====== Perimesencephalic subarachnoid hemorrhage treatment ======

{{rss>https://pubmed.ncbi.nlm.nih.gov/rss/search/1xqh3Z_PuJgCUPfZyszhjYQ4yeuKqE_By5Ab2bTwRKnGewZY-J/?limit=15&utm_campaign=pubmed-2&fc=20250320124117}}

===== Management Approach =====

==== 1. Initial Stabilization ====

[[Airway]] & [[Breathing]]: Evaluate the need for airway protection in patients with decreased consciousness (rare in PMSAH).

[[Blood Pressure]] Management: Maintain systolic BP < 160 mmHg to reduce the risk of rebleeding.

First-line agents: [[Labetalol]], [[nicardipine]], or [[esmolol]].

==== 2. Diagnostic Workup ====

Non-contrast CT Brain: Characteristic localized [[hyperdensity]] in [[perimesencephalic cistern]]s.

CT Angiography ([[CTA]]): Rule out [[aneurysm]]s.

[[Digital Subtraction Angiography]] (DSA): Indicated if CTA is inconclusive or in young patients with atypical hemorrhage patterns.

[[Lumbar Puncture]] (LP): Not usually required if CT is done within 6 hours of symptom onset.

==== 3. Supportive Care ====

Pain Control: [[Acetaminophen]] or mild [[opioid]]s.

Antiemetics: [[Ondansetron]] or [[metoclopramide]] for [[nausea]].

[[Hydration]]: IV fluids to maintain euvolemia (avoid overhydration).

[[Deep-Vein Thrombosis Prophylaxis]]: Intermittent compression devices; [[low-molecular-weight heparin]] can be considered after 48 hours if no aneurysm is found.

[[Seizure]] [[Prophylaxis]]: Not routinely recommended.

==== 4. Monitoring & Follow-Up ====

Neuro-ICU Admission: Monitor for delayed complications, though [[risk]]s are low.

Repeat Vascular [[Imaging]]: Typically not necessary unless initial imaging is inconclusive.

Long-term Follow-up: [[MRI]]/[[MRA]] may be considered in select cases.

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A survey aimed to evaluate the clinical management among neurosurgical departments in Germany. 135 neurosurgical departments in Germany received a hardcopy questionnaire. Encompassing three case vignettes with minor, moderate and severe NASAH on CT-scans and questions including the in-hospital treatment with initial observation, blood pressure (BP) management, cerebral vasospasm (CV) prophylaxis and the need for digital subtraction angiography (DSA). 80 departments (59.2%) answered the questionnaire. Whereof, centers with a higher caseload state an elevated complication rate (Chi2 < 0.001). Initial observation on the intensive care unit is performed in 51.3%; 47.5%, 70.0% in minor, moderate and severe NASAH, respectively. Invasive BP monitoring is performed more often in severe NASAH (52.5%, 55.0%, 71.3% minor, moderate, severe). CV prophylaxis and transcranial doppler ultrasound (TCD) are performed in 41.3%, 45.0%, 63.8% in minor, moderate and severe NASAH, respectively. Indication for a second DSA is set in the majority of centers, whereas after two negative ones, a third DSA is less often indicated (2nd: 66.2%, 72.5%, 86.2%; 3rd: 3.8%, 3.8%, 13.8% minor, moderate, severe). This study confirms the influence of bleeding severity on treatment and follow-up of NASAH patients. Additionally, the existing inconsistency of treatment pathways throughout Germany is highlighted. Therefore, we suggest to conceive new treatment guidelines including this finding
((Wolfert C, Maurer CJ, Sommer B, Steininger K, Motov S, Bonk MN, Krauss P, Berlis A, Shiban E. Management of perimesencephalic nonaneurysmal subarachnoid hemorrhage: a national survey. Sci Rep. 2023 Aug 7;13(1):12805. doi: 10.1038/s41598-023-39195-2. PMID: 37550334; PMCID: PMC10406943.))
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