Subarachnoid Hemorrhage

LITERATURE

• AHA 2023 Guidelines

• Subarachnoid Hemorrhage – between arachnoid- pia, cx:  aneurysm, AVMs, amyloid, vascuilitis, infectious emboli
  • “thunderclap headache” or “worst headache in my life”
  • CT after 6 hours from onset, if negative, must be followed by LP (if pt presents within 6 hours, CT and CTA are sufficient)
    • Note “perimesencephalic SAH” is localized around the brainstem, usually venous in origin, considered benign
  • Seizures and aSAH – treat with 7 days of AED (prophylactic AED not recommended)
  • Grading – Hunt & Hess Scale
    • 1 (I) – Asymptomatic, mild headache, slight nuchal rigidity
    • 2 (II) – Moderate to severe headache, nuchal rigidity, no neurologic deficit other than cranial nerve palsy
    • 3 (III) – Drowsiness / confusion, mild focal neurologic deficit
    • 4 (IV) – Stupor, moderate-severe hemiparesis
    • 5 (V) – Coma, decerebrate posturing
• Initial Therapy
  • Early repair of ruptured aneurysm (coiling or clipping, coiling preferred in posterior circulation)
    • VTE chemical prophylaxis can be started when secured
  • Goal SBP <160mmHg
  • Keep body in a “eu” state (euvolemia, euglycemia etc)
• What Feels Like Forever Therapy
  • Patients remain in ICU for 2-3 weeks to prevent DCI (Delayed Cerebral Ischemia)
    • Often from vasospasm – monitor with daily TCDs
    • Mostly between days 4-14
    • Prevent with daily nimodipine (enteral only, pt may need enteral access)
    • Treatment may require intravascular vasodilator therapy
    • Hydrocephalus requires EVD and/or lumbar drainage