Guideline sources The following summarized guidelines for the evaluation and management of subarachnoid hemorrhage (SAH) are prepared by our editorial team based on guidelines from the American Heart Association (AHA/ASA 2023; 2019; 2015), the European Society of Intensive Care Medicine (ESICM 2021), the European Stroke Organisation (ESO 2021; 2017), the European Stroke Organisation (ESO/ESSD 2021), and the United States Department of Defense (DoD/VA 2019). 1 3 4 5 6 7 8 9 10 Calculator Calculator Calculator Fisher Grading Scale for risk of v Hunt & Hess Classification of Su Hunt and https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 1/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway Guidelines 1. Classification and risk stratification Risk of aneurysm rupture: Recognize that: smoking increases the risk of unruptured intracranial aneurysm formation B hypertension may play a role in the growth and rupture of intracranial aneurysms B prior history of aneurysmal SAH may be an independent risk factor for future hemorrhage secondary to a different small unruptured aneurysm. B Risk assessment: consider using the Ottawa Subarachnoid Hemorrhage Rule in patients with acute-onset severe headache without a new neurological deficit to identify patients at high risk for aneurysmal SAH. C Severity assessment: use clinical scales (such as the Hunt and Hess grade or the World Federation of Neurosurgical Societies grade) to determine initial clinical severity and predict outcomes in patients with aneurysmal SAH. B 2. Diagnostic investigations General principles: As per ASA 2023 guidelines, obtain prompt diagnostic evaluation to diagnose/exclude aneurysmal SAH and minimize morbidity and mortality in patients with an acute-onset severe headache. B As per AHA 2015 guidelines, obtain a careful assessment for coexistent unruptured intracranial aneurysms in patients with aneurysmal SAH. B Computed tomography: Obtain a non-contrast head CT in patients with acute-onset severe headache presenting > 6 hours from symptom onset or having a new neurological deficit. B Consider obtaining a non-contrast head CT (on a high-quality scanner and interpreting by a board-certified neuroradiologist) to diagnose/exclude aneurysmal SAH in patients with acute- onset severe headache presenting < 6 hours from symptom onset and without new neurological deficit. C Digital subtraction angiography: Obtain digital subtraction angiography to diagnose/exclude cerebral aneurysms in patients with spontaneous SAH with a high level of concern for an aneurysmal source and a negative or inconclusive CT angiography. B Consider obtaining digital subtraction angiography to determine the optimal strategy for aneurysm intervention in patients with SAH from a confirmed cerebral aneurysm. C https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 2/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway 3. Diagnostic procedures Lumbar puncture: perform a lumbar puncture to diagnose/exclude aneurysmal SAH in patients with acute-onset severe headache presenting > 6 hours from symptom onset or having a new neurological deficit if CT is negative for aneurysmal SAH. B 4. Respiratory support Prone positioning/recruitment maneuver: consider performing rescue maneuvers, such as prone positioning and alveolar recruitment maneuvers with intracranial pressure monitoring, to improve oxygenation in patients with aneurysmal SAH developing severe ARDS and life- threatening hypoxemia. C 5. Medical management Setting of care: Transfer patients with aneurysmal SAH from hospitals with low-case volume to higher-volume centers with multidisciplinary neurointensive care services, comprehensive stroke center capabilities, and experienced cerebrovascular surgeons/neuroendovascular interventionists in a timely manner to improve outcomes. B Provide care to patients with aneurysmal SAH in a dedicated neurocritical care unit by a multidisciplinary team. B Anticoagulation reversal: administer appropriate agents for emergency anticoagulation reversal to prevent rebleeding in patients with aneurysmal SAH receiving anticoagulants. B Prevention of thrombosis: administer pharmacological or mechanical VTE prophylaxis to reduce the risk for VTE in patients with aneurysmal SAH with a secured ruptured aneurysm. B Antifibrinolytic agents: As per ASA 2023 guidelines, do not use antifibrinolytic agents routinely to improve functional outcomes in patients with aneurysmal SAH. D Landmark trials: ULTRA In adult patients with spontaneous CT-proven subarachnoid hemorrhage, tranexamic acid was not superior to control with respect to good clinical outcome at 6 months, mRS score of 0-3. Ren Post et al. Lancet. 