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neuro.sah.core.v1PRODUCTION
neuro.sah.core.v1

Subarachnoid Hemorrhage

neurologyacuteadult
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Acute SAH suspected — distinguish aneurysmal vs perimesencephalic vs traumatic [AHA/ASA 2023]

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Advance rule
Set
Advance when

SAH suspected with imaging plan

Patient inputs (10)

Age + family history shape aneurysm probability + decision for early securing [AHA/ASA 2023]

Sensitivity ~98% in first 6h; modified Fisher grade predicts vasospasm/DCI [Fisher 1980; AHA/ASA 2023]

Identifies aneurysm + collaterals; gates coiling vs clipping discussion [AHA/ASA 2023]

SIADH vs CSWS distinction for q6–8h Na monitoring [AHA/ASA 2023; NCS 2023]

GCS drives Hunt-Hess + WFNS grading + airway decision [Hunt-Hess 1968; WFNS 1988]

Hunt-Hess grade I–V drives prognosis + early securing strategy [Hunt-Hess 1968]

AHA/ASA 2023 — target SBP <160 until aneurysm secured (Class IIa); avoid <90 [Hoh Stroke 2023]

Reversal required before aneurysm securing [AHA/ASA 2023]

LP if CT negative >6h with clinical suspicion (xanthochromia + RBC count) [AHA/ASA 2023]

Neurogenic stunned myocardium / Takotsubo screen [AHA/ASA 2023]

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (21)

21 need judgement
  • informationallife_threateningrebleed
    Acute neurologic deterioration before or after securing → suspect rebleed [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghunt_hess_IV_V
    Hunt-Hess IV–V at presentation (stupor / coma / decerebrate posturing) [Hunt-Hess 1968]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghunt_hess_grade_IV
    Hunt-Hess IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing, possible vegetative disturbance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninghunt_hess_grade_V
    Hunt-Hess V — deep coma, decerebrate rigidity, moribund appearance
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateninganeurysm_location_basilar_tip
    Basilar tip / posterior circulation aneurysm — coiling clearly favoured by ISAT for posterior circulation due to surgical access difficulty
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningspecial_pop_pregnancy_aSAH
    Pregnant patient with aSAH — aneurysm rupture is a leading non-obstetric cause of maternal death; physiologic risk peaks 3rd trimester / peripartum
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehydrocephalus_acute
    Acute hydrocephalus on CT (ventricular enlargement) + GCS decline [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresymptomatic_vasospasm_DCI
    New focal deficit OR GCS drop ≥2 OR TCD MFV >120 days 3–14 post-secure [AHA/ASA 2023; NCS 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereneurogenic_stunned_myocardium
    Elevated troponin + new ECG changes + reduced LVEF on echo [AHA/ASA 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverehunt_hess_grade_III
    Hunt-Hess III — drowsiness / confusion OR mild focal neurologic deficit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaneurysm_location_anterior_communicating
    Anterior communicating artery (AComm) aneurysm — most common (~30%); frontal-lobe edema risk, hypothalamic injury, post-securing cognitive/behavioural changes
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaneurysm_location_posterior_communicating
    Posterior communicating artery (PComm) aneurysm — CN III palsy is a sentinel sign (pupil-involving "down-and-out")
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaneurysm_location_mca_bifurcation
    Middle cerebral artery (MCA) bifurcation aneurysm — often wide-necked with branch involvement; clipping historically favoured but coiling/stent-assisted now common
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereaneurysm_location_vertebral_pica
    Vertebral artery / PICA (posterior inferior cerebellar artery) aneurysm — often dissecting; risk of cerebellar infarct + medullary signs
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespecial_pop_elderly_aSAH
    Elderly aSAH (age advanced) — higher baseline mortality, more hydrocephalus and medical complications, less physiologic reserve for induced hypertension
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverespecial_pop_neurogenic_stunned_myocardium
    Neurogenic stunned myocardium / Takotsubo-pattern cardiomyopathy complicating aSAH — catecholamine surge → troponin rise, ECG changes, reduced LVEF, pulmonary oedema
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatecsws_vs_siadh
    Hyponatremia (Na <135) with high urine output = CSWS; with euvolemia/hypervolemia = SIADH [NCS 2023]
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehunt_hess_grade_I
    Hunt-Hess I — asymptomatic OR mild headache OR slight nuchal rigidity; no focal deficit
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatehunt_hess_grade_II
    Hunt-Hess II — moderate-to-severe headache, nuchal rigidity; no neurologic deficit other than CN palsy (often CN III or VI)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateaneurysm_location_perimesencephalic_angio_negative
    Perimesencephalic SAH pattern (blood centred around midbrain/pons with normal initial DSA) — often non-aneurysmal; favourable prognosis; repeat DSA at 1–2 wk
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatespecial_pop_adpkd_familial_aneurysm
    ADPKD or ≥2 first-degree relatives with aneurysm/SAH — heritable aneurysm predisposition; index event mandates family cascade screening
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONrequiredDrives severity classification
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Recommended regimen

