Key Patient Messages: Aneurysmal Subarachnoid Hemorrhage Guideline

  • What is an aSAH: An aneurysmal subarachnoid hemorrhage, or aSAH, is a sudden life-threatening emergency in which bleeding occurs in the subarachnoid space of the brain (one of the layers that covers and protects the brain). This bleeding is caused when part of an artery in the brain weakens, balloons, and then bursts (ruptures). aSAH is a severe and often deadly condition – up to 26% of people with aSAH die before they reach hospital. Women are more likely than men to have an aSAH, and risk increases with age. As our population ages, aSAH may become an even more significant public health burden. The persistently high pre-hospital and inpatient death rates, along with the aging population, require improved therapies and practice standards in the management of aSAH patients.
  • Risk Factors: There are many potential causes of an aSAH, but hypertension and tobacco use are important modifiable risk factors. Family history is a rare but important risk factor and, for individuals with two or more first-degree relatives (parent, sibling, or child) with known brain aneurysms, 12% of those will have a cerebral aneurysm.
  • Symptoms of an aSAH: The most common sign of aSAH is a sudden severe headache, often described as a thunderclap headache or the worst headache of your life. In patients who experienced an aSAH, warning headaches occurred in 10% - 43% of cases. Additional symptoms include decreased consciousness and alertness, nausea and vomiting, stiff neck, sudden weakness, dizziness, numbness in part of the body, light sensitivity, seizures, mood changes, and vision issues.
  • Timing is Critical: Individuals with any of the symptoms listed above should call 911 or go to the closest Emergency Room. Prompt evaluation and treatment of the ruptured aneurysm is critical, preferably within 24 hours. Timely transfers to centers with neurocritical care units and physician expertise in aneurysm treatment is associated with lower mortality and increased likelihood of good functional outcomes.
  • Treatment Methods: Patients with aSAH should undergo repair of their ruptured aneurysm as soon as possible to reduce the risk of aneurysm re-rupture, an event that is frequently fatal. Evaluation of the ruptured aneurysm by specialists with expertise in both endovascular coiling and neurosurgical clipping, individually or as a team, is preferable to optimally evaluate relative risks and benefits of each treatment strategy. Surgical options and endovascular techniques have different advantages and disadvantages that need to be carefully weighed for each individual patient, as there are many patient-specific factors that must be considered.
  • Treatment Decisions: Clinicians with expertise in endovascular and surgical treatments can assist patients, their family, and caregivers in making the best decisions about treatment options. Patients without irrecoverable and devastating neurological injury are candidates for aneurysm treatment. Patients of advanced age require careful consideration for treatment. The utilization of shared decision-making and discussions about treatment outcomes is necessary between the clinical staff and the family or surrogate decision maker.
  • Post-Treatment: Patient discharge planning should be done by a team of clinicians including physicians, nurses, therapists, and others. This team approach should also be used to develop a care plan for patients who require rehabilitation after leaving the hospital. Physical, cognitive, behavioral, and quality of life deficits are common and can persist, and early identification can improve long term outcomes.
  • Recovery: The most common cognitive complaints include mental slowness, memory, and attention difficulties, and 50% of aSAH patients continue to experience cognitive difficulties for a year or sometimes over a year. A strong support team, ideally family and friends, is crucial to help with medication administration, driving, appointment assistance, and social needs. Patients should be screened for depression and anxiety, and psychotherapy and pharmacotherapy are recommended to reduce symptoms.
  • Long Term: For aSAH patients who have undergone aneurysm repair, follow-up cerebrovascular imaging is recommended, and the patient should consult with their neurosurgical team for screening recommendations.
  • In Summary: For anyone experiencing any signs of an aSAH, timing is critical. Call 911 or go to the closest Emergency Center. Aneurysmal Subarachnoid Hemorrhages are treatable either surgically or endovascularly, and early aneurysm repair can reduce fatality and improve patient outcomes.


Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R; Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association [published online ahead of print May 22, 2023]. Stroke. doi: 10.1161/STR.0000000000000436

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