Materiały źródłowe

• #1 Subarachnoid Hemorrhage (SAH): Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/17871-subarachnoid-hemorrhage-sah

  Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate treatment. […] A subarachnoid hemorrhage is life-threatening. Get immediate medical care if you’re experiencing symptoms of it. […] The hospital care following the diagnosis of subarachnoid hemorrhage focuses on both discovering and treating the cause of the SAH, as well as managing its complications. […] As subarachnoid hemorrhage (SAH) is a life-threatening, emergency condition, it’s typically treated in the intensive care unit (ICU) in a hospital with neurological expertise. The goals of treatment are to: Save your life. Repair the cause of the bleeding (hemorrhaging). Relieve symptoms. Prevent complications, such as vasospasm, hydrocephalus and permanent brain damage. […] Life-saving treatment and treatment to manage symptoms may include: Life support. Placing a draining tube in your brain to relieve pressure. Methods to protect your airway. Medication to decrease swelling in your skull. Medication given through an IV to manage your blood pressure. Medication to prevent artery spasms (vasospasms). Painkillers and anti-anxiety medication to relieve headaches. Medication to prevent or treat seizures.

• #1 Subarachnoid hemorrhage – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/subarachnoid-hemorrhage/diagnosis-treatment/drc-20361014

  Treatment of a subarachnoid hemorrhage focuses on stabilizing the condition. Your healthcare team checks your breathing, blood pressure and blood flow. […] If you have a burst aneurysm, you’re treated for it and your healthcare team works to prevent complications. […] To treat a ruptured brain aneurysm, your healthcare professional might recommend: Surgery. The surgeon makes an incision in the scalp and locates the brain aneurysm. A metal clip is placed on the aneurysm to stop the blood flow to it. […] Endovascular embolization. The surgeon inserts a catheter into an artery and threads it to your brain. Detachable platinum coils are guided through the catheter and placed in the aneurysm. The coils reduce blood flow into the aneurysm and cause the blood to clot. Different types of coils have been developed to treat aneurysms.

• #1 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  The traditional treatment of subarachnoid hemorrhage (SAH) from a ruptured cerebral aneurysm included strict blood pressure control, with fluid restriction and antihypertensive therapy. This approach was associated with a high rate of morbidity and mortality from the ischemic complications of hypovolemia and hypotension. […] Current recommendations advocate the use of antihypertensive agents when the mean arterial pressure (MAP) exceeds 130 mm Hg. Intravenous beta-blockers, which have a relatively short half-life, can be titrated easily and do not increase intracranial pressure (ICP). Beta-blockers are the agents of choice in patients without contraindications. […] Most clinicians avoid the use of nitrates, such as nitroprusside or nitroglycerin, which elevate ICP. Hydralazine and calcium channel blockers have a fast onset and lead to a relatively lower increase in ICP than do nitrates. Angiotensin-converting enzyme inhibitors have a relatively slow onset and are not first-line agents in the setting of acute SAH.

• #1 Subarachnoid Hemorrhage – Treatment : Emergency Care BC

  https://emergencycarebc.ca/clinical_resource/clinical-summary/subarachnoid-hemorrhage-treatment/

  Neurological […] Stabilization – Initial care for patients with SAH involves ABCs and treatment of seizures. […] Intravascular volume resuscitation with isotonic fluids is recommended with a target for euvolemia (while monitoring for hyponatremia). […] Acute seizures affect 6-18% of patients with SAH and are treated with levetiracetam or benzodiazepines. Avoid phenytoin as associated with worse cognitive outcomes in patients with aneurysmal SAH. […] Pain control with short-acting opiates. […] Initial management of aneurysmal SAH includes patient stabilization, grading the severity of the SAH, and admitting the patient to an appropriate centre for SAH management. […] Admit versus transfer to expert center – Improved outcomes, including lower mortality, are associated with treating patients in centres with neurosurgical and IR capabilities.

• #1 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Pain is associated with a transient elevation in blood pressure and increased risk of rebleeding. Analgesia is preferably achieved with a short-acting and reversible agent such as fentanyl. Sedation is used with caution to avoid distorting subsequent neurologic evaluation. The preferred agent is a short-acting benzodiazepine such as midazolam. Antifibrinolytics have been shown to reduce the occurrence of rebleeding. However, outcome likely does not improve because of a concurrent increase in the incidence of cerebral ischemia. […] Surgical treatment to prevent rebleeding is by clipping the ruptured berry aneurysm. Endovascular treatment (ie, coiling) is an increasingly practiced alternative to surgical clipping. […] Early surgery or coiling is generally recommended in patients with straightforward aneurysms of a favorable clinical grade. Evidence from clinical trials suggests that patients who undergo surgery within 72 hours have a lower rate of rebleeding and tend to fare better than those treated later.

