Sub Arachnoid Hemorrhage

Unlock the complexities of Subarachnoid Hemorrhage with this detailed guide. From investigations and medical management for non-operated aneurysms to blood pressure targets and indications for coiling or clipping. Explore medication regimens, pain management strategies, and crucial details on the Hunt-Hess Grading Scale.

NON-OPERATED ANEURYSM

Investigations

1. Continuous EKG monitoring for ischemia
2. Cardiac enzymes
3. MRA brain

Medical Management:

•   Dilantin 100 mg po tid

•   Nimodipine 60 mg po q4h for prophylaxis against vasospasm for a total of 21 days

a. Hold if SBP < 120

b.   If SBP 120-140 range use 30 mg instead

•   Pneumoboots / SCDs

•   Pain management:

1.   Lortab 1-2 tab po q6h prn or

2.   Morphine 2mg iv q 2h prn

•   Pepcid 20 mg po bid

•   Colace 100mg pot id

•   Ondansetron 4mg po q6 h prn for nausea

Blood Pressure Management

Non-operated aneurysm

• Target MAP 70-100 
• Target SBP 90-140

Clipped aneurysm:

• Target SBP 120-180

If 140/90 - 230/120 on 2 readings 5 minutes apart use Labetelol

1. Labetelol 10 mg iv over 2 minutes
2. May repeat in 10 minutes at double the dose
3. Max cumulative dose in 24 hrs is 300mg
4. Hold for HR < 60

If SBP >230 or DBP 121-140 on 2 readings 5 minutes apart

1. May still try Labetelol
2. If ineffective go to Nicardipine

Nicardipine 5mg /hour infusion.

1.   Titrate up by 2.5 mg/h increments at 15 minute intervals.

2.   Max rate 15mg/h

3.   Once target range reached, reduce to 3mg/h

Indications for Coiling:

•   Posterior circulation

•   Cavernous segment of ICA

•   Neck diameter < 5mm

•   Neck to largest diameter ratio < 0.5 (ie if neck diameter is less than half of largest diameter)

Indications for Clipping

•   MCA aneurysm

•   Giant >25mm

•   Very small <3mm

•   Associated large hematoma / mass effect

Hunt- Hess Grading Scale

I   mild headache

II  severe headache

III Severe headache with focal deficit other than cranial nerve palsy

IV stupor

V  coma