1) The document discusses the principles of managing aneurysmal subarachnoid hemorrhage (SAH), an acute neurological emergency. 2) Key aspects of management include maintaining oxygenation and ventilation, rapidly restoring cerebral perfusion such as through external ventricular drain placement, preventing rebleeding via early treatment of the aneurysm, administering nimodipine to reduce the risk of cerebral vasospasm, and planning timely definitive treatment. 3) Complications of SAH like cerebral vasospasm, hydrocephalus, and delayed cerebral ischemia contribute to the high mortality and morbidity rates despite advancements in care.

1. A D E W I J A Y A , M D – A U G U S T 2 0 2 1
The principles of
Aneurysmal Subarachnoid Hemmorhage
Management

2. Introduction
 Aneurysmal subarachnoid hemorrhage (SAH) is an
acute neurologic emergency
 Catastrophic
 Prompt definitive treatment and managing
secondary insults and complications are essential
Sharma D. Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology. 2020 Dec;133(6):1283-305.

3. Epidemiology
 Intracranial aneurysms are estimated to occur with a
prevalence of 3.2% in the general population
 The global incidence of aneurysmal subarachnoid hemorrhage
is 2 to 16 per 100,000, with an incidence rate in low- and
middle-income countries almost double that of high-income
countries
 Aneurysmal subarachnoid hemorrhage accounts for
approximately 5% of strokes
 Despite substantial advancements in the care of patients with
aneurysmal subarachnoid hemorrhage, the mortality rates are
32% to 67%, and a third of the survivors remain dependent
Sharma D. Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology. 2020 Dec;133(6):1283-305.

4. Etiology
 Most often, aneurysmal subarachnoid hemorrhage
results from the rupture of a saccular (“berry”)
aneurysm
 Hemodynamic stress and turbulent blood flow may
lead to damage of the internal elastic lamina,
particularly at vascular branching points
 Hypertension, smoking, and connective tissue
disorders are known to exacerbate the vascular
damage, thereby increasing the risk of aneurysm
development
 Familial predisposition
Wiebers DO, Piepgras DG, Meyer FB, Kallmes DF, Meissner I, Atkinson JL, Link MJ, Brown Jr RD. Pathogenesis, natural history, and treatment of unruptured intracranial
aneurysms. InMayo clinic proceedings 2004 Dec 1 (Vol. 79, No. 12, pp. 1572-1583). Elsevier.

5. Pathophysiology
 The initial aneurysmal rupture typically leads to
blood quickly traversing through the intracranial
cisterns and subarachnoid space within seconds
 The subarachnoid hemorrhage may lead to loss of
consciousness owing to global cerebral ischemia
resulting from increased intracranial pressure (ICP),
decreased cerebral perfusion pressure (CPP), and
reduced cerebral blood flow
 Intraventricular bleeding can cause acute ventricular
dilatation and hydrocephalus
Welch TL, Brinjikji W, Lanzino G, Lanier WL. Real-time cineangiography visualization of cerebral aneurysm rupture in an awake patient: anatomic, physiological, and functional
correlates. InMayo Clinic Proceedings 2017 Sep 1 (Vol. 92, No. 9, pp. 1445-1451). Elsevier.

6. Pathophysiology
 A compensatory sympathetic response involving systemic
hypertension ensues within minutes
 Vasoactive mediators such as thromboxane and
serotonin are released within minutes to hours of
subarachnoid hemorrhage, leading to microcirculatory
constriction
 Delayed cerebral ischemia may be the manifestation of
interplay of pathophysiologic phenomena, including loss
of cerebrovascular autoregulation, cerebral vasospasm,
microvascular thrombosis, neuroinflammation, and
cortical spreading depolarization
Suhardja A. Mechanisms of disease: roles of nitric oxide and endothelin-1 in delayed cerebral vasospasm produced by aneurysmal subarachnoid hemorrhage. Nature Clinical Practice Cardiovascular
Medicine. 2004 Dec;1(2):110-6.
Welch TL, Brinjikji W, Lanzino G, Lanier WL. Real-time cineangiography visualization of cerebral aneurysm rupture in an awake patient: anatomic, physiological, and functional correlates. InMayo
Clinic Proceedings 2017 Sep 1 (Vol. 92, No. 9, pp. 1445-1451). Elsevier.
Geraghty JR, Testai FD. Delayed cerebral ischemia after subarachnoid hemorrhage: beyond vasospasm and towards a multifactorial pathophysiology. Current atherosclerosis reports. 2017
Dec;19(12):1-2.

7. Clinical Presentation
 Worst headache of life
 50 %  loss of consciousness
 Nausea and/or vomiting, nuchal rigidity, or
photophobia
 Seizures in 6-16 % patients
 3rd cranial nerve palsy
 Hypertension
Sharma D. Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology. 2020 Dec;133(6):1283-305.

