Subarachnoid hemorrhage occurs when there is bleeding into the subarachnoid space surrounding the brain. It carries a high mortality rate, with 10% dying before reaching the hospital and up to 45% dying within 30 days. Rebleeding and development of vasospasms are major risks that can lead to elevated intracranial pressure, cerebral ischemia, and neurological deficits. Aggressive management including early aneurysm repair, careful blood pressure control, nimodipine therapy, and ICP monitoring is required to prevent rebleeding and mitigate risks of vasospasms and cerebral ischemia.

1. Subarachnoid Hemorrhages

2. Subarachnoid Hemorrhage
• Subarachnoid hemorrhage (SAH) is
bleeding into the subarachnoid space.
• SAH may occur spontaneously from an
aneurysm or from head trauma.
• Mortality from SAH are very high (10%
die before the hospital, 25% with 24
hours & 45% with 30 days)Stroke 1994;25(7)1342

3. Subarachnoid Hemorrhage
• Signs and Symptoms of a SAH:
• Headaches
• Photophobia
• Nausea & Vomiting
• Seizures
• Decreased LOC
• Neurological Deficits
• Stiff Neck
• Seizures

4. Subarachnoid Hemorrhage
• The Hunt & Hess Classification grades the severity SAH based
on the patient’s clinical condition:

5. Subarachnoid Hemorrhage
Why are SAH so deadly?
• Hydrocephalus
• Rebleeding
• Vasospasms & Delayed Cerebral Ischemia
• Elevated ICP
0
20
40
60
First Hour First Day 30days

6. Subarachnoid Hemorrhages
• Hydrocephalus develops in 20 to 30% of
SAH patients. Stroke 2009;40(3)994
• Communicating hydrocephalus, the
type seen after SAH, occurs when CSF
cannot be absorbed normally through
the arachnoid villi.

7. Subarachnoid Hemorrhages
• 4% of patients
rebleed in the first
6 hours.
• 20% of patient
rebleed within 14
days.
• Rebleeding is
catastrophic (80%
mortality rate)

8. Subarachnoid Hemorrhages
• Vasospasms occur in 40-60%
of SAH patient.
• 20-30% of vasospasm
patients develop delayed
cerebral ischemia (DCI).
• Some patient develop DCI
without vasospasm.
• Pathogenesis of vasospasm
and DCI not fully
understood.

9. Subarachnoid Hemorrhages
+ +
80% 10% 10%
• The skull is rigid and can not expand.
• Volume = Brain (80%) + blood (10%) + CSF (10%).
• Increased volume within the skull will increase the ICP.
• Normal ICP is 10 – 20 mmHG
• Cerebral edema, blood, and hydrocephalus may caused an elevated ICP
(<20mmHg)
• Elevated ICP worsens outcomes

10. Subarachnoid Hemorrhage
• SAH is bleeding into the subarachnoid space
• The Hunt & Hess Classification grades the
degree of neurological deficits
• Grade I (mild deficits + mortality) → Grade V
(severe deficits + mortality)
• SAH patients have a substantial mortality
rate from hydrocephalus, rebleeding,
increased ICP & delayed cerebral ischemia
(vasospasms)
• Early, the risk of bleeding is higher. Later,
the risk of vasospasms increases (see next
slide).

11. Subarachnoid Hemorrhage
Vasospasm 0 to 21 days
❶Vasospasm can develop up to 3 weeks.
❷Highest prevalence between 7 and 21 days.
❸Vasospasms may not cause neurological deficits.
❹Pathogenesis of vasospasm is not fully understood.
❺Delayed Cerebral Ischemia results in new neurological
deficits.
Rebleeding 0 to 14 days
Highest risk in the first 6
hours
❶ Early surgical repair (day 1 to 3: clipping or coiling)
reduces the risk of rebleeding.
❷ Careful BP control reduces the risk of rebleeding.
Highest risk of vasospasm from 7 to 21 days

12. Subarachnoid Hemorrhage
• VS Q1H
• NVS as ordered
• Temperature Q4H + PRN
• Zero ICP Monitor Qshift + PRN
• ICP + CPP Q1H + PRN
• CSF Drainage Q1H
• ABG Qshift + PRN
• HOB 30degrees
Next, lets get more
specific:

13. Subarachnoid Hemorrhage
❶Hydrocephalus Management
❷Blood Pressure Control
❸Early Surgical Management (clipping or coiling)
❹Hypertensive Therapy
❺Nimodipine Therapy
❻Temperature Control
❼Seizure Control
❽ ICP Management
❾Pain / Nausea Control

