Management of subarachnoid haemorrhage in a non-neurosurgical centre

Subarachnoid haemorrhage is a common neurological emergency, which carries a high morbidity and mortality. It is usually caused by rupture of an intracerebral aneurysm or, less commonly, an arteriovenous malformation. Although most patients present to a non-neurosurgical hospital, they often require urgent neurosurgical or neuroradiological intervention. Whilst awaiting transfer to a neurological centre, active management of the patient must be instituted. This should include confirmation of the diagnosis with CT imaging, lumbar puncture or both, and recognition of the complications of subarachnoid haemorrhage, which include hydrocephalus, further haemorrhage and cerebral vasospasm. Medical management is directed towards maintaining adequate cerebral perfusion pressure whilst avoiding large increases in arterial blood pressure. Nimodipine therapy must be started early in an attempt to prevent cerebral vasospasm. The treatment options available at the neurological centre include surgical treatment or endovascular obliteration of the aneurysm or arteriovenous malformation.