Treatment Options for Subarachnoid Hemorrhage: A Comprehensive Guide

Subarachnoid hemorrhage (SAH) is a life-threatening form of stroke that occurs when bleeding happens in the space between the brain and the surrounding membrane. Immediate diagnosis and intervention are critical to improving patient outcomes. Once SAH is suspected, clinicians typically perform urgent imaging studies such as cerebral angiography or CT angiography (CTA) to identify the underlying cause—most commonly a ruptured intracranial aneurysm. Early detection allows for prompt surgical or endovascular treatment, which significantly reduces the risk of rebleeding, cerebral vasospasm, and long-term neurological deficits.

Key Goals in Managing Subarachnoid Hemorrhage

The primary objectives in treating subarachnoid hemorrhage include preventing secondary complications such as rebleeding, delayed cerebral ischemia due to vasospasm, hydrocephalus, and brain edema. Effective management not only improves survival rates but also enhances the chances of full neurological recovery. Treatment strategies are multifaceted and require coordinated care from neurologists, neurosurgeons, and intensive care specialists.

1. Stabilization and Neurological Monitoring

Patient stabilization is the first step in SAH management. This involves continuous monitoring of vital signs and neurological status using standardized scales like the Glasgow Coma Scale (GCS). Ensuring airway protection and respiratory support may require intubation in unconscious patients. Maintaining hemodynamic stability is crucial. Patients should remain on strict bed rest in a quiet environment to minimize stimulation. Emotional stress and physical exertion must be avoided to prevent sudden increases in intracranial pressure. Symptomatic medications such as sedatives, antitussives for cough suppression, and prophylactic antiepileptic drugs may be administered based on clinical need.

2. Intracranial Pressure (ICP) Management

Elevated intracranial pressure is common after SAH and can lead to herniation and irreversible brain damage. Osmotic diuretics like mannitol and loop diuretics such as furosemide are routinely used to reduce cerebral edema and lower ICP. Fluid intake should be carefully regulated to avoid volume overload while maintaining adequate cerebral perfusion. In select cases, albumin infusion may be considered to support oncotic pressure and improve fluid balance, although its use remains controversial and is guided by individual patient factors.

3. Prevention of Rebleeding

Rebleeding carries a high mortality rate and is most likely within the first 24 hours after the initial hemorrhage. To minimize this risk, patients are advised to remain absolutely bedridden for 4–6 weeks post-event. Blood pressure control is essential—antihypertensive agents are used cautiously to maintain systolic levels around 140–160 mmHg, balancing the need to prevent rebleeding without compromising cerebral blood flow. Aggressive pain management helps mitigate stress-induced hypertension caused by severe headache, a hallmark symptom of SAH.

4. Antifibrinolytic Therapy and Surgical Intervention

While antifibrinolytic drugs like tranexamic acid can temporarily reduce early rebleeding by inhibiting clot breakdown, they are generally used short-term due to increased risks of thromboembolic events. The definitive method for preventing rebleeding is eliminating the aneurysm itself. This can be achieved through two main approaches: surgical clipping, where a titanium clip is placed at the base of the aneurysm during open craniotomy, or endovascular coiling, a minimally invasive procedure in which platinum coils are inserted via catheter to block blood flow into the aneurysm. Recent advances have expanded options to include flow diverters and stent-assisted coiling for complex cases.

5. Preventing Cerebral Vasospasm

Delayed cerebral ischemia due to vasospasm typically occurs 4–14 days after the initial bleed and is a leading cause of morbidity. Prophylactic administration of calcium channel blockers, particularly oral nimodipine, has been shown to improve neurological outcomes. Induced hypertension, hypervolemia, and hemodilution—collectively known as "triple-H therapy"—are often employed in symptomatic patients to increase cerebral perfusion. Early aneurysm repair and removal of subarachnoid blood clots through surgical or minimally invasive techniques can further reduce vasospasm risk.

6. Managing Hydrocephalus

Acute hydrocephalus develops in up to 20% of SAH patients due to impaired cerebrospinal fluid (CSF) circulation. Medications that reduce CSF production, such as acetazolamide, may offer temporary relief. However, more effective interventions include ventriculostomy or external drainage of CSF. When hydrocephalus persists despite medical management, a permanent solution like ventriculoperitoneal (VP) shunt placement may be necessary to restore normal CSF dynamics and relieve pressure on the brain.

In summary, the treatment of subarachnoid hemorrhage requires a comprehensive, time-sensitive approach focused on stabilizing the patient, securing the ruptured aneurysm, and preventing potentially devastating complications. With advancements in neuroimaging, endovascular techniques, and critical care protocols, outcomes for SAH patients continue to improve. Early recognition, rapid intervention, and multidisciplinary coordination remain the cornerstones of successful treatment.