14. Subarachnoid Hemorrhage
• Hydrocephalus is a frequent
complication of a SAH.
• EVD are inserted to drain excessive CSF
and to monitor ICP.
• Initially, CSF is bright red but slowly
becomes yellow (xanthochromia).
• Nursing Care:
• NVS as ordered
• Q1H ICP Monitoring
• Q1H CCP Monitoring
• Q1H CSF Drainage Output
• Qshift Zero EVD
• Ensure collection chamber is at the
correct height (cmH20 or mmHg)
• Level EVD PRN

15. Subarachnoid Hemorrhage
• BP should be kept between 120 to 160mmHg
• BP goal set by Neurosurgery Team
• Hypertension increases the risk of rebleeding
Stroke 2009;43:1711-37
• Aggressive BP management (too low) increases
the risk of infraction Stroke 2012;43: 1711-37
• Nursing Care:
• NVS
• Q1H BP (and PRN)
• Minimize stimulation
• Prevent emesis
• Pain Control
• Medication PRN

16. Subarachnoid Hemorrhage
• Typically, the aneurysm is secured
within the first 3 days (coiling or
clipping depending upon type of
aneurysm and location).
• Reduces the risk of rebleeding.
• Allows more aggressive
management of vasospasm and
delayed cerebral ischemia.

17. Subarachnoid Hemorrhage
• Hypertensive therapy is utilized to combat
vasospasms.
• Vasospasm can cause cerebral ischemia and
neurological deficits.
• Levophed (as well as Milrinone) is used to
increase BP which preserve cerebral blood flow
and prevent ischemia.
• In extreme cases, endovascular rescue
therapies (balloon dilation and intra-arterial
medications) may be attempted.
• Nursing Care:
• NVS as ordered
• Ensure BP parameters are achieved

18. Subarachnoid Hemorrhage
• Nimodipine, a calcium channel blocker
used to help prevent vasospasms
induced cerebral ischemia
• Mechanism of action of Nimodipine
not fully understood. N England Journal of Medicine
1983;308:619-624
• Nursing Care:
• NVS as ordered
• Administer Nimodipine as orders (60mg Q4h
or 30mg Q2H)
• Monitor carefully for neurological deficits
• Monitor BP closely (may cause hypotension)

19. Subarachnoid Hemorrhage
• Neurogenic Hyperthermia is
common in SAH (41-71%) Neurosurgery 2010;
66:696-700
• Normothermia improved
outcomes.
• Nursing Care:
• Temperature Q4H & PRN
• Cooling as ordered
• Tylenol as ordered

20. Subarachnoid Hemorrhage
• During hospitalization, 5% of
SAH patients, will have
seizures.
• Anticonvulsant therapy may be
indicted in these patients.
• Nursing Care:
• NVS
• Monitor for seizure activity
• Administer anticonvulsants and
benzodiazepines as ordered.

21. Subarachnoid Hemorrhage
• Elevated ICP will result in a
poor neurological outcome.
• Draining CSF can lower ICP.
• Nursing Care:
• NVS as ordered
• Q1H + PRN ICP & CPP
• Sedation
• HOB 30 degrees
• PaCo2 between 35-45 mmHg

22. Subarachnoid Hemorrhage
• Severe headaches are common in
SAH.
• Pain control is essential for patient
comfort.
• Excessive pain may cause
unwanted hypertension.
• Nausea and emesis is common
with SAH patients
• Administer antiemetic
medications, as ordered, to
prevent vomiting.
• Vomiting increases the risk of
rebleeding, and increases ICP.

23. Subarachnoid Hemorrhage
• Rebleeding is an early and catastrophic
complication of SAH.
• Early aneurysm repair reduces the risk of
rebleeding.
• EVD are inserted to drain excessive CSF and to
monitor ICP.
• Nimodipine Therapy is used to mitigate
vasospasm, and to prevent cerebral ischemia.
• Once the aneurysm is secured Hypertensive
Therapy is used to prevent cerebral ischemia.
• Careful neurological assessment is essential.

24. Subarachnoid Hemorrhage
Thank you….
References:
https://www.youtube.com/watch?v=
WNcGiM5kH5s
Stroke 1994; 25(7) 1342
Stroke 2009; 40(3) 994
Stroke 2012; 43:1711-37
NEJM 1983; 308:619-624