Critical care of poor-grade subarachnoid hemorrhage

PURPOSE OF REVIEW: Early aggressive treatment of poor-grade subarachnoid hemorrhage patients has resulted in more favorable long-term outcomes. This article covers the aspects of neurocritical care management directed to the patient with poor-grade subarachnoid hemorrhage (Hunt and Hess 4 and 5) and outlines important prognostic features. RECENT FINDINGS: Immediate cardiopulmonary and neurological support, early aneurysm repair, neuromodality and multimodality monitoring under the care of neurointensivists, treatment of medical complications, prevention and appropriate management of delayed cerebral ischemia have improved long-term outcomes after poor-grade subarachnoid hemorrhage. This includes control of intracranial hypertension, optimization of cerebral perfusion pressure and cardiac hemodynamics, correction of electrolyte abnormalities, and management of complications. Global cerebral edema, acute ischemic injury seen on diffusion-weighted imaging, and early vasospasm are disease states in the poor-grade patients that require attention and further investigation. Monitoring techniques such as surface and intracortical continuous electroencephalography, brain tissue oxygen monitoring, and microdialysis may detect secondary brain injury in a potentially reversible state. SUMMARY: Poor-grade subarachnoid hemorrhage patients have the potential to recover and should therefore be fully resuscitated and treated aggressively with the available standards and monitoring techniques.