Blood Pressure Management in Acute Subarachnoid Hemorrhage

Blood Pressure Management in Acute Subarachnoid Hemorrhage

Case

You have a 66-year-old female history of hypertension and diabetes presenting at 0100 for a headache, history is hard to obtain as the patient is distressed due to the pain. Collateral from the daughter is that the patient woke her up from sleep about 1 hour prior to arrival complaining of a headache and inability to move her upper extremities, which has now resolved. The patient currently endorses 10/10 headache, has had headaches before, but is not similar to this.

Clinical Pearls

We have all had patients who present with 10/10 headache without similar headaches prior. A large majority of these patients are not suffering from a SAH, however, clinical context is always key. This patient was diaphoretic, grimacing, tachypneic, tachycardic, and hypertensive, overall looking extremely ill. This is what led down the path of calling code stroke and emergent non contrast head CT.

Obviously, the title gives it away, but this patient was ultimately diagnosed with a subarachnoid hemorrhage.

Initial management

Traditional ABCs, take the airway if needed and early, maintain oxygen saturations, and regarding o circulation, target blood pressure will be the main goal, which is the main discussion point.

Blood pressure management in acute SAH:

  • Most recommendations are to target an SBP of <160 -180mmHg or MAP of <100mmHg, while not lowering the SBP more than 25% of the initial presenting blood pressure. This being said, 2023 AHA guidelines are not totally clear and agreed upon

  • BP should be monitored and controlled to balance the risk of stroke, hypertension related rebleeding, hypotension, and maintenance of cerebral perfusion pressure. One must also prevent hypotension and fluctuations in BP as much as possible

Medication Options for BP management:

  • Nicardipine (Calcium Channel Blocker): 5mg/hour titrating by 2-5 mg/hour every 5 minutes to achieve goal BP, max dose 15mg/hour

    • Benefits: Easily titratable, long duration of action, can use oral BP meds in combination with nicardipine to bridge

    • Cautions: relative contraindication for patients with severe aortic stenosis

  • Labetalol (beta-blocker): 10-20mg IV push doses over two minutes, can be repeated another 10mg every 10 minutes for a max total dose of 80mg

    • At county, we usually do one push dose followed by continuous infusion as needed at 2 — 8 mg/min

    • Benefits: good if drips aren't easily available in the emergent setting

    • Cautions: be careful in patients with bradydysrhythmias, recent sympathomimetic use (cocaine and methamphetamines) and patients with asthma history

  • Clevidipine (CCB):  1-2mg/hour titrating up by doubling the dose every 90 seconds, max dose 21mg/hour

    • Benefits: Fast on fast off, non-weight based dosing, easily titratable, vasodilatory effects are useful for maintaining coronary perfusion with lowering of the blood pressure

    • Cautions: Reflex tachycardia in response to hypotension, reflex hypertension when discontinued, is a lipid emulsion, do not use in patients with lipid disorders, soy/egg allergies

    • This agent is not available at CCH, however, may be available at other sites who rotate

Other considerations for SAH in the acute setting:

Anticoagulation reversal in patients on anticoagulation

Seizure Prophylaxis

Pain control

Disposition: Neuro ICU

Other key takeaways and pearls:

  • No history or physical exam finding rules out SAH

  • Seizure or LOC at time of onset can predict worse outcomes

This is meant to be an overview of blood pressure management in the ED and is by no means fully comprehensive of management of SAH. 




Sources:

Hine J, Ashenburg N, Marcolini E. Aneurysmal Subarachnoid Hemorrhage. In: Swadron S, Nordt S, and Mattu A, eds. CorePendium. 6th ed. Burbank, CA: CorePendium, LLC. https://www.emrap.org/corependium/chapter/recTI59VW0TPBpesx/Aneurysmal-Subarachnoid-Hemorrhage#h.xkxioldm7pxd. Updated November 7, 2024. Accessed October 5, 2026. 

Hoh BL, Ko NU, Amin-Hanjani S, Chou SH-Y, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke. 2023 Jul;54(7):e314-e370. doi: 10.1161/STR.0000000000000436. Epub 2023 May 22. Erratum in: Stroke. 2023 Dec;54(12):e516. doi: 10.1161/STR.0000000000000449. PMID: 37212182. 

Long B, Koyfman A, Runyon MS. Subarachnoid Hemorrhage: Updates in Diagnosis and Management. Emerg Med Clin North Am. 2017 Nov;35(4):803-824. doi: 10.1016/j.emc.2017.07.001. Epub 2017 Aug 24. PMID: 28987430. 

Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, Sivilotti ML. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med. 2016 Sep;23(9):963-1003. doi: 10.1111/acem.12984. Epub 2016 Sep 6. PMID: 27306497; PMCID: PMC5018921.