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Subarachnoid hemorrhage is bleeding in the space between the arachnoid membrane and the pia. The most common cause of subarachnoid hemorrhage is trauma. Traumatic subarachnoid hemorrhage (tSAH) often occurs along the con­vexity of the brain within its sulci, or within expansions of the subarachnoid space such as the cistern of the sylvian ssure or the basal cisterns of the skull surrounding the brain stem. Some components of tSAH are frequently found in moderate and severe traumatic brain injuries. TSAH can contribute to adverse outcomes by its pathophysiologic sequelae that include cerebral vasospasm, electrolyte imbalances, intracranial hypertension, and disruptions in cerebrospinal uid dynamics producing hydrocephalus.

Patients with signs of intracranial hyperten­sion such as dilated and xed pupil, decerebrate or decorticate posturing, and rapid neurologic deterioration are administered a 1 gram per kilo­gram bolus of mannitol; however, mannitol is contraindicated in patients having hypotension or congestive heart failure. Prophylactic administra­tion of mannitol is also contraindicated. Patients receiving mannitol infusion must undergo inser­tion of a urethral catheter into the urinary bladder in order to facilitate diuresis.

6. Maintain oxygen saturation above 90%; all those with GCS <9 should be intubated and put on mechanical ventilator.

Once SICH is conrmed, neurosurgical con­sultation is made, and typical admission orders are very similar to the initial management of sub­arachnoid hemorrhage (see above), with the exception of nimodipine administration. Orders should include admission to a neurointensive care unit with hourly neurological examination, maintenance of head-of-bed elevation to at least 30 degrees, strict control of blood pressure with a systolic blood pressure target of less than 160mm Hg, and anticonvulsant therapy for seizure pro­phylaxis. Assessment and prognostication of SICH relies on a conuence of patient factors that include patient age, baseline function and preexisting patient comorbidities, neurological ndings, and radiologic characteristics of the hemorrhage. These factors can be estimated by the intracerebral hemorrhage (ICH) score, a 0–6­point grading scale that integrates GCS score, ICH volume, presence or absence of intraven­tricular hemorrhage, presence or absence of an infratentorial origin of hemorrhage, and patient age into a composite estimate of 30-day mortal­ity. ICH volume in this score is calculated using the ABC/2 method, in which the greatest diame­ter of the hematoma chosen from the slice in which it appears largest (“A”) is multiplied by the diameter perpendicular to “A” (i.e., component “B”), multiplied by the estimated number of axial slices with hemorrhage multiplied by slice thick­ness (“C”). The product of these three compo­nents (A×B×C) is then divided by 2 [16]. The ICH score, as with other clinical scoring algo­rithms, should be validated in each context where it may be used since the original research informing the score was performed in a distinct population that may differ in important ways from other socioeconomic contexts. Such scores do, however, provide clinical tools that may prove useful in all contexts once they have been validated. The ICH scoring algorithm appears below (Table23.3).