2021 Jan 9. As per ESICM 2021 guidelines, insufficient evidence to support the use of tranexamic acid in critically ill patients with SAH. I https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 3/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway Prevention of delayed cerebral ischemia: consider initiating enteral nimodipine early to prevent delayed cerebral ischemia and improve functional outcomes in patients with aneurysmal SAH. B Show 2 more Management of delayed cerebral ischemia: consider elevating systolic BP values to reduce the progression and severity of delayed cerebral ischemia in patients with aneurysmal SAH and symptomatic vasospasm. C Show 4 more Prevention of seizures: As per AHA 2023 guidelines, consider administering prophylactic antiseizure agents to prevent seizures in patients with aneurysmal SAH and high-seizure-risk features (ruptured middle cerebral artery aneurysm, high-grade SAH, intracerebral hemorrhage, hydrocephalus, and cortical infarction). C Show 2 more As per ESO 2017 guidelines: Avoid administering primary or secondary antiepileptic drug prophylaxis to prevent acute symptomatic seizures in patients with SAH. D Avoid administering primary antiepileptic drug prophylaxis to prevent unprovoked seizures after SAH. D Management of seizures: Consider administering antiseizure medications for 7 days to reduce seizure-related complications in the perioperative period in patients with aneurysmal SAH presenting with seizures. C Do not administer antiseizure medications beyond 7 days to reduce future SAH-associated seizure risk in patients with aneurysmal SAH without prior epilepsy presenting with seizures. D Management of hydrocephalus: perform urgent CSF diversion (external ventricular drain and/or lumbar drainage) to improve neurological outcomes in patients with aneurysmal SAH and acute symptomatic hydrocephalus. B Show 2 more Management of volume status: consider obtaining close monitoring and administering goal- directed treatment of volume status to maintain euvolemia in patients with aneurysmal SAH. C Show 2 more Management of blood pressure: as per ASA 2023 guidelines, obtain frequent BP monitoring and administer short-acting medications to control BP to avoid severe hypotension, hypertension, and BP variability in patients with aneurysmal SAH and an unsecured aneurysm. B Management of body temperature: as per ASA 2023 guidelines, insufficient evidence to recommend therapeutic temperature management during the acute phase of aneurysmal SAH in patients with fever refractory to antipyretic medications. I Management of glucose levels: https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 4/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway As per ASA 2023 guidelines, consider providing effective glycemic control, strict hyperglycemia management, and avoiding hypoglycemia to improve outcomes in patients with aneurysmal SAH. C As per ESO 2017 guidelines, avoid administering IV insulin routinely to achieve tight glycemic control in order to improve functional outcomes or survival in patients with hemorrhagic stroke. D 6. Inpatient care Serial neurological assessment: Obtain frequent neurological assessment with a neurological assessment tool, such as the Glasgow Coma Scale or the NIHSS, to monitor delayed cerebral ischemia and other secondary complications in patients with aneurysmal SAH. B Obtain frequent vital sign and neurological monitoring for the detection of neurological change and prevention of secondary cerebral insults and poor outcomes in patients with aneurysmal SAH. B Monitoring for delayed cerebral ischemia: consider obtaining CT angiography or CT perfusion to detect vasospasm and predict delayed cerebral ischemia in patients with aneurysmal SAH with suspected vasospasm or limited neurological examination. C Show 3 more Monitoring for seizures: consider obtaining continuous EEG monitoring to detect seizures in patients with aneurysmal SAH and either fluctuating neurological examination, depressed mental state, ruptured middle cerebral artery aneurysm, high-grade SAH, intracerebral hemorrhage, hydrocephalus, or cortical infarction. C 7. Therapeutic procedures Indications for treatment: consider offering aneurysm treatment to optimize outcomes in patients with high-grade aneurysmal SAH after carefully discussing the likely prognosis with family members. C Show 2 more Timing for treatment: As per AHA 2023 guidelines, perform surgical or endovascular treatment of the ruptured aneurysm as early as feasible after presentation, preferably within 24 hours of onset, to improve outcomes in patients with aneurysmal SAH. B As per ESO 2021 guidelines, consider performing early surgical or endovascular intervention in patients experiencing intracranial artery dissection with SAH. C Goals of treatment: Perform complete obliteration of the ruptured aneurysm whenever feasible to reduce the risk of rebleeding and retreatment in patients with aneurysmal SAH. B https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 5/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway Consider performing partial obliteration to secure the rupture site and providing retreatment in a delayed fashion