The guidelines are generated from a large meta-analysis of existing literature, multicenter prospective cohort analyses and multicenter, prospective, randomized trials. Recommendations were made by group concensus based on the strenght of this existing data, as many specific treatments for SAH are not amenable to testing by clinical trial due to practical or ethical considerations. Therefore, these guidelines are intended to serve as a scientific framework for developing treatments for individual patients and as a basis for future research in Aneurysmal Subarachnoid Hemorrhage.

Diagnosis

1. Subarachnoid Hemorrhage is a Medical Emergency. Rapid referral to centers with appropriate facilities is warranted.

2. Abrupt, Severe Headache alone, or in conjunction with Nausea, Vomiting, Loss of Consciousness, Stiff Neck, or Focal Neurologic Findings are highly discriminative of Subarachnoid Hemorrhage. In addition, 1/3 of patients have a prodromal severe headache a week to a few days prior to a Subarachnoid Hemorrhage.

3. Non-contrast CT scan for suspected SAH is strongly recommended.

4. Lumbar puncture for CSF analysis is strongly recommended for confirmation when CT scan is negative.

5. Additional diagnostic testing include an EKG, Chest X-ray, Urinalysis, and Blood Labs (Complete Blood Cell Count, PT/PTT/INR, Erythrocyte Sedimentation Rate, Blood Glucose, Electrolytes, ABG).

In patients with documented SAH,

Selective cerebral angiography , to determine the presence and disposition of aneurysms, is strongly recommended. MRA or infusion CT is recommended when conventional angiography cannot be performed.

TCD (Transcranial Doppler ultrasonography) is recommended for diagnosing and monitoring vasospasm, although cerebral angiography may be required for definitive diagnosis.

Emergency Management
Neurologic Condition is highly predictive of overall prognosis and can be assessed by grading scales:

Hunt & Hess Scale

Grade	Neurologic Status
1	Asymptomatic
2	Severe headache or meningismus: no neurological deficit (except cranial nerve palsy)
3	Drowsy; minimal neurological deficit
4	Stuporous; moderate to severe hemiparesis
5	Deep coma; decerebrate posturing

Glasgow Coma Outcome Scale

Category	Outcome
1	Good recovery; independent lifestyle
2	Moderate disability; independent lifestyle
3	Severe disability; conscious but not independent
4	Vegetative state
5	Death

Graded levels in these scales determine levels of observation:

Alert: (Hunt & Hess grades of 1 or 2)

• Admit for frequent observation and neurologic assessment
• Strict bed rest
• Prophylaxis for DVT (Deep Vein Thrombosis) - pneumatic compression devices
• IV Central line recommended
• Monitoring Intracranial Pressure
• Oral Nimodipine therapy initiated
• Cranial Angiography

Significant Lethargy or Neurologic Deficit: (H&H grades 3-5)

• Admission to ICU
• IV Central line with Central Venous Pressures or Pulmonary Artery Pressures
• Isotonic or Hypertonic IV fluids administered
• Endotracheal Intubation for obtunded patients to protect airway 

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