eMedicine Specialties > Neurology > Neurological Emergencies

Subarachnoid Hemorrhage: Treatment & Medication

Author: George I Jallo, MD, Associate Professor of Neurosurgery, Pediatrics and Oncology, Director, Clinical Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine
Coauthor(s): Tibor Becske, MD, Assistant Professor, Department of Neurology, New York University Medical Center
Contributor Information and Disclosures

Updated: Dec 4, 2008

Treatment

Medical Care

The patient with acute subarachnoid hemorrhage needs to be managed in an intensive care (ICU) setting, placed in a quiet room, and given mild sedation if agitated. The head end of the bed should be kept elevated at 30° to ensure optimal venous drainage. Blood pressure must be maintained with consideration of the patient's neurological status. Optimally, systolic blood pressure (SBP) of no more than 130-140 mm Hg should be the goal, unless clinical evidence of vasospasm is noted. Indwelling catheters include arterial line, central venous access, and Foley catheter. Seizure prophylaxis and calcium channel blockade are standard medical measures. Stool softeners are given to prevent Valsalva maneuvers with resultant peaks in SBP and ICP.

• Hydrocephalus
  • Since acute hydrocephalus (HCP) is associated with lower preoperative grade and poorer prognosis, the clinician must carefully monitor the patient for early signs of acute HCP. The most reliable clinical measure is the patient's level of consciousness. Any change in the level of consciousness requires an emergent CT scan to evaluate ventricular size. An obtunded patient with dilated ventricles deserves an immediate ventriculostomy.
  • Increased risk for rebleeding may be associated with ventriculostomy placement, along with known infectious risk; therefore, patients with dilated ventricles (but no compromise of level of consciousness) should be treated conservatively with close monitoring of mental status and prompt intervention in case their clinical status declines. Some have used serial LPs to monitor such patients.
  • Ventriculostomy, when done correctly, is a relatively low-risk procedure that can result in dramatic and immediate clinical improvement in about two thirds of patients. If the patient's grade improves enough as a result of ventriculostomy, the patient may become a candidate for early surgery.
  • When grading patients clinically, great care must be taken to note possibly reversible deficits related to HCP, which may be contributing to the patients' poor condition. According to a study of 47 patients with poor-grade aneurysm without CT evidence of irreversible brain destruction who underwent ventriculostomy, early control of the ICP and aggressive management appeared to be the appropriate treatment in this subset of patients.
• Vasospasm lethargy
  • Lethargy with or without focal neurological deficit is vasospasm, until proven otherwise.
  • Emergency CT must be performed to rule out other pathology.
  • Swan-Ganz catheterization is indicated; hypertensive hypervolemic hemodilution (ie, triple H) management is used to target a pulmonary capillary wedge pressure (PCWP) of 14.
  • The goal is to maximize cerebral blood flow (CBF) to areas of vasospasm to prevent or reverse neurological symptoms.
  • Cardiac output and cardiac index should be monitored.