in patients with aneurysmal SAH with functional recovery to prevent rebleeding if complete obliteration of the ruptured aneurysm by either clipping or primary coiling treatment is not feasible in the acute phase. C Choice of treatment modality, general principles: As per ASA/AHA 2023 guidelines, evaluate the ruptured aneurysm by specialists with endovascular and surgical expertise to determine the relative risks and benefits of surgical or endovascular treatment according to patient and aneurysm characteristics in patients with aneurysmal SAH. B As per ESO 2021 guidelines, condider deciding on the choice of intervention in patients with acute intracranial artery dissection-related SAH based on a multidisciplinary assessment. E Choice of treatment modality (endovascular coiling vs. microsurgical clipping): perform coiling in preference to clipping to improve outcomes in patients with aneurysmal SAH from ruptured aneurysms of the posterior circulation amenable to coiling. B Show 5 more Choice of treatment modality (endovascular adjuncts): consider performing endovascular treatment with stent-assisted coiling or flow diverters to reduce the risk of rebleeding in patients with aneurysmal SAH from ruptured wide-neck aneurysms not amenable to surgical clipping or primary coiling. C Show 2 more Red blood cell transfusion: insufficient evidence to recommend a restrictive (7 g/dL) over a liberal (9-11.5 g/dL) transfusion threshold in critically ill adult patients with SAH. I 8. Perioperative care General anesthesia: include minimizing postprocedural pain, nausea, and vomiting in anesthetic goals in patients with aneurysmal SAH. B Intraoperative neuromonitoring: consider obtaining intraoperative neuromonitoring to guide anesthetic and operative management in patients with aneurysmal SAH. C Intraoperative induced hypothermia: do not induce mild hypothermia during aneurysm surgery routinely in patients with good-grade aneurysmal SAH. D Intraoperative adenosine administration: consider administering adenosine to facilitate aneurysm clip placement by inducing cardiac standstill and temporary profound pause in patients with aneurysmal SAH and an uncontrolled intraoperative aneurysmal rupture. C Management of intraoperative blood pressure: consider obtaining frequent intraoperative BP monitoring and controlling BP to prevent ischemia and rupture in patients with aneurysmal SAH and an unsecured ruptured aneurysm. C Management of intraoperative glucose levels: consider preventing intraoperative hyperglycemia and hypoglycemia during aneurysm surgery to improve outcomes in patients with https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 6/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway aneurysmal SAH. C Management of intraoperative intracranial hypertension: consider administering intraoperative mannitol or hypertonic saline to reduce intracranial pressure and cerebral edema in patients with aneurysmal SAH. C Postoperative imaging: obtain perioperative cerebrovascular imaging after aneurysm repair to identify remnants or recurrence of the aneurysm likely to require further treatment. B 9. Preventative measures Primary prevention: Advise smoking cessation in patients with unruptured intracranial aneurysms. B Monitor BP and treat hypertension in patients with unruptured intracranial aneurysms. B 10. Follow-up and surveillance Discharge from hospital: use validated grading scores or patient-reported outcome measures before hospital discharge to screen for physical, cognitive, behavioral, and quality-of-life deficits in patients with aneurysmal SAH. B Rehabilitation, approach and timing: As per ASA/AHA 2023 guidelines, offer an early multidisciplinary team-based approach to treatment and rehabilitation to reduce the length of stay and identify discharge needs in patients with aneurysmal SAH. B Show 2 more As per ASA/AHA 2019 guidelines, provide early rehabilitation in patients hospitalized for stroke in environments with organized, interprofessional stroke care. A Show 3 more As per DoD/VA 2019 guidelines, provide a team-based approach in an organized inpatient unit encompassing comprehensive rehabilitation in order to improve the likelihood of discharge to home after acute stroke. A Show 3 more Rehabilitation (neurostimulants): consider administering neurostimulants early to promote consciousness recovery in patiens with aneurysmal SAH in coma. C Rehabilitation, motor therapy: As per ASA/AHA 2023 guidelines, do not use fluoxetine to enhance post-stroke functional status in patients with aneurysmal SAH without depression. D Landmark trials: AFFINITY https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 7/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway In adult patients with acute stroke, brain imaging consistent with ischemic or hemorrhagic stroke, and a persisting neurological deficit, fluoxetine was not superior to placebo with respect to new depression at 6 months. AFFINITY Trial Collaboration. Lancet Neurol. 