2. Stroke – Subarachnoid Hemorrhage

Stroke – Subarachnoid Hemorrhage

Date: 06/2026 | Location: MH Katy

Stroke is an acute neurologic injury caused by ischemia or hemorrhage that stems from a wide range of pathologies. While hemorrhagic strokes are less common than ischemic subtypes, they are a major cause of death and disability, often present more aggressively, and often have more severe sequelae than ischemic strokes. The two types of hemorrhagic stroke are intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). These occur in different locations but also differ in the underlying mechanisms responsible for their acute and subacute symptoms. However, the aim of this guideline is to discuss management specifically of hemorrhagic stroke with associated SAH.

Preoperative Management Strategy:

  • Initial imaging should include CT brain without contrast, CTA head and neck as well as transthoracic ECHO with goal to secure aneurysm within 24h of presentation.
  • In cases where hydrocephalus is seen on imaging, EVD or lumbar drain may be required prior to OR. In these cases, patients should be maintained as follows:
    • HOB > 30 degrees
    • Level EVD open to 20cm H2O
      • Any change in drainage character, including bloody output, should prompt immediate neurosurgical notifications as this can be the first sign SAH of rupture event.
    • Continuous cardiac monitoring.
  • Patient should be kept NPO with Q1H neuro checks.
  • Several medications should be utilized in this patient population:
    • Levetiracetam 500mg Q12H for seizure prophylaxis.
    • Nicardipine or clevidipine to maintain SBP < 160.
    • Nimodipine 60mg Q4H to decrease cerebral vasospasm risk.

Postoperative Management Strategy:  

  • Postoperatively, these patients are at high risk for vasospasm. While vasospasm most often occurs between 4-14 days postoperatively but it can occur any time.
  • Postoperative neuro checks should occur hourly as subtle changes can occur, signaling vasospasm is present.
    • Concerning findings include headache, pronator drift, facial weakness and/or changes in behavior, etc.
    • If neuro status becomes altered, Neurovascular Surgery should be notified immediately.
  • EEG monitoring recommended for patients with high grade SAH when comatose due to concern for non-convulsive status epilepticus in this population.
  • Fevers are common and can obscure the neuro exam.
    • Prioritize cooling measures and use of antipyretics.
    • Low threshold for pan-cultures and initiating antibiotics.
  • Blood pressure goals are liberalized: SBP goal 120-220mmHg while in the vasospasm window and euvolemia should be prioritized.
  • BP augmentation is used as a first line management of suspected vasospasm.
  • For patients with Takatsubo’s cardiomyopathy/catecholamine toxicity, favor milrinone or dobutamine for BP augmentation if needed.
  • Nimodipine should be continued for 21 days.
    • May be decreased from 60mg Q4H to 30mg Q2H to augment hypotension if present. If necessary, pressor support may be added.
  • Daily labs should be obtained (CBC/BMP) and normonatremia (Na 135-145) maintained.
  • In setting of vasospasm with EVD in place:
    • Lower EVD to 10cm H2O
    • May be lowered to 0cm H20 in patients with symptomatic vasospasm to augment cerebral perfusion pressures (CPP).
  • Follow up imaging:
    • CTA: Ordered in patients with suspected vasospasm
    • Angiography:
      • Planned for postoperative day 7 to evaluate for vasospasm
      • May require multiple angiograms for treatment of symptomatic vasospasm