national-clinical-guidelines-for-stroke-fourth-edition

prevent rebleeding are urgent. CT scanning is the most sensitive non-invasive way to
detect subarachnoid blood reducing the need for lumbar puncture. Usually angiography
(CT, magnetic resonance or intra-arterial) should be done in the neurosciences centre
rather than the referring centre.
4.8.1 Recommendations
A Every patient presenting with sudden severe headache and an altered neurological
state should have the possible diagnosis of subarachnoid haemorrhage investigated
by:
● immediate CT brain scan
● lumbar puncture between 12 hours and 14 days if the CT brain scan is negative
and does not show any contraindication
● spectrophotometry of the cerebrospinal fluid for xanthochromia.
B Every patient diagnosed as having a subarachnoid haemorrhage should be referred
immediately to a tertiary neuroscience centre and:
● be started on oral nimodipine 60 mg 4 hourly unless there are specific
contraindications
● not be given anti-fibrinolytic agents or steroids.
C In the specialist service the patient should have:
● CT angiography (if this has not been done by agreed protocol in the referring
hospital) with or without catheter angiography to identify the site of bleeding
● specific treatment of any aneurysm related to the haemorrhage by endovascular
embolisation or surgical clipping if appropriate. Treatment to secure the aneurysm
should be available within 48 hours of ictus, especially for good grade patients.
D After any immediate treatment, all patients should be observed for the development
of treatable complications, especially hydrocephalus and delayed cerebral ischaemia.
E Every patient who survives should be assessed for treatable risk factors (ie
hypertension and smoking), and have these treated.
F Every patient who survives and has any residual symptoms or disability should be
referred for, and transferred to, specialist rehabilitation as soon as possible after
definitive treatment.
G Every patient with a strong family history of two or more affected first-degree
relatives and/or a history of polycystic renal disease should:
● be advised that their family may be at increased risk of subarachnoid haemorrhage
● be considered for a referral to a neurovascular and/or neurogenetic specialist for
up-to-date information and advice.
H Patients with subarachnoid haemorrhage with focal neurological signs should receive
their rehabilitation in a stroke specialist service.
4.8.2 Sources
A Consensus
B Allen et al 1983; Barker and Ogilvy 1996; Pickard et al 1989
C Molyneux et al 2005; Society of British Neurological Surgeons 2004
4 Acute phase care
© Royal College of Physicians 2012 49