8. Clinical Grading System
Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. Journal of neurosurgery. 1968 Jan 1;28(1):14-20.
Drake CG. Report of World Federation of Neurological Surgeons Committee on a universal subarachnoid hemorrhage grading scale. J neurosurg. 1988;68:985-6.

9. Imaging-based Grading System
Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980 Jan 1;6(1):1-9.
Claassen J, Bernardini GL, Kreiter K, Bates J, Du YE, Copeland D, Connolly ES, Mayer SA. Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid
hemorrhage: the Fisher scale revisited. Stroke. 2001 Sep 1;32(9):2012-20.

10. ( 1 ) M A I N T E N A N C E O F O X Y G E N A T I O N A N D V E N T I L A T I O N ;
( 2 ) R A P I D R E S T O R A T I O N O F C E R E B R A L P E R F U S I O N ;
( 3 ) P R E V E N T I O N O F R E B L E E D I N G ;
( 4 ) S E I Z U R E P R O P H Y L A X I S ;
( 5 ) I N I T I A T I O N O F N I M O D I P I N E , A N D ;
( 6 ) P L A N N I N G T I M E L Y D E F I N I T I V E C A R
Management

11. Oxygenation and Ventilation
Conscious patients : supplemental oxygen
Intubation and mechanical intubation is required if
 (1) the patient remains comatose and is unable to
protect his/her airway;
 (2) there is hypoxia or hypoventilation;
 (3) patient is hemodynamically unstable, or;
 (4) there is need for heavy sedation and/or
pharmacologic paralysis to keep the patient safe
(e.g., owing to excessive agitation during imaging or
external ventricular drain placement).
Sharma D. Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology. 2020 Dec;133(6):1283-305.

12. Rapid Restoration of Cerebral Perfusion
 Early placement of an external ventricular drain
 Glasgow Coma Scale less than or equal to 12 or Hunt
and Hess grade greater than or equal to 2 has been
recommended as a threshold for external ventricular
drain placement
Sharma D. Perioperative Management of Aneurysmal Subarachnoid Hemorrhage: A Narrative Review. Anesthesiology. 2020 Dec;133(6):1283-305.

13. Prevention of Rebleeding
 Early definitive treatment by surgery or
endovascular intervention
 Treat hypertension (nicardipine)
 Control of headache with analgesics, anxiolysis and
bed rest is important.
 Short-term (less than 72 h) use of antifibrinolytic
aminocaproic acid or tranexamic acid is allowable to
reduce the risk of rebleeding if a delay in the
definitive treatment of the aneurysm is unavoidable
Connolly Jr ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB. Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2012 Jun;43(6):1711-37.
Starke RM, Kim GH, Fernandez A, Komotar RJ, Hickman ZL, Otten ML, Ducruet AF, Kellner CP, Hahn DK, Chwajol M, Mayer SA. Impact of a protocol for acute
antifibrinolytic therapy on aneurysm rebleeding after subarachnoid hemorrhage. Stroke. 2008 Sep 1;39(9):2617-21.

14. Seizure Prophylaxis
 No prophylaxis needed
 Initiation of seizure prophylaxis is reasonable in the
immediate posthemorrhage period in patients with
poor neurologic grade, unsecured aneurysm, and
associated intracerebral hemorrhage
Connolly Jr ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB. Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2012 Jun;43(6):1711-37.
Raper DM, Starke RM, Komotar RJ, Allan R, Connolly Jr ES. Seizures after aneurysmal subarachnoid hemorrhage: a systematic review of outcomes. World neurosurgery.
2013 May 1;79(5-6):682-90.
Naidech AM, Kreiter KT, Janjua N, Ostapkovich N, Parra A, Commichau C, Connolly ES, Mayer SA, Fitzsimmons BF. Phenytoin exposure is associated with functional and
cognitive disability after subarachnoid hemorrhage. Stroke. 2005 Mar 1;36(3):583-7.

15. Nimodipine
 Administration of 60 mg nimodipine orally or by
nasogastric tube every 4 h, starting within 48 h of
aneurysmal subarachnoid hemorrhage and
continued for 21 days, is considered a standard of
care
 If hypotension: it is recommended to first use
vasopressors to treat hypotension. If this is
ineffective, dose may be reduced to half and, in cases
of refractory hypotension, nimodipine may have to
be stopped.
Connolly Jr ES, Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, Hoh BL, Kirkness CJ, Naidech AM, Ogilvy CS, Patel AB. Guidelines for the
management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association.
Stroke. 2012 Jun;43(6):1711-37.
Sandow N, Diesing D, Sarrafzadeh A, Vajkoczy P, Wolf S. Nimodipine dose reductions in the treatment of patients with aneurysmal subarachnoid hemorrhage.
Neurocritical care. 2016 Aug;25(1):29-39.
Hernández-Durán S, Mielke D, Rohde V, Malinova V. Does nimodipine interruption due to high catecholamine doses lead to a greater incidence of delayed cerebral
ischemia in the setting of aneurysmal subarachnoid hemorrhage?. World neurosurgery. 2019 Dec 1;132:e834-40.

16. Summary

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