Management of Subarachnoid Hemorrhage

• Influenced by neurologic condition, general medical state of patient, and the location and morphology of the aneurysm.

Medical thearpy– initial management of patients with SAH is

directed at patient stabilization

Management of Subarachnoid Hemorrhage

Medical therapy– bed rest– fluid administration to maintain above-normal

circulating blood volume and CVP– protect the airway by performing endotracheal

intubation– antihypertensive medications to reduce BP and

maintain systolic BP at 150 mmHg or less

Management of Subarachnoid Hemorrhage

Medical therapy– prevention and/or treatment of complications

including:• Rerupture/rebleeding• Hydrocephalus• Vasospasm• Hyponatremia• Pulmonary embolism

Management of Subarachnoid Hemorrhage

• Surgical therapy– direct aneurysmal clipping

- involves placing a metal clip across the aneurysm neck, eliminating the risk of rebleeding. This requires craniotomy and brain retraction

– endovascular obliteration of the lumen of the aneurysm- involves placing platinum coils, or other embolic material within the aneurysm via catheter passed through the femoral artery

Vasospasm

Vasospasm

• It is the narrowing of the arteries at the base of the brain following SAH which may lead to ischemia and infarction.

• It appears 4-14 days after the hemorrhage, usually on the 7th day.

• Most often, the terminal internal carotid artery or the proximal portions of the anterior and middle cerebral arteries are involved.

Identification

• X-ray angiography• Transcranial Doppler ultrasound• Other tests:– single photon emission computed tomography

(SPECT)– positron emission tomography (PET) – xenon CT scan– radioactive xenon clearance

Grading

Management

• Nimodipine (Calcium-Channel Blocker), 60mg PO every 4 hours– Prevents the spasm of blood vessels by

preventing calcium from entering the smooth muscle cells

– Nimodipine improves the outcome within 3 months after SAH

– Not recommended for traumatic subarachnoid hemorrhage

Management

• “Triple H” therapy– Hypertension– Hypervolemia– Hemodilution

This involves the use of intravenous fluids to prevent hypotension, augments cardiac output, and reduces blood viscosity.

Management

• If medical therapy does not improve the symptoms of delayed ischemia– Angiography• With infusion of Papaverine (smooth muscle relaxant)

– Angioplasty