Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – stabilization and cardiopulmonary support

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1st line – 

stabilization and cardiopulmonary support

Patients should be admitted to dedicated neurocritical care unit.[37]

Consciousness level should be assessed using the Glasgow Coma Scale, and need for endotracheal intubation and mechanical ventilation should be established. Blood pressure, heart rate, and respiratory function should be closely monitored. In patients with aSAH and unsecured aneurysm, frequent blood pressure (BP) monitoring and BP control with short-acting medication(s) is recommended to avoid severe hypotension, hypertension, and BP variability.[37] There is insufficient evidence to recommend a particular BP target.[37] Sudden, profound reduction of BP should be avoided.[37][101]

Tracheal intubation: animated demonstration
Tracheal intubation: animated demonstration

How to insert a tracheal tube in an adult using a laryngoscope.

Bag-valve-mask ventilation: animated demonstration
Bag-valve-mask ventilation: animated demonstration

How to use bag-valve-mask apparatus to deliver ventilatory support to adults. Video demonstrates the two-person technique.

In patients who are receiving anticoagulants, emergency reversal with appropriate agents should be performed to prevent rebleeding.[37] Reversal strategies should follow current published standards for life-threatening bleeding.[37][102]​ See Anticoagulation management principles.

Close monitoring and goal-directed treatment of volume status are reasonable to maintain euvolemia.[37][103][104][105] Induction of hypertension and hypervolemia is potentially harmful because of the association with excess morbidity including cerebral edema, hemorrhagic transformation in areas of infarction, reversible leukoencephalopathy, myocardial infarction, and congestive heart failure.[37][106][107][108][109][39]​ Therefore, prophylactic hemodynamic augmentation should not be performed to reduce iatrogenic patient harm.[37] Electrolyte imbalances (e.g., hyponatremia) are common and should be corrected.[37]

Plus – surgical clipping or coil embolization

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Plus – 

surgical clipping or coil embolization

Treatment recommended for ALL patients in selected patient group

Surgical or endovascular treatment of the ruptured aneurysm should be performed as early as feasible after presentation, preferably within 24 hours of onset, to improve outcome.[37] A neurosurgeon and interventional neuroradiologist should be involved. Most surgeons operate on patients with good neurologic status during the first 72 hours to prevent rebleeding, a practice that also seems to be associated with improved outcome.[126]

Complete obliteration of the ruptured aneurysm is indicated whenever feasible to reduce the risk of rebleeding and retreatment.[37][123][124][125] Treatment should be individualized according to patient-specific factors such as medical comorbidities and prehhemorrhage functional status and should incorporate shared decision-making with the family or surrogate decision makers.[37]

AHA/ASA recommends:[37]

  • In patients with high-grade aSAH, aneurysm treatment is reasonable, after careful discussion of likely prognosis with family members, to optimize patient outcome

  • In patients with aSAH and advanced age, aneurysm treatment is reasonable, after careful discussion of prognosis with family members, to improve survival and outcome.

  • In patients with aSAH who do not improve after correction of modifiable conditions and are deemed unsalvageable because of evidence of irreversible neurologic injury, treatment of the aneurysm is not beneficial.

Controversy exists over the choice between clipping and coil embolization. For patients with SAH, the ruptured aneurysm should be evaluated by specialist(s) with endovascular and surgical expertise to determine the relative risks and benefits of surgical or endovascular treatment according to patient (e.g., age, neurologic status on admission, comorbid conditions) and aneurysm characteristics (e.g., size and location).[37]For patients with good-grade SAH from ruptured aneurysms of the anterior circulation equally suitable for both primary coiling and clipping, AHA/ASA recommends primary coiling in preference to clipping to improve 1-year functional outcome.[37][128][138]​​ However, the guideline notes both treatment options are reasonable in this patient group to achieve a favorable long-term outcome.[37]

AHA/ASA recommends coiling in preference to clipping in patients with aSAH from ruptured aneurysms of the posterior circulation that are amenable to coiling, to improve both short- and long-term outcomes.[37][138][139][140]​​​ Patient age may inform the modality of treatment. For aSAH patients <40 years of age, clipping of the ruptured aneurysm might be considered the preferred mode of treatment to improve durability of the treatment and outcome. Longer life expectancy and better long-term protection from re-rupture favor consideration of clipping in younger patients.[37][128][141]​ ​However, for patients >70 years of age, the superiority of coiling or clipping to improve outcome is not well established.[37][128][142]​​ For patients with aSAH deemed salvageable and with depressed level of consciousness due to large intraparenchymal hematoma, emergency clot evacuation should be performed to reduce mortality.[37]

Controversy exists over the choice between clipping and coil embolization. Patient factors that should be taken into account include age, neurologic status on admission, comorbid conditions, and size and location of the aneurysm.

Complications of clipping include aneurysm rupture, injury to vascular structures, postoperative stroke, and clipping of arterial perforators.

