Patient handout

Aneurysmal SAH — Poor Grade (Hunt-Hess IV–V)

PRODUCTION

1. Your condition

This handout is for aneurysmal sah — poor grade (hunt-hess iv–v). Your care team identified this based on: stupor + moderate-to-severe hemiparesis + early decerebrate posturing (hh iv) [hunt-hess 1968].

Other reasons your team may use this plan: deep coma + decerebrate rigidity + moribund appearance (hh v) [hunt-hess 1968]; acute neurologic deterioration pre-securing → rebleed (mortality ~50–70%) [aha/asa 2023]; ct showing thick diffuse sah ± ivh (modified fisher iv) in stuporous/comatose patient [frontera 2006].

2. Your medications

Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.

Medication	Starting dose	How	When	What it does
rocuronium	0.6–1.2 mg/kg IV	IV	PRN intubation	Use rocuronium + sugammadex; AVOID succinylcholine in raised-ICP (AHA/ASA 2023)
etomidate	0.2–0.3 mg/kg IV	IV	one-time induction	Hemodynamically neutral induction in HH IV–V (NCS 2023)
hypertonic_saline_3pct	250 mL IV bolus then continuous to Na 145–150	IV	bolus + continuous	NCS 2023 — preferred over mannitol for sustained ICP control
mannitol	0.5–1 g/kg IV bolus	IV	PRN	Cerebral edema bridge (AHA/ASA 2023)
external_ventricular_drain	—	—	—	AHA/ASA 2023 Class I — STAT EVD in HH IV–V with hydrocephalus/IVH

Plan: Poor-grade aSAH (HH IV–V) — intubation + ICP/EVD + aggressive critical care with parallel goals-of-care (AHA/ASA 2023 + NCS 2023)

3. When to call your provider

Contact your care team if any of the following happen:

Any thunderclap → ED for re-rupture (AHA/ASA 2023)
New focal deficit → STAT CT/CTA (AHA/ASA 2023)
Caregiver burnout → social work + respite (AHA/ASA 2023)

4. When to seek emergency care

Call 911 or go to the nearest emergency room right away if you have:

HH IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing; mortality ~30–45% [Hunt-Hess 1968](life-threatening)
HH V — deep coma, decerebrate rigidity, moribund appearance; mortality ~50–80% [Hunt-Hess 1968](life-threatening)
Acute neurologic deterioration before securing — rebleed; mortality ~50–70%; pre-secure window is highest-risk period [AHA/ASA 2023](life-threatening)
HH V trajectory → ~80% mortality; prognostic anchor for goals-of-care discussion; early palliative consult mandatory [AHA/ASA 2023](life-threatening)
Routine antifibrinolytic TXA NOT recommended in HH IV–V per NCS 2023 — no functional-outcome benefit, thrombotic-event signal [ULTRA NEJM 2021 PMID 33357465; NCS 2023 PMID 37202712]
Identifying patients in good neurological-uncertainty state — multidisciplinary trajectory huddle (neurosurgery + neurointerventional + critical care + palliative + family) within 24 h of HH IV–V presentation [AHA/ASA 2023]
HH V with brain-death trajectory — formal brain-death exam + ancillary testing + organ donor coordination if family consents [NCS 2023](life-threatening)
Severe NSM/Takotsubo in HH IV–V — elevated troponin + ECG changes + reduced heart pumping strength (LVEF); complicates BP/CPP management [AHA/ASA 2023]
Refractory ICP despite EVD + osmotic + sedation in HH IV–V — escalate to barbiturate coma + decompressive craniectomy consideration [AHA/ASA 2023](life-threatening)

5. Follow-up

If survivor — IRF/SNF rehab + long-term cognitive + family support; if death — donor coordination + bereavement [AHA/ASA 2023]

6. Sources

Guideline: 2023 AHA/ASA aSAH Guideline (Hoh et al, Stroke 2023 PMID 37212182) + 2023 NCS aSAH Management (Treggiari et al, Neurocrit Care 2023 PMID 37202712)