2020 Aug. As per ASA/AHA 2019 guidelines, insufficient evidence to support the use of fluoxetine or other SSRIs to enhance motor recovery. I As per DoD/VA 2019 guidelines, offer task-specific practice ("task-oriented practice" or "repetitive task practice") for improving upper- and lower-extremity motor function, gait, posture, and activities of daily living. A Show 17 more Rehabilitation (evaluation for cognitive dysfunction): Consider using a validated screening tool in the post-acute period to identify cognitive dysfunction in patients with aneurysmal SAH. B Consider using the Montreal Cognitive Assessment over the MiniMental Status Examination to identify cognitive impairment in patients with aneurysmal SAH. C Rehabilitation, cognitive, speech, and sensory therapy: As per ASA/AHA 2023 guidelines, consider counseling patients and caregivers on the high long- term risk of cognitive dysfunction to identify long-term needs in patients with aneurysmal SAH. C As per DoD/VA 2019 guidelines, insufficient evidence to recommend for or against the use of any specific cognitive rehabilitation methodology or pharmacotherapy to improve cognitive outcomes. I Show 4 more Rehabilitation, evaluation for dysphagia: As per ASA/AHA 2023 guidelines, use a validated dysphagia screening protocol before initiating oral intake to reduce the incidence of pneumonia in patients with aneurysmal SAH. B As per ESSD/ESO 2021 guidelines, obtain a formal dysphagia screening test (either water- swallow tests or multiple-consistency tests) as soon as possible after admission to prevent post- stroke pneumonia and decrease the risk of early mortality in all patients with acute stroke. B Show 2 more As per ASA/AHA 2019 guidelines, obtain dysphagia screening before the patient begins eating, drinking, or receiving oral medications to identify patients at increased risk for aspiration. B Consider obtaining dysphagia screening by speech-language pathologists or other trained healthcare providers. B Show 2 more Rehabilitation, dysphagia therapy, nutritional support: As per ESSD/ESO 2021 guidelines, do not administer any food or liquid items, including oral medications, until a dysphagia screening is obtained and swallowing is deemed safe. D Show 2 more https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 8/9 6/24/23, 3:14 PM Subarachnoid hemorrhage Pathway As per DoD/VA 2019 guidelines, consider placing a gastrostomy tube to maintain optimal nutrition in patients with dysphagia in the post-acute phase of stroke requiring tube feeding. C Rehabilitation, dysphagia therapy, exercises: As per ESSD/ESO 2021 guidelines, consider offering behavioral swallowing exercises to rehabilitate swallowing function in patients with post-stroke dysphagia. Avoid limiting behavioral interventions to one specific maneuver or training but tailor the treatment to the specific swallowing impairment of the individual patient with post-stroke dysphagia based on a careful assessment of dysphagia. C As per DoD/VA 2019 guidelines, consider offering Shaker exercise or chin tuck against resistance exercises in addition to conventional dysphagia therapy. C Show 2 more Rehabilitation, dysphagia therapy, oral hygiene: As per ESSD/ESO 2021 guidelines, consider implementing oral health care interventions to reduce the risk of pneumonia in patients with stroke. C As per ASA/AHA 2019 guidelines, consider implementing oral hygiene protocols to reduce the risk of pneumonia after stroke. C Rehabilitation (dysphagia therapy, pharmacotherapy): offer pharmacological treatment of post- stroke dysphagia within clinical trial settings. B Show 3 more Rehabilitation, dysphagia therapy, electrical stimulation: As per ESSD/ESO 2021 guidelines, offer neurostimulation techniques in patients with post- stroke dysphagia within clinical trial settings. B Show 2 more As per DoD/VA 2019 guidelines, insufficient evidence to recommend for or against neuromuscular electrical stimulation or pharyngeal electrical stimulation for the treatment of dysphagia. I Rehabilitation (dysphagia therapy, acupuncture): consider offering acupuncture for the rehabilitation of swallowing function in patients with post-stroke dysphagia. C Rehabilitation (evaluation for depression and anxiety): use validated screening tools in the post-acute period to identify depression and anxiety in patients with aneurysmal SAH. B Rehabilitation (management of depression and anxiety): Offer psychotherapy and pharmacotherapy to reduce symptoms of depression in patients with aneurysmal SAH and depression. B Screen and offer intervention for depression, anxiety, and sexual dysfunction to improve long- term outcomes in adult patients with aneurysmal SAH. B Rehabilitation (return to work): Insufficient evidence to recommend for or against any specific assessments or interventions regarding return to work. I https://web.pathway.md/diseases/rechN1MB1iJVVEh2W 9/9