Complications of coiling include stroke, vessel rupture, and dissection, and incomplete embolization, and recurrences requiring reintervention.[133][134][135][136][137]

Plus – nimodipine

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Plus – 

nimodipine

Treatment recommended for ALL patients in selected patient group

Early initiation of enteral nimodipine (a calcium-channel blocker) is beneficial in preventing vasospasm, delayed cerebral ischemia and improving functional outcomes in patients with aneurysmal SAH.[37]​​ [ Cochrane Clinical Answers logo ]

Primary options

nimodipine: 60 mg orally/nasogastrically every 4 hours for 21 days

Plus – venous thromboembolism (VTE) prophylaxis

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all patients
Plus – 

venous thromboembolism (VTE) prophylaxis

Treatment recommended for ALL patients in selected patient group

In patients with aneurysmal SAH whose ruptured aneurysm has been secured, pharmacologic or mechanical venous (intermittent pneumatic compression) VTE prophylaxis is recommended to reduce the risk for VTE.[37] Follow your local anticoagulation protocols. See  Venous thromboembolism (VTE) prophylaxis

Consider – anticonvulsants

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Consider – 

anticonvulsants

Treatment recommended for SOME patients in selected patient group

​​Prophylactic use of anticonvulsants following SAH is controversial.[114][115]​ US guidelines suggest that prophylactic anticonvulsants may be considered in patients with SAH and high-seizure-risk features (i.e., ruptured middle cerebral artery aneurysm, high-grade SAH, intracranial hemorrhage, hydrocephalus, and cortical infarction).[37] These guidelines recommend against the routine use of anticonvulsants in patients with SAH without high-seizure-risk features since phenytoin for seizure prophylaxis is associated with excess morbidity and mortality.[37][88][116]​​​​ The risk of seizures is significantly lower after coil embolization than following surgical clipping of aneurysm.[37]  Short-course treatment may be adequate prophylaxis, and some evidence suggests that it is better tolerated than a longer course.[87][117]​​ Routine long-term use of anticonvulsants is not recommended, but may be considered for patients with known risk factors for delayed seizure disorder.[37] In patients with SAH who present with seizures, treatment with anticonvulsants for ≤7 days is reasonable to reduce seizure-related complications in the perioperative period.[37] In patients with SAH without prior epilepsy who present with seizures, treatment with anticonvulsants beyond 7 days is not effective for reducing future SAH-associated seizure risk.[37][39]​​[114]​​

There is some evidence that in the US levetiracetam may be the most commonly prescribed agent for the prevention of seizures following SAH.[118]​ One small prospective study comparing levetiracetam with phenytoin for seizure prophylaxis after neurologic injury (including SAH) found the same outcomes with respect to mortality and seizure control, but levetiracetam-treated patients experienced better long-term functional outcomes than those treated with phenytoin (as evaluated by the Glasgow Outcome Scale-Extended and Disability Rating Scale).[119]​

Plus – stool softeners

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Plus – 

stool softeners

Treatment recommended for ALL patients in selected patient group

Stool softeners to prevent straining can reduce the risk of rebleeding. There are many available, including docusate and senna.

Consider – antitussives

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cough
Consider – 

antitussives

Treatment recommended for SOME patients in selected patient group

Cough suppression can help prevent rebleeding. An antitussive agent such as codeine may be given. Cough and cold medications that include opioids, such as codeine or hydrocodone, should not be used in children aged 18 years or younger as the risks (slowed or difficult breathing, misuse, abuse, addiction, overdose, and death) outweigh the benefits when used for cough in these patients.[122]

Opioids may cause respiratory depression and have the potential for addiction, abuse, and misuse. Opioids may be used for headaches in patients with SAH so it is important to take this into account when considering whether to prescribe opioids for cough suppression.

Primary options

codeine sulfate: 15-30 mg orally every 4-6 hours when required, maximum 120 mg/day

Consider – analgesia

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all patients
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headache
Consider – 

analgesia

Treatment recommended for SOME patients in selected patient group

Analgesia should be provided to conscious patients.

Acetaminophen can be used as a first-line option.[39]​ For severe pain, opioids such as codeine or tramadol should be given.[39]​ If a patient is still in pain, morphine or oxycodone may be required.[39]​ Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) should be avoided before aneurysm occlusion.[39]

Opioids may cause respiratory depression and have the potential for addiction, abuse, and misuse. Opioids may be used for cough suppression in patients with SAH so it is important to take this into account when considering whether to prescribe opioids.

Mental status also needs to be closely monitored, especially in patients at risk of acute hydrocephalus or vasospasm. Judicious use of analgesia is therefore recommended.

Primary options

acetaminophen: oral: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day; intravenous (<50 kg body weight): 15 mg/kg intravenously every 6 hours when required, maximum 75 mg/kg/day; intravenous (≥50 kg body weight): 1000 mg intravenously every 6 hours when required, maximum 4000 mg/day

Secondary options

codeine sulfate: 15-60 mg orally every 4-6 hours when required, maximum 360 mg/day

OR

tramadol: 50-100 mg orally (immediate-release) every 4-6 hours when required, maximum 400 mg/day

Tertiary options

morphine sulfate: 10-30 mg orally (immediate-release) every 4 hours when required initially, adjust dose according to response; 2.5 to 10 mg subcutaneously/intramuscularly/intravenously every 2-6 hours when required

OR

oxycodone: 5-15 mg orally (immediate-release) every 4-6 hours when required initially, adjust dose according to response

Consider – sodium replacement

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hyponatremia
Consider – 

sodium replacement

Treatment recommended for SOME patients in selected patient group

Electrolyte imbalances (e.g., hyponatremia) are common and should be corrected.[37] See  Hyponatremia

Consider – fludrocortisone

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hyponatremia
Consider – 

fludrocortisone

Treatment recommended for SOME patients in selected patient group

The American Heart Association states that use of fludrocortisone is reasonable to treat natriuresis and hyponatremia, as supported by several RCTs.[37]​ However, although fludrocortisone use reduces excess sodium excretion, urine volume, and intravenous fluid use in patients with SAH, it has not been found to consistently affect outcome.[37][110][111][112]​​​[113] Some guidelines state there is insufficient evidence to support its use in maintaining normal serum sodium concentrations or improving functional outcome.[113]​​

Primary options

fludrocortisone: consult specialist for guidance on dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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