Management of subarachnoid hemorrhage in a neurological department (clinical case)

Abstract

Subarachnoid hemorrhage (SAH) is a life-threatening form of stroke (5—10 % of strokes) caused predominantly by aneurysm rupture. In 10 % to 15 % of patients with spontaneous subarachnoid hemorrhage, no aneurysm is detected on the first angiogram. In two thirds of these patients the CT scan shows a perimesencephalic pattern of hemorrhage. Patients typically present with sudden thunderclap headache, neck stiffness, vomiting, and neurological deficits. Early mortality is 25—50 %, and complications such as rebleeding, vasospasm, and hydrocephalus drive outcomes. Non-aneurysmal SAH generally has a better prognosis than aneurysmal SAH, with many patients experiencing full recovery. Modern management requires rapid CT-based diagnosis (high sensitivity if within 6 h), prompt angiography, and neurocritical unit management. Key measures include meticulous blood pressure (BP) control (e.g. systolic BP <160 mmHg), oral nimodipine for 21 days, intracranial pressure reduction, seizure prophylaxis if needed, and deep vein thrombosis prophylaxis. Remaining controversies (e.g. optimal BP targets, nimodipine dosing) are noted. Complications include rebleeding mainly in first 24—72 h, cerebral vasospasm in 60—70 % angiographically, hydrocephalus, seizures which present in 5—15 %, cardiac and pulmonary disorders, hyponatremia, ventriculitis.