• #1 Subarachnoid Hemorrhage (SAH) – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/stroke/subarachnoid-hemorrhage-sah

  Treatment is with supportive measures and neurosurgery or endovascular measures, preferably in a comprehensive stroke center. […] Patients with subarachnoid hemorrhage should be treated in a comprehensive stroke center whenever possible. […] Bed rest is mandatory. Restlessness and headache are treated symptomatically. Stool softeners are given to prevent constipation, which can lead to straining. […] Hypertension should be treated only if mean arterial pressure is 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for intracerebral hemorrhage. […] Vasospasm is prevented by giving nimodipine 60 mg orally every 4 hours for 21 days to prevent vasospasm, but BP needs to be maintained in the desirable range (usually considered to be a mean arterial pressure of 70 to 130 mm Hg and a systolic pressure of 120 to 185 mm Hg).

• #1 Subarachnoid hemorrhage – Wikipedia

  https://en.wikipedia.org/wiki/Subarachnoid_hemorrhage

  If a cerebral aneurysm is identified on angiography, two measures are available to reduce the risk of further bleeding from the same aneurysm: clipping and coiling. Clipping requires a craniotomy (opening of the skull) to locate the aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the large blood vessels (endovascularly): a catheter is inserted into the femoral artery in the groin and advanced through the aorta to the arteries (both carotid arteries and both vertebral arteries) that supply the brain. […] The decision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of a neurosurgeon, neuroradiologist, and often other health professionals. […] The use of calcium channel blockers, thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for prevention. The calcium channel blocker nimodipine when taken by mouth improves outcome if given between the fourth and twenty-first day after the bleeding, even if it does not reduce the amount of vasospasm detected on angiography. It is the only Food and Drug Administration (FDA)-approved drug for treating cerebral vasospasm.

• #1 Subarachnoid hemorrhage – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/subarachnoid-hemorrhage/diagnosis-treatment/drc-20361014

  Other endovascular treatments. Certain aneurysms can be treated with endovascular embolization that uses newer technology. These newer techniques include stent-assisted or balloon-assisted coiling or devices that divert blood flow. […] Treating the ruptured aneurysm quickly can help prevent bleeding from happening again. […] It’s also important to prevent other complications. A subarachnoid hemorrhage may lead to low salts such as sodium in the blood. It also may cause high or low blood sugar. Your healthcare team monitors these levels and treats them if needed. […] There also may be poor blood flow to the brain. A common complication of a subarachnoid hemorrhage due to a burst aneurysm is a constriction and narrowing of the blood vessels in the brain, known as vasospasm. This can cause a stroke if blood flow decreases to a certain level. A stroke may be avoided by raising blood pressure or by widening blood vessels in the brain with medicines. The medicine nimodipine (Nymalize) also can lower the risk of vasospasm.

• #1 Subarachnoid Hemorrhage Medication: Opioid Analgesics, Calcium Channel Blockers, Anticonvulsants, Other, Stool Softeners, Beta-Blockers, Alpha Activity, Antiemetic Agents, Diuretics, Osmotic Agents, Diuretics, Loop, Hemostatics, General Anesthetics, Syste

  https://emedicine.medscape.com/article/1164341-medication

  The goals of treatment in patients with subarachnoid hemorrhage (SAH) are as follows: […] Medications used for these purposes include analgesics, calcium channel blockers, antiepileptic drugs, stool softeners, antihypertensive agents, antiemetics, osmotic agents, diuretics, and general anesthetics. The use of aminocaproic acid for hemostasis is controversial. […] Nimodipine is indicated to reduce poor outcome related to aneurysmal subarachnoid hemorrhage. […] Begin therapy within 96 hours of SAH. Nimodipine is given orally. […] These agents prevent seizure recurrence and terminate clinical and electrical seizure activity. […] Docusate is an anionic surfactant used for patients who should avoid straining during defecation. […] In patients who have suffered SAH from a ruptured aneurysm, these agents are used to maintain blood pressure in a range that allows for sufficient cerebral perfusion yet limits the risk of rebleeding from elevated ICP.

