Update on the Management of Subarachnoid Hemorrhage

Katja E Wartenberg


Future Neurology. 2013;8(2):205-224. 

In This Article

Abstract and Introduction


Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular disease. Outcome after SAH is mainly determined by the initial severity of the hemorrhage. Neuroimaging, in particular computed tomography, and aneurysm repair techniques, such as coiling and clipping, as well as neurocritical care management, have improved during the last few years. The management of a patient with SAH should have an interdisciplinary approach with case discussions between the neurointensivist, interventionalist and the neurosurgeon. The patient should be treated in a specialized neurointensive care unit of a center with sufficient SAH case volume. Poor-grade patients can be observed for complications and delayed cerebral ischemia through continuous monitoring techniques in addition to transcranial Doppler ultrasonography such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism, cerebral blood flow and serial vascular imaging. Neurocritical care should focus on neuromonitoring for delayed cerebral ischemia, management of hydrocephalus, seizures and intracranial hypertension, as well as of medical complications such as hyperglycemia, fever and anemia.


Subarachnoid hemorrhage (SAH) is an acute cerebrovascular event with profound effects on the CNS and several other organs. SAH occurs with an incidence of two to 22.5 cases per 100,000 individuals.[1,2] Risk factors include an age of ≥50 years (most common: 40–60 years), female sex[3,4] depending on the hormonal status[5] and African–American race.[6] Further risk factors include arterial hypertension, cigarette smoking, alcohol, cocaine or any other sympathomimetic agents, prior SAH from a separate aneurysm or a family history of SAH, multiple aneurysms, arteriovenous malformations, coarctation of the aorta, moyamoya disease, pituitary gland tumors, connective tissue disease associated with intracranial aneurysms such as autosomal dominant polycystic kidney disease, Ehlers–Danlos syndrome (type IV), Marfan syndrome, pseudoxanthoma elasticum and fibromuscular dysplasia.[3–20] Current developments in neurocritical care including advanced continuous neuromonitoring, a shift of focus to immediate real-time normalization of pathophysiological states and better recognition and management of complications following SAH have improved the level of care and clinical outcome.