We believe in early surgical repair of ruptured aneurysms followed by aggressive medical therapy, if necessary, for vasospasm. It is preferable that patients be transferred to a neurosurgical centre as soon as possible following their haemorrhage. The thought that patients need to be observed for a period prior to transfer is an erroneous concept and only serves to delay treatment unnecessarily and place patients at risk of rebleeding. We have found that immediate transfer once the diagnosis of SAH is suspected provides the best chance for optimal patient outcome. It is imperative that pertinent radiographic studies, including arteriograms, be sent along with the patient. Sending poor quality copies of radiographs or not sending the complete angiogram because of individual hospital administrative policy results in needless and dangerous repetition of vital diagnostic examinations.

We admit patients with SAH directly to the surgical intensive care unit, where further assessment is performed. Patients are graded according to the Hunt-Hess grading scale and accompanying radiographic studies are evaluated.79,80 If not previously obtained, angiography is performed as soon as possible after admission, with each case individualised for the patient. Early angiography is beneficial for early diagnosis, even if patients are not offered immediate surgery. An angiogram obtained early after SAH will confirm the diagnosis and allow for preoperative planning or immediate surgery or coil embolisation. Preoperative preparation usually includes routine blood tests, type and crossmatch of packed red blood cells, placement of central venous access and radial arterial monitoring catheters, and premedication. All patients are assessed for peri-SAH cardiac ischaemia. In our experience of using preoperative serum cardiac troponin levels (cTnl), 17% of patients with SAH had evidence of cardiac ischaemia. The presence of ischaemia leads to echocardiographic evaluation, the result of which may affect the type of treatment and anaesthetic utilised.158

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