• #1 Subarachnoid Hemorrhage Medication: Opioid Analgesics, Calcium Channel Blockers, Anticonvulsants, Other, Stool Softeners, Beta-Blockers, Alpha Activity, Antiemetic Agents, Diuretics, Osmotic Agents, Diuretics, Loop, Hemostatics, General Anesthetics, Syste

  https://emedicine.medscape.com/article/1164341-medication

  These agents are used for the treatment of nausea or vomiting. […] These agents are used in an attempt to lower ICP and cerebral edema by creating an osmotic gradient across an intact blood-brain barrier; as water diffuses from the brain into the intravascular compartment, ICP decreases. […] Furosemide is used in the acute setting for reduction of increased ICP. […] These agents are potent inhibitors of fibrinolysis and can reverse states that are associated with excessive fibrinolysis. Their use is controversial; consultation with admitting physicians is urged prior to use. […] Thiopental depresses consciousness and diminishes or terminates seizure effects; it facilitates transmission or impulses from the thalamus to the cortex of the brain, resulting in an imbalance in central inhibitory and facilitating mechanisms. […] Midazolam is a shorter-acting benzodiazepine sedative-hypnotic that is useful in patients requiring acute or short-term sedation.

• #1 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Additional medical management is directed to prevent and treat the following common complications of SAH: Rebleeding, Vasospasm, Hydrocephalus, Hyponatremia, Seizures, Pulmonary complications, Cardiac complications. […] Ideally, management of the complications of SAH should take place in a neurologic ICU or in an ICU similarly equipped. To minimize stimuli that may lead to an elevation of ICP, have the patient placed in a darkened, quiet, private room and given mild sedation if agitated. The head of the bed should be kept elevated at 30 to ensure optimal venous drainage. […] Blood pressure must be maintained with consideration of the patient’s neurologic status. Optimally, systolic blood pressure (SBP) of no more than 130-140 mm Hg should be the goal, unless clinical evidence of vasospasm is noted.

• #1 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Indwelling catheters include an arterial line, central venous access, and Foley catheter. Seizure prophylaxis and calcium channel blockade are standard medical measures. Some centers favor volume expansion to treat vasospasm that develops days after the initial bleeding episode. […] Surgical treatment to prevent rebleeding consists of clipping the ruptured berry aneurysm. Endovascular treatment (ie, coiling) is an increasingly practiced alternative to surgical clipping. The neurosurgeon/neurointerventionalist must be involved early in the care of the patient with an aneurysmal SAH. […] Rebleeding is the most dreaded early complication of SAH. The greatest risk of rebleeding occurs within the first 24 hours of rupture (4.1%). The cumulative risk of rebleeding is 19% at 14 days. The overall mortality rate from rebleeding is reported to be as high as 78%. Measures to prevent rebleeding include bed rest in a quiet room, analgesia, and sedation. Stool softeners are given to prevent Valsalva maneuvers with resultant peaks in SBP and ICP. Clipping or coiling aneurysms is the surgical approach to prevent rebleeding.

• #1 Subarachnoid hemorrhage (SAH)

  https://mayfieldclinic.com/pe-sah.htm

  Clotted blood and fluid buildup in the subarachnoid space may cause hydrocephalus and elevated intracranial pressure. Blood pressure is lowered to reduce further bleeding and to control intracranial pressure. Excess cerebrospinal fluid (CSF) and blood can be removed with: 1) a lumbar drain catheter inserted into the subarachnoid space of the spinal canal in the low back, or 2) a ventricular drain catheter, which is inserted into the ventricles of the brain. […] Five to 10 days after an SAH, the patient may develop vasospasm. Vasospasm narrows the artery and reduces blood flow to the region of the brain that the artery feeds. Vasospasm occurs in 70% of patients after SAH. Of these, 30% have symptoms that require treatment. […] A patient in the NSICU will be monitored for signs of vasospasm, which include weakness in an arm or leg, confusion, sleepiness, or restlessness.

• #1 Subarachnoid hemorrhage – Diagnosis and treatment – Mayo Clinic

  https://www.mayoclinic.org/diseases-conditions/subarachnoid-hemorrhage/diagnosis-treatment/drc-20361014

  Another common complication is a buildup of fluid in cavities within the brain, known as hydrocephalus. This can be treated with drains inserted in the head or lower back. […] Sometimes, procedures need to be repeated. After your initial treatment, follow-up appointments with your healthcare team are important to watch for any changes. You also may need physical, occupational and speech therapies.

• #1 Subarachnoid Hemorrhage (SAH) | UW Department of Neurological Surgery

  https://neurosurgery.uw.edu/patients-and-family/what-we-treat/conditions/subarachnoid-hemorrhage-sah

  Today, good medical care allows the brain to heal after a stroke. Physical, occupational and speech therapy all play an important role in patients that have disabilities from their stroke. […] The results from some experimental studies show that some medicines that stimulate brain cell activity or cause brain cells to grow can increase recovery from stroke. […] There are many reasons to be optimistic about meaningful recovery after a stroke.