Surgical Care

• Surgical treatment involves clipping of the ruptured berry aneurysm. Endovascular treatment (ie, coiling) is an increasingly practiced alternative to surgical clipping. At many institutions, higher-grade patients and those with significant medical comorbidities tend to be treated by coiling as opposed to clipping. Posterior circulation aneurysms are preferentially treated by coiling because of the significant morbidity and mortality associated with surgical clipping.
• The large randomized prospective study ISAT found coiling to be significantly safer when comparing ruptured aneurysms that were deemed equally suitable candidates for either surgical or endovascular treatment. The incidence of rebleeding was slightly higher in the coiled group, but the endovascularly treated group did so much better overall that the study was stopped after reviewing the one-year outcome data. Partially because of the ISAT study, endovascular treatment is becoming the first-line treatment for many aneurysms.
• The data to establish long-term results of endovascular treatment are insufficient, however. In general, the incidence of recanalization is higher with coiling. Significant advances have been made in recent years with the introduction of new coated coils that either swell within the aneurysm or promote fibrous tissue formation and organization of the intraarterial clot.
• Other advances include the use of intracranial stents to promote coiling (especially in aneurysms with wide necks) and decrease inflow into the aneurysm in certain instances. The stents have also provided a novel approach to treating certain types of aneurysms that have historically been untreatable. At the moment, no long-term follow-up data exist to assess the efficacy of these new treatment modalities.
• The timing of surgery has been the subject of controversy for more than 40 years. Early surgery/coiling is generally recommended in patients with straightforward aneurysms of a favorable clinical grade. Poor-grade patients who fail to improve after stabilizing measures (including ventriculostomy placement), may not get treated in the acute period or may be preferentially treated by coiling.
  The goals of early surgical/endovascular treatment are to prevent rebleeding and to institute triple H therapy (for vasospasm prevention).
• Delayed surgery/coiling is recommended in patients with poor-grade aneurysms, those with medical complications, and those with giant or complicated aneurysms.

Consultations

• The neurosurgeon/neurointerventionalist must be involved early in the care of the patient with an aneurysmal subarachnoid hemorrhage.
• A clinician with critical care experience, pulmonologist, cardiologist, or anesthesiologist should manage the patient in the ICU.

Activity

Patients must be admitted to the ICU with strict bed rest until the etiology of hemorrhage is determined. Patients should not be allowed out of bed for any reason.

Medication

Therapeutic goals of subarachnoid hemorrhage are blood pressure control, prevention of seizures, treatment of nausea, management of ICP, prevention of vasospasm, control of pain, and maintenance of cerebral perfusion.

Calcium channel blocker

In specialized conducting and automatic cells in the heart, calcium is involved in the generation of the action potential. The calcium channel blockers inhibit movement of calcium ions across the cell membrane, depressing both impulse formation (automaticity) and conduction velocity.

Nimodipine (Nimotop)

For improvement of neurological impairments resulting from spasms following SAH caused by ruptured congenital intracranial aneurysm in patients who are in good postictal neurological condition.
While studies show benefit on severity of neurological deficits caused by cerebral vasospasm following SAH, no evidence exists that drug either prevents or relieves spasms of cerebral arteries. Thus, actual mechanism of action is unknown.

Antiepileptic agents

These agents prevent seizure recurrence and terminate clinical and electrical seizure activity.

Phenytoin (Dilantin)

May act in motor cortex where may inhibit spread of seizure activity. Activity of brainstem centers responsible for tonic phase of grand mal seizures also may be inhibited.
Dose should be individualized. Administer larger dose before retiring if dose cannot be divided equally.

Phenobarbital (Barbita, Luminal, Solfoton)

Elevates seizure threshold, limits spread of seizure activity, sedative.

Stool softeners

These agents prevent elevation of intracranial pressure associated with Valsalva maneuver.

Docusate sodium (Surfak, Colace, Dialose)

Anionic surfactant; for patients who should avoid straining during defecation. Allows incorporation of water and fat into stool causing stool to soften. Has minimal laxative effect.

Senna (Senokot, Ex-Lax, Senexon, Senna-Gen)

Anthraquinone stimulant hydrolyzed by colonic bacteria into active compound. More potent than cascara sagrada and produces considerably more abdominal pain. Usually produces action 8-12 h after administration.

Antihypertensive agents

After SAH due to ruptured aneurysm, blood pressure must be maintained in a range that allows for sufficient cerebral perfusion yet limits the risk of rebleeding.

Nitroprusside (Nitropress)

Produces vasodilation in nonselective fashion via nitric oxide and increases inotropic activity of heart; causes only modest reflex tachycardia. Very potent, close monitoring necessary; short acting.

Labetalol (Trandate, Normodyne)

Blocks alpha-, beta1-, and beta2-adrenergic receptor sites, decreasing blood pressure.

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