Deep T-wave inversions ("cerebral T waves"), ST changes, QT prolongation, arrhythmias — all may be neurogenic; do NOT misdiagnose as primary cardiac event
Indication: CT-negative suspected SAH. If CT head is normal but clinical suspicion (thunderclap headache "worst of my life") remains — LP (CPT 62270) is MANDATORY. Wait ≥6h (ideally 12h) from headache onset for xanthochromia to develop.
Timing: URGENT — but ≥6h from headache onset to allow xanthochromia development.
Study
ED
HOSP
OPD
Rationale
Target Finding
Opening pressure
URGENT
ROUTINE
-
Elevated in SAH
Often elevated (>20 cm H2O)
Cell count (tubes 1 AND 4)
URGENT
ROUTINE
-
Distinguish SAH from traumatic tap: SAH = RBC count does NOT clear significantly between tube 1 and tube 4
RBC in tube 4 ≥ tube 1 (SAH); if tube 4 << tube 1 = traumatic tap
Xanthochromia (visual and/or spectrophotometry)
URGENT
ROUTINE
-
Yellow discoloration from RBC breakdown (bilirubin); develops >6h after SAH; spectrophotometry more sensitive than visual inspection
Special Handling: Xanthochromia sample must be protected from light (wrap tube in foil); centrifuge immediately; spectrophotometry if available (more sensitive than visual inspection).
Note: CT within 6h of ictus has near 100% sensitivity. If CT is obtained within 6h and is clearly negative, some guidelines suggest LP may not be needed if CTA is also negative. However, LP remains standard of care for CT-negative thunderclap headache in most institutions.
Blood pressure control: Nicardipine IV (CPT 96365)
IV
-
5 mg/h :: IV :: - :: 5 mg/h IV; titrate by 2.5 mg/h q5-15min; max 15 mg/h. Target SBP <160 mmHg UNTIL aneurysm is secured (re-bleed risk highest in first 24h with uncontrolled HTN); after securing: target SBP <180 (or higher if vasospasm)
Severe aortic stenosis
Continuous arterial BP; neuro checks q1h
STAT
STAT
-
STAT
Blood pressure control: Labetalol IV (CPT 96374)
IV
-
10-20 mg :: IV :: - :: 10-20 mg IV q10-20min; max 300 mg. Alternative to nicardipine
Heart block; severe bradycardia; asthma
HR; BP continuous
STAT
STAT
-
STAT
Blood pressure control: Clevidipine IV (CPT 96365)
IV
-
1-2 mg/h :: IV :: - :: 1-2 mg/h IV; max 32 mg/h
Soy/egg allergy
BP continuous
STAT
STAT
-
STAT
Nimodipine (CORNERSTONE of vasospasm prevention)
IV
-
60 mg :: IV :: q4h :: 60 mg PO/NG q4h x 21 days. START within 96h of SAH onset. If hypotension: 30 mg q2h. This is an ORAL calcium channel blocker — do NOT give IV (severe hypotension). Proven to reduce poor outcomes from vasospasm
Hypotension (SBP <90 — reduce dose); do NOT crush extended-release formulations; use oral syringe if NG
BP with each dose; do NOT give IV; ensure enteral route only
-
STAT
-
STAT
External ventricular drain (EVD)
-
-
N/A :: - :: once :: For acute hydrocephalus (GCS declining; CT showing ventriculomegaly); allows ICP monitoring and CSF drainage. Set drain height per neurosurgery (typically 15-20 cm above tragus)
Coagulopathy (correct first)
ICP continuous; CSF output q1h; drain position; infection surveillance (CSF culture q3 days per some protocols)
STAT
STAT
-
STAT
Seizure prophylaxis (short-term)
IV
-
1000 mg :: IV :: BID :: Levetiracetam 1000 mg IV/PO load, then 500-1000 mg BID. AHA 2012: short-term (3-7 days) prophylaxis is reasonable. Avoid phenytoin (associated with worse cognitive outcomes in SAH — Naidech et al.)