aSAH bundle — secure aneurysm, vasospasm prevention, BP, hydrocephalus (AHA/ASA 2023 + NCS 2023)
axis: sah_acute_managementstep 1 - Step 1 — Vasospasm/DCI prevention (Day 0 of admission)
Selected step "Step 1 — Vasospasm/DCI prevention (Day 0 of admission)" — Any confirmed aSAH; start within 96 h of bleed
  • nimodipine
    first line
    CCB_dihydropyridine
    60 mg PO/NG q4h × 21 days (or 30 mg q2h if hypotensive) • PO • q4h (max: 60 mg q4h)
    triggers: confirmed_aSAH
    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).
    rxcui 7426

outpatient playbook — drug actions (4)

  1. 1. ACEI/ARB + thiazide
    Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily • PO • daily
    trigger: BP ≥130/80
    2025 AHA/ACC HTN — target <130/80 to reduce recurrent SAH + de-novo aneurysm formation
  2. 2. atorvastatin
    40–80 mg PO daily per ASCVD risk • PO • once daily
    trigger: ASCVD 10-y risk ≥7.5% OR known atherosclerosis
    2026 ACC/AHA Lipid — primary/secondary prevention per risk; note STASH NEJM 2014 showed simvastatin no benefit on DCI in acute phase, but chronic statin per ASCVD risk is independent
  3. 3. varenicline OR nicotine replacement OR bupropion
    Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk • PO / patch / lozenge • per agent
    trigger: Active tobacco use
    AHA/ASA 2023 Class I — smoking is the strongest modifiable risk factor for both initial and recurrent aneurysm formation
  4. 4. donepezil (if cognitive impairment)
    5–10 mg PO daily • PO • daily
    trigger: MoCA <26 with functional impact post-SAH
    Off-label use considered in vascular cognitive impairment; AHA/ASA 2023 supports individualised consideration

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Thunderclap headache (worst-of-life, peak <1 min) [AHA/ASA 2023 Hoh Stroke]; Headache with meningismus / nuchal rigidity [AHA/ASA 2023]; Sudden altered consciousness with headache [Hunt-Hess 1968].

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Subarachnoid Hemorrhage** (neuro.sah.core.v1).
Phenotype framing: Phenotype: aneurysmal / perimesencephalic / arteriovenous malformation / RCVS / dissection / cortical superficial siderosis [AHA/ASA 2023]
Scope: Acute SAH suspected — distinguish aneurysmal vs perimesencephalic vs traumatic [AHA/ASA 2023]

No severity triggers fired against current inputs.

Plan

Regimen axis: **aSAH bundle — secure aneurysm, vasospasm prevention, BP, hydrocephalus (AHA/ASA 2023 + NCS 2023)** — step "Step 1 — Vasospasm/DCI prevention (Day 0 of admission)".
1. nimodipine 60 mg PO/NG q4h × 21 days (or 30 mg q2h if hypotensive) PO q4h (CCB_dihydropyridine, first line) — 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).

Setting playbook (outpatient) — Cerebrovascular clinic long-term follow-up: BP <130/80, smoking cessation, family aneurysm screening, cognitive rehab, repeat MRA at 6 mo for residual neck / de-novo aneurysm, return-to-work + driving evaluation (AHA/ASA 2023)
2. ACEI/ARB + thiazide Lisinopril 10–40 mg PO daily; chlorthalidone 12.5–25 mg PO daily PO daily — BP ≥130/80 (2025 AHA/ACC HTN — target <130/80 to reduce recurrent SAH + de-novo aneurysm formation)
3. atorvastatin 40–80 mg PO daily per ASCVD risk PO once daily — ASCVD 10-y risk ≥7.5% OR known atherosclerosis (2026 ACC/AHA Lipid — primary/secondary prevention per risk; note STASH NEJM 2014 showed simvastatin no benefit on DCI in acute phase, but chronic statin per ASCVD risk is independent)
4. varenicline OR nicotine replacement OR bupropion Varenicline 0.5 mg PO daily × 3 d → 0.5 BID × 4 d → 1 mg BID × 11 wk PO / patch / lozenge per agent — Active tobacco use (AHA/ASA 2023 Class I — smoking is the strongest modifiable risk factor for both initial and recurrent aneurysm formation)
5. donepezil (if cognitive impairment) 5–10 mg PO daily PO daily — MoCA <26 with functional impact post-SAH (Off-label use considered in vascular cognitive impairment; AHA/ASA 2023 supports individualised consideration)

