Subarachnoid Haemorrhage AND Intracranial Haemorrhage

The answer first

Spontaneous intracranial haemorrhage divides into two mechanistically and therapeutically distinct syndromes: aneurysmal subarachnoid haemorrhage (SAH) from rupture of a saccular intracranial aneurysm, and spontaneous intracerebral haemorrhage (ICH) from rupture of small deep vessels damaged by hypertensive arteriopathy or cerebral amyloid angiopathy. The answer-first physician approach is to recognise the pattern of a thunderclap headache or acute focal deficit, secure the diagnosis with non-contrast computed tomography (CT), then act with three time-critical levers — blood-pressure control, urgent vascular imaging in suspected SAH, and early definitive aneurysm obliteration in confirmed SAH — while starting nimodipine for delayed cerebral ischaemia prevention. [1] [2] [9]

For the FRACP candidate the intracranial haemorrhage long case rewards a tight one-sentence synthesis ("a 58-year-old hypertensive woman with a WFNS grade 2 aneurysmal subarachnoid haemorrhage from a ruptured anterior communicating artery aneurysm, now day 5 with delayed cerebral ischaemia"), a problem list ordered by threat, and a plan that integrates resuscitation, neurocritical care, neurointerventional and neurosurgical pathways, plus secondary prevention and rehabilitation. [1] [9] The trap is treating "a bleed" as a unitary diagnosis: SAH and ICH are managed in entirely different ways, and the threshold, target and timing of blood-pressure lowering, the role of surgery, and the indication for nimodipine all hinge on the mechanism. [2] [9]

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1. [1]Vergouwen MDI, Ramos-Pachon A, Terecoasa EO, Willett N, et al. European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage Eur Stroke J, 2026.PMID 42095754
2. [2]Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association Stroke, 2012.PMID 22556195
3. [3]Allen GS, Ahn HS, Preziosi TJ, et al. Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage N Engl J Med, 1983.PMID 6338383
4. [4]Pickard JD, Murray GD, Illingworth R, et al. Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial BMJ, 1989.PMID 2496789
5. [5]Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysm Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial Lancet, 2002.PMID 12414200
6. [6]Molyneux AJ, Kerr RS, Yu LM, et al. International subarachnoid aneurysm trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised comparison of effects on survival, dependency, seizures, rebleeding, subgroups, and aneurysm occlusion Lancet, 2005.PMID 16139655
7. [7]Post R, Germans MR, Tjerkstra MA, et al. Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial Lancet, 2021.PMID 33357465
8. [8]Vergouwen MD, Vermeulen M, van Gijn J, et al. Definition of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage as an outcome event in clinical trials and observational studies: proposal of a multidisciplinary research group Stroke, 2010.PMID 20798370
9. [9]Greenberg SM, Ziai WC, Cordonnier C, et al. 2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association Stroke, 2022.PMID 35579034
10. [10]Anderson CS, Heeley E, Huang Y, et al. Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage N Engl J Med, 2013.PMID 23713578
11. [11]Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage N Engl J Med, 2016.PMID 27276234
12. [12]Mendelow AD, Gregson BA, Fernandes HM, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial Lancet, 2005.PMID 15680453
13. [13]Mendelow AD, Gregson BA, Rowan EN, et al. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial Lancet, 2013.PMID 23726393