Subarachnoid Hemorrhage (SAH)

Prevent rebleeding before the aneurysm is secured - Avoid hypertension and surges (laryngoscopy, straining, light anesthesia); a smooth induction with blood-pressure control is critical until the aneurysm is clipped or coiled.

Balance against ischemia - After securing, the concern shifts to vasospasm and delayed ischemia — maintain perfusion and euvolemia and avoid hypotension.

Manage ICP and brain relaxation - Support cerebral perfusion while controlling intracranial pressure, and provide brain relaxation for clipping as needed.

Cardiac stunning - SAH causes neurogenic myocardial injury — expect ECG changes, arrhythmias, and sometimes reduced function; interpret and support accordingly.

Sodium and seizures - Watch for hyponatremia (cerebral salt wasting) and seizures, and manage carefully.

Subarachnoid hemorrhage is bleeding into the subarachnoid space, most often from a ruptured cerebral aneurysm. It causes a sudden severe headache, raised intracranial pressure, and a cascade of complications.

Those include rebleeding until the aneurysm is secured, cerebral vasospasm with delayed ischemia, hydrocephalus, seizures, neurogenic cardiac stunning with arrhythmias and ECG changes, and cerebral salt wasting with hyponatremia. Anesthesia for aneurysm securing walks a tightrope between preventing rebleeding and preventing ischemia.