Critical Care Management of Subarachnoid Hemorrhage

  • Audrey C. Quinn
  • Simon P. Holbrook
Part of the Competency-Based Critical Care book series (CBCC)

Key Points

  1. 1.

    Spontaneous aneurysmal subarachnoid hemorrhage (SAH) is associated with high mortality, and is a significant cause of morbidity including permanent functional deficit.

  2. 2.

    A thorough clinical assessment including WFNS grading and computed tomography is vital when SAH is suspected.

  3. 3.

    All confirmed cases should be referred to a specialist neurosurgical center early.

  4. 4.

    Critical-care management should aim to maintain CPP and prevent rapid changes in transmural pressure (TMP) across the aneurysm wall.

  5. 5.

    Nimodipine should be commenced in all cases of aneursymal SAH.

  6. 6.

    Delayed ischemic deficits (DID) and re-bleeding are the most frequent complications.

  7. 7.

    Occlusion of the aneurysm is achieved through endovascular coiling or surgical clipping.

  8. 8.

    Triple-H therapy is the mainstay of treatment for DID after aneurysm occlusion.

  9. 9.

    Magnesium sulfate and statin therapy show promise for DID reduction, but more research is needed.



Cerebral Vasospasm Aneurysm Wall Poor Grade Endovascular Coiling Neurogenic Pulmonary Edema 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Al-Shahi R, White PM, Davenport RJ, Lindsay KW (2006) Subarachnoid hemorrhage. BMJ 333:235–240CrossRefPubMedGoogle Scholar
  2. Drake CG, Hunt WE, Sano K, Kassell N, Teasdale G, Pertuiset B (1988) Report of world federation of neurosurgeons committee on a universal subarachnoid hemorrhage grading scale. J Neurosurg 68:985–986Google Scholar
  3. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG (2004) Prevention of venous thromboembolism: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126:338S–400SCrossRefGoogle Scholar
  4. Guy J, McGrath BJ, Borel CO, Friedman AH, Warner DS (1995) Perioperative management of aneurysmal subarachnoid hemorrhage: Part 1. Operative management. Anesth Analg 81:1060–1072CrossRefPubMedGoogle Scholar
  5. International subarachnoid hemorrhage collaborative group (2002) International subarachnoid hemorrhage trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 360:1267–1274CrossRefGoogle Scholar
  6. Lynch JR, Wang H, McGirt MJ, Floyd J, Friedman AH, Coon AL, Blessing R, Alexander MJ, Graffagnino C, Warner DS, Laskowitz DT (2005) Simvastatin reduces vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 36:2024–2026CrossRefPubMedGoogle Scholar
  7. Ohman J, Servo A, Heiskanen O (1991) Long-term effects of nimodipine on cerebral infarcts and outcome after aneurysmal subarachnoid hemorrhage and surgery. J Neurosurg 74:8–13CrossRefPubMedGoogle Scholar
  8. Poberskin LH (2001) Incidence and outcome of subarachnoid hemorrhage: a retrospective population based study. J Neurol Neurosurg Psychiatry 70:340–343CrossRefGoogle Scholar
  9. Quinn AC, Inwergbu K, Sharma A, Beecroft L, Thomson S, Ross S (2004) Gender and cerebral vasospasm in Yorkshire, England. In: Macdonald R (ed) Cerebral vasospasm. Springer, ChicagoGoogle Scholar
  10. Rinkel GJE, Feigin VL, van Gijn J (2004) Circulatory volume expansion therapy for aneurysmal subarachnoid hemorrhage (Cochrane Review). The Cochrane Library 2Google Scholar
  11. Rinkel GJE, Feigin VL, Algra A, van den Bergh, Vermeulen M, van Gijn J (2005) Calcium antagonists for aneurysmal subarachnoid hemorrhage (Cochrane Review). The Cochrane Database of Systematic Reviews 1Google Scholar
  12. Roos YB, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M (1997) Timing of surgery in patients with aneurysmal subarachnoid hemorrhage: rebleeding is still the major cause of poor outcome in neurosurgical units that aim at early surgery. J Neurol Neurosurg Psychiatry 63(4):490–493CrossRefPubMedGoogle Scholar
  13. Sen J, Belli A, Albon H, Morgan L, Petzold A, Kitchen N (2003) Triple-H therapy in the management of aneurysmal subarachnoid hemorrhage. Lancet Neurol 2:614–621CrossRefPubMedGoogle Scholar
  14. The Association of Anaesthetists of Great Britain and Ireland (2006) Recommendations for the safe transfer of patients with brain injuryGoogle Scholar
  15. Thiagarajan A, Goverdhan PD, Mahajan RP (1998) The effect of hyperventilation and hyperoxia on cerebral venous oxygen saturation in patients with traumatic brain injury. Anesth Analg 87:850–853CrossRefPubMedGoogle Scholar
  16. Torbey MT, Bhardwaj A (2001) How to manage blood pressure in critically ill neurologic patients. J Crit Ill 16:179–192Google Scholar
  17. Treggiari MM, Walder B, Suter PM, Romand J-A (2003) Systematic review of the prevention of delayed ischaemic neurological deficits with hypertension, hypervolaemia, and haemodilution therapy following subarachnoid hemorrhage. J Neurosurg 98:978–984CrossRefPubMedGoogle Scholar
  18. Tseng M-Y, Czosnyka M, Richards H, Pickard JD, Kirkpatrick PJ (2005) Effects of acute treatment with pravastatin on cerebral vasospasm, autoregulation, and delayed ischemic deficits after aneurysmal subarachnoid hemorrhage. Stroke 36:1627–1632CrossRefPubMedGoogle Scholar
  19. van den Bergh WM (2005) On behalf of the MASH study group. magnesium sulfate in aneurysmal subarachnoid hemorrhage. Stroke 36:1011–1015CrossRefPubMedGoogle Scholar
  20. van den Bergh WM, Algra A, van der Sprenkel JWB, Tulleken CAF, Rinkel GJE (2003) Hypomagnesemia after aneurysmal subarachnoid hemorrhage. Neurosurgery 52(2):276–282CrossRefPubMedGoogle Scholar
  21. Wilson SR, Hirsch NP, Appleby I (2005) Management of subarachnoid hemorrhage in a non-neurosurgical center. Anaesthesia 60:470–485CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag London Limited 2010

Authors and Affiliations

  • Audrey C. Quinn
    • 1
  • Simon P. Holbrook
    • 2
  1. 1.Leeds General Infirmary Leeds Teaching Hospitals NHS TrustLeedsUK
  2. 2.Academic Unit of AnesthesiaSt. James’s University HospitalLeedsUK

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