European Society of Hypertension (ESH 2023), the European Stroke Organisation (ESO/ESSD 2021), the European Society of Intensive Care Medicine (ESICM 2021), the European Stroke Organisation (ESO 2021; 2017), and the United States Department of Defense (DoD/VA 2019).


1.Classification and risk stratification

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

  • Severity assessment

2.Diagnostic investigations

General principles: as per 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.

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  • CT

  • Digital subtraction angiography

3.Diagnostic procedures

Lumbar puncture: 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.

4.Respiratory support

Prone positioning/recruitment maneuvers: 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.

5.Medical management

Setting of care
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.
Provide care to patients with aneurysmal SAH in a dedicated neurocritical care unit by a multidisciplinary team.

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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

6.Inpatient care

Serial neurological assessment
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.
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.

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  • Monitoring for delayed cerebral ischemia

  • Monitoring for seizures

7.Therapeutic procedures

Indications for treatment: consider offering aneurysm treatment to optimize outcomes in patients with high-grade aneurysmal SAH after carefully discussing the likely prognosis with family members.
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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

8.Perioperative care

General anesthesia: include minimizing postprocedural pain, nausea, and vomiting in anesthetic goals in patients with aneurysmal SAH.

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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

9.Preventative measures

Primary prevention
Advise smoking cessation in patients with unruptured intracranial aneurysms.
Monitor BP and treat hypertension in patients with unruptured intracranial aneurysms.

10.Follow-up and surveillance

Discharge from hospital: 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.

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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

11.Quality improvement

Care protocols: implement evidence-based protocols and order sets to improve standardization of care in patients with aneurysmal SAH.
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