The treatment of Subarachnoid Hemorrhage (SAH) hinges on completely sealing the ruptured aneurysm within 72 hours of onset. The swiftness of this initial treatment is the single most important factor determining the patient’s survival and prognosis, as it prevents the most dangerous complication: re-bleeding.
Subarachnoid Hemorrhage (SAH) Treatment Methods
| Timing | Objective | Essential Treatment (Nearly 100% Performed) | Optional/Additional Treatment (Depending on Situation) |
| Onset ∼24 Hours | ① Prevent re-bleeding ② Preserve life | * Strict Blood Pressure Control (SBP 120–140 mmHg) * Strict bed rest + Analgesics (e.g., Pentazocine) | * Impaired consciousness →Endotracheal intubation * Mechanical ventilation * Seizures → Levetiracetam IV |
| Onset ∼ 3 Days | Completely seal the aneurysm (Most critical step!) | Aneurysm Obliteration Surgery (One of the following): $\text{ ① Coiling (Approx. 75–80%)}$ $\text{ ② Clipping (Approx. 20–25%)}$ | * Small aneurysms → Latest Flow Diverter (Stent-like device) * Wide-necked aneurysms → Stent-assisted coiling |
| Days 4 ∼14 Post-Onset | Prevent and treat Cerebral Vasospasm | * Fasudil Hydrochloride 30mg×3 times/day IV for 14 days * Ozagrel Na | * If vasospasm occurs → Endovascular treatment (Angioplasty/intra-arterial drug delivery) |
| 2 Weeks ∼1 Month Post-Onset | Prevent and treat Hydrocephalus | * Temporary lumbar drainage or ventricular drainage | * Chronic hydrocephalus → VP shunt surgery |
| Recovery Phase Onward | Reduce residual deficits | * Early rehabilitation (starting from day 3 post-onset) * Higher brain dysfunction → Speech-Language Pathologist (SLP) * Depression →SSRIs |
Coiling vs. Clipping: Which to Choose in 2025? (Latest Criteria)
| Item | Coiling (Catheter-based Embolization) | Clipping Surgery (Craniotomy) |
| 2025 Usage Ratio | Approx. 75–80% (Dominant) | Approx. 20–25% |
| Advantages | * No need to open the skull * Safe for the elderly * Discharge possible within 2 weeks | * 100% sealed in one procedure * Nearly 0% recurrence rate |
| Disadvantages | * 1–3% recurrence over 5–10 years * Difficult for wide-necked aneurysms | * Highly invasive (opening the skull) * Scarring remains on the head/scalp |
| 2025 Criteria for Coiling | * Age 70+ * Posterior communicating artery aneurysms * Small aneurysms with a narrow neck | * Age 20–50 * Middle cerebral artery aneurysms * Giant or wide-necked aneurysms |
Latest Topics in 2025
- Flow Diverters (e.g., Pipeline) have expanded insurance coverage → Giant or wide-necked aneurysms, previously difficult to coil, can now be treated endovascularly.
- AI systems to predict cerebral vasospasm 72 hours in advance are being introduced in some universities.
- Numerous data indicate further improvement in prognosis with ultra-early coiling performed within 6 hours of onset.
Summary
“Worst Headache + Vomiting” → Call 911 immediately → Coiling or Clipping within 3 days → Fasudil infusion for 14 days.
This is the “Golden Pattern” in Japan for maximizing the chance of survival in 2025!
