Management of Aneurysmal Subarachnoid Hemorrhage
Grading and Management of Aneurysmal Subarachnoid Hemorrhage (SAH)
- Control rebleeding: 4% incidence in first 24 hrs of bleed
Blood pressure (BP) control:
No evidence for a target BP
“Triple H therapy” to treat vasospasm: Hypervolemia, hypertension, hemodilution
- Ventriculostomy, if hydrocephalus (occurs in 33-50% of SAH patients)
- Nimodipine: Vasospasm and delayed cerebral ischemia: Usually occurs 7-10 days after bleed.
- Definitive treatment: Microvascular aneurysm clipping or endovascular coil embolization
Grading Scales
Hunt-Hess Scale (subjective and poor inter-rater variability)
| Grade | Description |
|---|---|
| 0 | Unruptured |
| 1 | Asymptomatic, or mild H/A and slight nuchal rigidity |
| 1a | Acute meningeal/brain reaction, but with fixed neuro deficit |
| 2 | Cranial nerve palsy, moderate to severe headache, or nuchal rigidity |
| 3 | Mild focal deficit, lethargy, or confusion |
| 4 | Stupor, moderate to severe hemiparesis, or clearly decerebrate rigidity |
| 5 | Deep coma, decerebrate rigidity, moribund appearance |
Increase by 1 grade for serious system disease, or severe vasospasm on arteriography
World Federation of Neurosurgical Societies (WFNS)
| WFNS Grade | Glasgow Coma Score | Major Focal Deficit |
|---|---|---|
| 0 (unruptured) | ----- | ------ |
| 1 | 15 | Absent |
| 2 | 13-14 | Absent |
| 3 | 13-14 | Present |
| 4 | 7-12 | Present/absent |
| 5 | 3-6 | Present/absent |
References
- Edlow JA, Malek AM, Ogilvy CS. Aneurysmal subarachnoid hemorrhage: update for emergency physicians. J Emerg Med. 2008 Apr;34(3):237-51. Epub 2007 Dec 26. [PubMed]