Non-pharmacologic actions:
- Cerebrovascular clinic visit at 6 wk post-discharge + 3 mo + 6 mo + 12 mo (AHA/ASA 2023)
- Family aneurysm screening (MRA) offered if ≥2 first-degree relatives with aneurysm/SAH OR ADPKD (AHA/ASA 2023)
- Neuropsychological testing at 3 mo for cognitive baseline (AHA/ASA 2023)
- Return-to-work plan tiered by Hunt-Hess at admission (HH I–II often 3 mo; HH III 6–12 mo; HH IV–V often unable)
- Driving evaluation per jurisdiction — typically 3–6 mo abstention then formal road test (AHA/ASA 2023)
- Vocational rehab + physical therapy continuation as needed (AHA/ASA 2023)
- Aerobic exercise prescription 150 min/wk moderate intensity once cleared (AHA/ASA 2023)
- Annual influenza + pneumococcal + COVID per ACIP 2026

AVOID / contraindication checks:
- No_routine_seizure_prophylaxis (AHA/ASA 2023)
- Abandon_triple H_in_favour_of_euvolemic_induced_HTN (HIMALAIA Gathier Stroke 2017 PMID 29158449 — RR poor outcome 1.0, SAE RR 2.1; AHA/ASA 2023; NCS 2023)
- Avoid_SBP_<90_on_nimodipine (AHA/ASA 2023)
- No_long_course_antifibrinolytic (ULTRA Post Lancet 2021 PMID 33357465 — mRS 0 3 60% vs 64%, adj OR 0.86; NCS 2023)
- No_statin_for_DCI_prevention (STASH Kirkpatrick Lancet Neurol 2014 PMID 24837690 — common OR 0.97 [0.75 1.25] p=0.803, mortality 10% vs 9%; AHA/ASA 2023)
- Nimodipine_PO_NG_only_never_IV (FDA boxed warning — fatal hypotension)

Monitoring

Regimen monitoring:
- TCD daily days 3-14 for vasospasm (AHA/ASA 2023)
- q1-2h neuro checks (AHA/ASA 2023)
- CT perfusion if clinical decline (AHA/ASA 2023)
- serum Na q6-8h for SIADH vs CSWS (NCS 2023)
- GCS continuous (AHA/ASA 2023)
- continuous arterial BP (AHA/ASA 2023)

Setting (outpatient) monitoring:
- BP home log + clinic check q3 mo until at goal then q6 mo (2025 AHA/ACC HTN)
- Lipid panel at 4–6 wk after statin start; then q6–12 mo (2026 ACC/AHA Lipid)
- MRA at 6 mo then per residual / family screen schedule (AHA/ASA 2023)
- mRS at 90 d, 6 mo, 12 mo (AHA/ASA 2023)
- MoCA + PHQ-9 at 3 mo, 6 mo, 12 mo (AHA/ASA 2023)

Follow-up plan: 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
- Close-out criterion: rehab + cerebrovascular clinic + risk-factor plan set

Monitoring phase: Daily TCD days 3–14 for vasospasm [AHA/ASA 2023]; q1–2h neuro checks; CT perfusion if clinical decline; q6–8h serum Na [NCS 2023]; cEEG if declining

Disposition

Current setting: outpatient — Cerebrovascular clinic long-term follow-up: BP <130/80, smoking cessation, family aneurysm screening, cognitive rehab, repeat MRA at 6 mo for residual neck / de-novo aneurysm, return-to-work + driving evaluation (AHA/ASA 2023)

Disposition criteria:
- Continue indefinite cerebrovascular clinic follow-up; transition to PCP for routine BP/lipid after stable year if no residual aneurysm (AHA/ASA 2023)
- Lifelong family aneurysm awareness counselling (AHA/ASA 2023)

Escalation triggers (move to higher acuity):
- 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)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Acute neurologic deterioration before or after securing → suspect rebleed [AHA/ASA 2023]
- [LIFE_THREATENING] Hunt-Hess IV–V at presentation (stupor / coma / decerebrate posturing) [Hunt-Hess 1968]
- [LIFE_THREATENING] Hunt-Hess IV — stupor, moderate-to-severe hemiparesis, early decerebrate posturing, possible vegetative disturbance

Citations

- 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) [PMID:37212182](https://pubmed.ncbi.nlm.nih.gov/37212182/)
- Cited evidence (PMID 37202712) [PMID:37202712](https://pubmed.ncbi.nlm.nih.gov/37202712/)
- Cited evidence (PMID 33357465) [PMID:33357465](https://pubmed.ncbi.nlm.nih.gov/33357465/)
- Cited evidence (PMID 2496789) [PMID:2496789](https://pubmed.ncbi.nlm.nih.gov/2496789/)
- Cited evidence (PMID 16139655) [PMID:16139655](https://pubmed.ncbi.nlm.nih.gov/16139655/)

Last reconciled with current guidelines: 2026-05-18.
References
  • 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) — PMID:37212182
  • Cited evidence (PMID 37202712) — PMID:37202712
  • Cited evidence (PMID 33357465) — PMID:33357465
  • Cited evidence (PMID 2496789) — PMID:2496789
  • Cited evidence (PMID 16139655) — PMID:16139655