Non-traumatic Subarachnoid Hemorrhage Treatment

Maintain Cerebral Perfusion Pressure

- Remember CPP = MAP - ICP (cerebral perfusion pressure = mean arterial pressure - intracranial pressure)

- Avoid hypotension

- Avoid increases in ICP

Reduce Intracranial Pressure

- Prevent rebleeding

- Maintain normotension (SBP < 160, may vary by institution and may be more strict) 

- Cardene, labetolol, enalapril

- Avoid nitroprusside, nitroglycerin (can elevate ICP)

- Reverse anticoagulation if indicated

- Elevate head of bed

- Analgesia

- Seizure prophylaxis (controversial)

- Prevent vasospasm

- Nimodipine - start within 96 hours, PO only; may cause profound hypotension

- If obtunded → more invasive measures to reduce ICP

- EVD (external ventricular drain by neurosurgery)

- If neurosurgery unavailable: mannitol

Definitive treatment

- Endovascular coiling > aneurysm clipping

- ICU for q1 hour neuro checks

References:

Connolly ES et al. Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. Stroke. 2012; 43:1711-1737