How we do it: Acute management of subarachnoid hemorrhage

Objectives: Acute subarachnoid hemorrhage (SAH) is a neurological emergency with significant potential for long-term morbidity and mortality. We review our management of acute SAH and some of the evidence base supporting our practices. Methods: We reviewed our standardized and multi-disciplinary approach to the management of SAH. Results: Management of SAH treatment can be divided into acute, aneurysmal, waiting, and post-waiting phases. Acute issues upon presentation include hemodynamic and respiratory stability, prevention of rebleeding, and treatment of hydrocephalus. The aneurysm must then be secured through endovascular or microsurgical methods. Observation for signs and symptoms of vasospasm must be closely undertaken. Prevention of subsequent medical complications must also be undertaken. Weaning from cerebrospinal fluid diversion and possible shunting is the final step. Discussion: Standardized multi-modality management of rebleeding, hydrocephalus, aneurysmal obliteration, vasospasm, cerebral salt wasting, and other medical complications during these phases, is critical.