Patient handout

Subarachnoid Hemorrhage

PRODUCTION

1. Your condition

This handout is for subarachnoid hemorrhage. Your care team identified this based on: thunderclap headache (worst-of-life, peak <1 min) [aha/asa 2023 hoh stroke].

Other reasons your team may use this plan: headache with meningismus / nuchal rigidity [aha/asa 2023]; sudden altered consciousness with headache [hunt-hess 1968]; ct showing subarachnoid blood [fisher 1980].

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
nimodipine	60 mg PO/NG q4h × 21 days (or 30 mg q2h if hypotensive)	PO	q4h	BRANT (Pickard BMJ 1989;298:636-642, PMID 2496789) — n=554 RCT: cerebral infarction 22% vs 33% placebo (RRR 34%, 95% CI 13-50); poor outcome (death/severe disability, 3 mo) 20% vs 33% (RRR 40%, 95% CI 20-55). Class I per 2023 AHA/ASA; reduces poor outcome from DCI; NOT for vasospasm reversal. NEVER give IV (fatal hypotension; FDA boxed warning).

Plan: aSAH bundle — secure aneurysm, vasospasm prevention, BP, hydrocephalus (AHA/ASA 2023 + NCS 2023)

3. When to call your provider

Contact your care team if any of the following happen:

Any thunderclap or sentinel headache → ED for re-rupture / new aneurysm (AHA/ASA 2023)
New focal deficit → STAT CT/CTA for de-novo aneurysm or AVM (AHA/ASA 2023)
BP persistently >140/90 despite 3-drug regimen → resistant HTN workup (cardio.htn.resistant.v1; 2025 AHA/ACC HTN)
PHQ-9 ≥15 OR suicidal ideation → urgent psych referral (AHA/ASA 2023)
MoCA <26 with functional decline → neurocognitive workup (AHA/ASA 2023)

4. When to seek emergency care

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

Acute neurologic deterioration before or after securing → suspect rebleed [AHA/ASA 2023](life-threatening)
Acute hydrocephalus on CT (ventricular enlargement) + GCS decline [AHA/ASA 2023]
New focal deficit OR GCS drop ≥2 OR TCD MFV >120 days 3–14 post-secure [AHA/ASA 2023; NCS 2023]
Hunt-Hess IV–V at presentation (stupor / coma / decerebrate posturing) [Hunt-Hess 1968](life-threatening)
Elevated troponin + new ECG changes + reduced heart pumping strength (LVEF) on echo [AHA/ASA 2023]
Hunt-Hess III — drowsiness / confusion OR mild focal neurologic deficit
Hunt-Hess IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing, possible vegetative disturbance(life-threatening)
Hunt-Hess V — deep coma, decerebrate rigidity, moribund appearance(life-threatening)
Anterior communicating artery (AComm) aneurysm — most common (~30%); frontal-lobe edema risk, hypothalamic injury, post-securing cognitive/behavioural changes
Posterior communicating artery (PComm) aneurysm — CN III palsy is a sentinel sign (pupil-involving "down-and-out")
Middle cerebral artery (MCA) bifurcation aneurysm — often wide-necked with branch involvement; clipping historically favoured but coiling/stent-assisted now common
Basilar tip / posterior circulation aneurysm — coiling clearly favoured by ISAT for posterior circulation due to surgical access difficulty(life-threatening)
Vertebral artery / PICA (posterior inferior cerebellar artery) aneurysm — often dissecting; risk of cerebellar infarct + medullary signs
Pregnant patient with aSAH — aneurysm rupture is a leading non-obstetric cause of maternal death; physiologic risk peaks 3rd trimester / peripartum(life-threatening)
Elderly aSAH (age advanced) — higher baseline mortality, more hydrocephalus and medical complications, less physiologic reserve for induced hypertension
Neurogenic stunned myocardium / Takotsubo-pattern cardiomyopathy complicating aSAH — catecholamine surge → troponin rise, ECG changes, reduced heart pumping strength (LVEF), pulmonary oedema

5. Follow-up

Long-term BP control; smoking cessation; family aneurysm screening [AHA/ASA 2023]; rehab; cognitive evaluation; repeat MRA at 6 mo for residual neck / de-novo aneurysm

6. Sources

Guideline: 2023 AHA/ASA Guideline for Aneurysmal SAH (Hoh et al, Stroke 2023;54:e314-e370) + 2023 NCS Neurocritical Care Management Guidelines (Treggiari et al, Neurocrit Care 2023;39:1-28)