The Problem:
  Cerebral aneurysm usually presents dramatically by unexpected subarachnoid hemorrhage. Sentinel bleeds may be much less dramatic but resemble the picture of major SAH qualitatively with sudden meningeal  pain with or without cranial nerve or cerebral deficits. Efficient but careful initial management is crucial to prevent unnecessary death and disability from rebleeds or hydrocephalus or cerebral herniation. Excruciating pain and great stress in family and other associates also require prompt attention. 

  Risk factors include family history and smoking and hypertension so enquire about those. Hypertension and cardiac dysrhythmia and ischemia can occur as consequences of SAH. Hydrocephalus can be a critical problem in a few hours after SAH. CT scans miss a few SAH's so consider LP if CT is negative or if meningitis of infectious type is still in the differential list after imaging. Aneurysms may be shown by CT angio and by MR angio though selective angiography is still the gold standard at most centres. Be sure to get allergy history and creatinine blood tests out of the way promptly to avoid delays in angio performance. ECG, troponin, and CK levels need measurement. If the CT shows intracerebral hemorrhage or hydrocephalus needing a ventricular drain quick access to the OR may be needed. Early communication with radiology and OR staff may make initial management more efficient. ICU admission is usually appropriate.

What We Do:
  Hx & Px -> CBC, INR, lytes, CR, urea, glu, troponin, CK, ECG, CXR, CT or LP -> selective angio. Assign scores including GCS, Fisher, Hunt & Hess or WFNS scale. IV analgesia. Ventric drain prn signs of herniation or hydrocephalus. Early OR for clipping if Grade 3 or less. Especially urgent OR if significant clot. Antihypertensives such as enalapril IV or apresoline IV to keep systolic 120 - 140 range if possible. Interventional radiology if basilar tip or carotid bifurcation aneurysm that might be coiled. ICU admission. Arterial line and foley. Social worker and family counselling. Nimodipine 60 mg po/NG q 4 hours. 

  Vasospasm can present post op as decreased LOC or a focal deficit...initially treat with HHH... hydration, hypertension and hemodilution. IV fluids post op = N/S with KCL @ 150-200 cc/hr .If  change in neurological status .. CT head to R/O bleed then transcranial doppler and/or angiogram to identify spasm .  Increase intravascular volume to get the CVP at 9-13 if possible then increase BP... the goal is to raise the BP high enough to reverse the symptoms of vasospasm ... even if this means raising the MAP to 170 or higher... whatever it takes... fluid, then inotropes and pressors... push then until they get resolution of symptoms or CHF. If HHH therapy is ineffective, then the patient needs an angiogram and either papaverin injection or balloon angioplasty. Spasm peaks about day 7 post bleed and can last for up to 2 weeks.

Note: HHH, angioplasty and papaverin are NOT a good idea before the aneurysm is clipped.

Links:
the links

Evidence Footnotes:
1. reference