Renal impairment (dose adjust)
Seizure monitoring
STAT
STAT
-
STAT
Intubation / Airway protection
-
-
N/A :: - :: once :: GCS ≤8; inability to protect airway; respiratory failure; impending herniation
N/A
Avoid hypotension during RSI; maintain SBP goal
STAT
STAT
-
STAT
Aminocaproic acid (antifibrinolytic) (CPT 96365)
IV
-
4g :: IV :: once :: 4g IV load then 1g/h IV infusion. ONLY use for short-term (<72h) if aneurysm securing will be delayed. Reduces re-bleeding risk but increases thrombotic risk. Discontinue once aneurysm is secured
Active DIC; DVT/PE; renal impairment
Coagulation; thrombotic events; discontinue when aneurysm treated
STAT
STAT
-
STAT
IV isotonic fluids (euvolemia)
IV
-
1-1.5 mL/kg :: - :: - :: NS at 1-1.5 mL/kg/h (80-125 mL/h); goal euvolemia. Avoid hypovolemia (worsens vasospasm) and avoid aggressive hypervolemia (no proven benefit; risk of pulmonary edema). Target CVP 5-8 or clinical euvolemia
Volume overload; CHF
I/O; daily weights; CVP if central line; serum Na q6-8h
STAT
STAT
-
STAT
Stress ulcer prophylaxis: Pantoprazole
IV
-
40 mg :: IV :: daily :: 40 mg IV/PO daily
C. diff risk
GI symptoms
-
ROUTINE
-
ROUTINE
DVT prophylaxis: Pneumatic compression devices
-
-
N/A :: - :: continuous :: Apply bilaterally on admission; SAH patients are HIGH VTE risk
N/A :: - :: once :: Interventional neuroradiology; catheter-based platinum coil deployment into aneurysm sac. Preferred per ISAT trial for posterior circulation and many anterior circulation aneurysms
Difficult vascular access; very wide neck without stent option
-
-
-
-
-
Surgical clipping (craniotomy)
-
-
N/A :: - :: once :: Neurosurgical; microsurgical clip placement across aneurysm neck
Poor grade with brain swelling (relative — may clip if accessible); medically unstable
-
-
-
-
-
Flow diverter (Pipeline, FRED)
-
-
N/A :: - :: per protocol :: For large/giant or wide-necked aneurysms not amenable to standard coiling
Requires dual antiplatelet therapy (may not be ideal in acute SAH)
60 mg :: PO :: q4h :: Continue 60 mg PO q4h x 21 days total
Hypotension
BP with each dose
-
STAT
-
STAT
Induced hypertension
IV
-
N/A :: IV :: continuous :: If clinical vasospasm (new deficit days 4-14, aneurysm MUST be secured first): raise SBP to 180-220 mmHg using vasopressors. Phenylephrine 0.5-5 µg/kg/min or norepinephrine 0.05-0.3 µg/kg/min IV
500-1000 mL :: - :: once :: NS bolus 500-1000 mL if hypovolemic; maintain euvolemia. Avoid prophylactic hypervolemia (no benefit per current evidence — Robertson et al.)
Volume overload
CVP; I/O; daily weights
-
-
-
STAT
Milrinone IV (alternative vasospasm treatment)
IV
-
0.25-0.75 µg/kg/min :: IV :: continuous :: 0.25-0.75 µg/kg/min IV continuous; some centers use as rescue for vasospasm not responding to induced hypertension; acts as cerebral vasodilator
5-10 mg :: PO :: - :: Verapamil 5-10 mg intra-arterial or nicardipine 5-10 mg intra-arterial; via catheter into spastic vessel during angiography. For medically refractory vasospasm
Hemodynamic instability during procedure
Angiographic improvement; clinical response; BP
-
-
-
STAT
Angioplasty (balloon)
-
-
N/A :: - :: per protocol :: Mechanical dilation of spastic proximal vessels during angiography. For focal proximal vasospasm refractory to medical treatment
Vessel rupture risk; distal vasospasm (not amenable to balloon)
Angiographic result; clinical response
-
-
-
STAT
Magnesium sulfate (supplemental)
IV
-
2.0 mg :: IV :: PRN :: Target serum Mg >2.0 mg/dL; replete with MgSO4 2-4 g IV over 1-2h PRN. MASH-2 trial: IV magnesium infusion did NOT improve outcomes, but maintaining normal-high Mg is standard
Recurrent thunderclap headaches over days-weeks; triggered by exertion, Valsalva, sexual activity; vasospasm on CTA; may have convexity SAH; no aneurysm
CTA (multifocal segmental narrowing); MRI (may show edema, infarct, cortical SAH); DSA; clinical course (resolves in weeks)
Never discharge from ED with confirmed SAH. Discharge from hospital when: aneurysm secured; past vasospasm window (day 14-21); stable neurologic exam; Na stable; able to take oral nimodipine; no EVD dependency; adequate follow-up
Admit to Neuro-ICU
ALL confirmed aneurysmal SAH patients; minimum 14-21 days ICU-level monitoring during vasospasm window. Transfer to step-down only after vasospasm window passed
Transfer to comprehensive stroke center / Neurovascular center
If no neurosurgery or interventional neuroradiology on-site — TRANSFER IMMEDIATELY. SAH requires tertiary neurovascular services
Inpatient rehabilitation
Significant deficits but medically stable; past vasospasm window; able to participate in 3h/day therapy
Skilled nursing facility
Cannot tolerate intensive rehab; requires ongoing skilled care
Hospice / Comfort care
Devastating SAH (Hunt-Hess V with poor prognostic factors); after appropriate observation period and family discussion