What to Do in Case of Aneurysmal Subarachnoid Hemorrhage
When a cerebral aneurysm ruptures, it can lead to a life-threatening condition known as aneurysmal subarachnoid hemorrhage (aSAH). This type of bleeding occurs in the space between the brain and the surrounding membrane, often causing sudden and severe symptoms such as thunderclap headache, nausea, vomiting, and loss of consciousness. Immediate medical intervention is crucial to prevent further complications and improve patient outcomes.
Initial Medical Management
Upon suspicion of subarachnoid hemorrhage, rapid stabilization becomes the top priority. Intravenous administration of hemostatic agents like tranexamic acid or aminocaproic acid helps reduce the risk of rebleeding during the early critical phase. While these medications do not replace definitive treatment, they serve as a bridge to more permanent interventions by minimizing additional blood loss in the brain.
Controlling Intracranial Pressure
Elevated intracranial pressure (ICP) is a common and dangerous consequence of bleeding. To manage this, osmotic diuretics such as mannitol are frequently used. Mannitol works by drawing excess fluid out of brain tissue, thereby reducing swelling and lowering pressure inside the skull. Close monitoring of neurological status and vital signs is essential during this stage to prevent secondary brain injury.
Preventing Cerebral Vasospasm
One of the most feared complications after aSAH is delayed cerebral ischemia caused by vasospasm—narrowing of brain arteries that can lead to stroke. Nimodipine, a calcium channel blocker, is routinely prescribed because it has been shown to significantly reduce the risk of poor neurological outcomes. Administered orally or via feeding tube, nimodipine improves blood flow to vulnerable areas of the brain without substantially affecting systemic blood pressure.
Supportive Neuroprotective Therapies
In addition to acute interventions, neuroprotective strategies play an important role in recovery. Medications such as citicoline (cytidine diphosphate-choline) and gangliosides may support neuronal repair and enhance cognitive recovery. These agents help maintain cell membrane integrity and promote synaptic regeneration, offering potential long-term benefits when used alongside rehabilitation programs.
Diagnostic Confirmation with Angiography
To determine the exact location, size, and shape of the ruptured aneurysm, clinicians rely on cerebral angiography—either through digital subtraction angiography (DSA), CT angiography (CTA), or MR angiography (MRA). DSA remains the gold standard due to its high resolution and ability to capture dynamic blood flow patterns in real time.
Definitive Treatment Options
Once diagnosed, prompt intervention is necessary to prevent re-rupture, which carries a high mortality rate. There are two primary approaches:
- Surgical clipping: A neurosurgeon performs a craniotomy to access the aneurysm and places a metal clip across its neck, sealing it off from the circulation.
- Endovascular coiling or flow diversion: A minimally invasive procedure where a catheter is threaded from the groin up into the brain vessels. Coils or stent-like devices are deployed within the aneurysm to block blood flow and encourage clot formation.
The choice between these methods depends on factors such as aneurysm anatomy, patient age, overall health, and institutional expertise. In many cases, endovascular techniques are preferred for their lower complication rates and faster recovery times.
Recovery and Long-Term Outlook
Survivors of aneurysmal subarachnoid hemorrhage often require extensive rehabilitation involving physical therapy, speech-language pathology, and psychological support. Cognitive deficits, emotional disturbances, and fatigue are common during recovery. Early and multidisciplinary care significantly enhances functional independence and quality of life.
Regular follow-up imaging and neurological assessments are recommended to monitor healing and detect any new vascular abnormalities. With timely diagnosis, advanced treatments, and comprehensive post-acute care, many patients can achieve meaningful recovery—even after a devastating initial event.