We prefer to use the World Federation of Neurosurgical Societies (WFNS) scale (Table 3.1), which is based on the Glasgow Coma Scale (GCS), to evaluate the patient’s initial clinical condition (i.e., state of consciousness and focal neurologic deficits) [1]. The WFNS score during day zero is not a static entity, but is influenced by multiple factors. In approximately half of all patients, SAH is accompanied by coma; in about half of this group, the coma is transient. Depending on the time of assessment, the momentary responsiveness does not adequately reflect the impact of SAH. Early hydrocephalus also leads secondarily to significant functional depression within the first hours or days. Therefore, the course of the WFNS score over the initial day must be evaluated for a prognostic estimate.

The overall clinical assessment must include additional general medical risk factors, which are well known to influence outcome. Prognostic factors that are especially unfavorable in aneurysm patients include hypertension, diabetes, coronary heart disease, use of an oral anticoagulant, or advanced age.

Initial ancillary tests should include standard blood laboratory tests and cranial computed tomography (CCT) for localization and assessment of the extent of hemorrhage (Fisher Grading Scale, Table 3.2) [2]. After 4–5 days, the blood in the basal cisterns becomes isodense, and SAH is no longer detectable by CCT in some 50 % of cases. In these patients, a spinal tap is necessary to detect xanthochromic cerebrospinal fluid (CSF). Traces of the SAH can be detected in the CSF up to 4 weeks after hemorrhage.

If neurologic deterioration occurs after the initial CT scan, the exam must be repeated to rule out a rerupture or hydrocephalus.

We recommend baseline assessment and monitoring of cerebral perfusion and vasospasm with transcranial Doppler sonography (TCD) and perfusion CT (pCT). Both methods are semiquantitative tools with limited sensitivity and specificity. To get the maximum from TCD, it is important to thoroughly examine the intracranial arteries and also investigate the high cervical internal carotid artery (ICA) to appreciate overall hemispheric perfusion and determine the Lindegaard index (blood velocity in the middle cerebral artery [vMCA] divided by the velocity in the ipsilateral ICA [vICA]) [3]. Lindegaard indices greater than 3 denote vasospasm. TCD should be performed daily during the first week and then depending on the clinical course. Perfusion CT should not be done daily, owing to the necessary exposure to radiation and contrast medium. We recommend routine performance of an initial baseline exam and then one or two follow-up studies during the first 10 days. Additional exams must be performed in patients with secondary neurologic deterioration.

Panangiography should be planned for clinically stable patients within 24 h after admission, but it should be avoided within the first 6 h after the initial ictus because of a high risk of rerupture [4]. We do not recommend angiography during the night in stable patients admitted late. In these cases, CT angiography can be considered to be an exploratory investigation.

Panangiography should be dispensed with in emergencies with intracerebral mass hemorrhage and impending transtentorial herniation. We recommend giving these patients mannitol (1–2 g/kg body weight) and taking them immediately to the operating room following CT, which always can be completed by a contrast angiography series. Space-occupying intracerebral mass bleeding most often results from MCA aneurysms or less frequently from anterior communicating artery aneurysms. Acute subdural hematoma usually results from ICA–posterior communicating artery (Pcom) aneurysms.

The management of patients with early ventricular dilatation on CT must remain individualized, depending on the state of consciousness. If the state of consciousness is marginal or deteriorating, external CSF drainage should be installed prior to angiography.

Avoidance of rerupture is the primary objective following hospital admission. Patients with WFNS grades II or higher are optimally cared for in the ICU, but Grade I patients are more comfortable in a quiet room on the normal ward.

Stress avoidance is more important than recording vital signs and checking neurologic status. Stress reduction should include relative bed rest. Getting up to go to the toilet is associated with less stress than not getting up. Visits from relatives and friends should be restricted to the closest family members. Smoking, watching television, and using phones and computers are typically not recommended.

Analgesia for headache with paracetamol or other oral drugs, mild sedation, and stool softeners should be prescribed prophylactically. Injections should be avoided.

In unstable, comatose, or uncooperative patients, insertion of a central venous line is necessary before angiography. Otherwise, a central venous line can be inserted together with induction of anesthesia for surgery or endovascular therapy.

Patients who have been intubated for transport or medical procedures after admission should not be extubated until the ruptured aneurysm has been secured.

Total fluid intake orally or via infusion should amount to about 3,000 mL/day.

We recommend giving corticosteroids (e.g., dexamethasone 3 × 4 mg p.o./IV), although their effect remains a matter of discussion. A possibly protective effect with regard to vasospasm and cerebral edema remains unproven, but we believe that the obvious reduction of meningeal irritation and headache effect justifies prescribing them during the first week following SAH.