Update on the Management of Subarachnoid Hemorrhage

Katja E Wartenberg


Future Neurology. 2013;8(2):205-224. 

In This Article


SAH is a devastating cerebrovascular disease. Improved NICU management and repair techniques reduced the impact of DCI on long-term functional outcome after SAH. The initial severity expressed in Hunt and Hess or WFNS grades became the major determinant of the long-term clinical and functional status of the patient. CTA facilitates screening for the ruptured aneurysm at the time of SAH diagnosis and helps to plan the most appropriate repair procedure; coiling or clipping. All treatment decisions should be made in a multidisciplinary team approach of neurointensivists, neurosurgeons and interventional neuroradiologists. The patients should be treated at high-volume centers with expertise and NICUs in place.

DCI is monitored with neurological exams and/or transcranial Doppler sonography. However, DCI is not recognized in poor-grade patients with standard monitoring techniques. Vascular and perfusion imaging studies may be helpful, as well as continuous multimodality neuromonitoring tools such as continuous electroencephalography, brain tissue oxygenation, cerebral metabolism and CBF. Controlled induced hypertension is the mainstay of medical management of DCI, followed by balloon angioplasty and/or intra-arterial vasodilators in refractory cases. The targets of intensive care management are euvolemia, normoglycemia avoiding hypoglycemia, normonatremia, normothermia, normal ICP and sufficient CPPs considering the states of failed autoregulation.