• #1 Subarachnoid hemorrhage (SAH)

  https://mayfieldclinic.com/pe-sah.htm

  Treatment for SAH varies, depending on the underlying cause of the bleeding and the extent of damage to the brain. Treatment may include lifesaving measures, symptom relief, repair of the bleeding vessel, and complication prevention. […] For 10 to 14 days following SAH, the patient will remain in the neuroscience intensive care unit (NSICU), where doctors and nurses can watch closely for signs of renewed bleeding, vasospasm, hydrocephalus, and other potential complications. […] Pain medication will be given to alleviate headache, and anticonvulsant medication may be given to prevent or treat seizures. […] If the SAH is from a ruptured aneurysm, surgery may be performed to stop the bleeding. Options include surgical clipping or endovascular coiling. […] If the SAH is from a bleeding arteriovenous malformation, surgery may be performed to remove the AVM.

• #1 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Critical care management of patients with SAH is challenging and requires awareness of all potential medical and neurological complications, with timely intervention and treatment. Care of patients with aSAH requires a multidisciplinary team approach. […] Aims of critical care management summarised in (Fig. 2) include initial stabilisation of the patient to prevent rebleeding and allow for definite early treatment, limiting secondary neurological injury and early recognition and treatment of complications. […] Definitive treatment hinges on early securement of the aneurysm, within 72h or ideally within 48h of diagnosis. […] Following the international subarachnoid aneurysm trial (ISAT), coiling is preferred as it is associated with improved mortality and functional outcomes, with a marginally higher rate of aneurysm recurrence. […] The choice of securement method should be made after a multidisciplinary team discussion between the interventional radiologists, neurosurgeons, and neurocritical specialists.

• #1 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. […] The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. […] Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. […] This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

• #1 Clinical review: Prevention and therapy of vasospasm in subarachnoid hemorrhage | Critical Care | Full Text

  https://ccforum.biomedcentral.com/articles/10.1186/cc5958

  The sustained effect of angioplasty may well be due to its ability to disrupt connective tissue, as has been seen in the media of cerebral arteries removed at autopsy from patients who underwent the procedure. […] Intra-arterial vasodilators have been shown to transiently improve regional CBF. […] A number of therapies are currently being developed and are at different stages of testing. […] Statins, or 3-hydroxy-3-methylglutaryl-CoA reductase inhibitors, appear to have a promising role in vasospasm prevention. […] A phase IIa trial of clazosentan (an ETA antagonist) demonstrated reduction in the incidence and severity of angiographic vasospasm. […] Most recently, clazosentan was tested in a controlled clinical trial enrolling 413 patients with SAH.

• #1 Treatment of subarachnoid hemorrhage – PubMed

  https://pubmed.ncbi.nlm.nih.gov/25257737/

  Nontraumatic subarachnoid hemorrhage from intracranial aneurysm rupture presents with sudden severe headache. Initial treatment focuses on airway management, blood pressure control, and extraventricular drain for hydrocephalus. After identifying the aneurysm, they may be clipped surgically or endovascularly coiled. Nimodipine is administered to maintain a euvolemic state and prevent delayed cerebral ischemia (DCI). Patients may receive anticonvulsants. Monitoring includes serial neurologic assessments, transcranial Doppler ultrasonography, computed tomography perfusion, and angiographic studies. Treatment includes augmentation of blood pressure and cardiac output, cerebral angioplasty, and intra-arterial infusions of vasodilators. […] Although early mortality is high, about one half of survivors recover with little disability.

• #2 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. […] The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. […] Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. […] This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.

• #2 Aneurysmal subarachnoid hemorrhage: Treatment and prognosis – UpToDate

  https://www.uptodate.com/contents/aneurysmal-subarachnoid-hemorrhage-treatment-and-prognosis

  Aneurysmal subarachnoid hemorrhage: Treatment and prognosis […] The treatment of aneurysmal SAH and its complications are reviewed here. […] Initial care of patients with SAH is directed at identifying the clinical severity and reversing or stabilizing life-threatening conditions, particularly for comatose patients. […] Important steps include ensuring a secure airway, normalizing cardiovascular function, and treating seizures. […] Indications for endotracheal intubation include a Glasgow Coma Scale (GCS) score ≤8, elevated intracranial pressure (ICP), poor oxygenation or hypoventilation, hemodynamic instability, and requirement for heavy sedation or paralysis.

• #2 Subarachnoid Hemorrhage (SAH) – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/stroke/subarachnoid-hemorrhage-sah

  Treatment is with supportive measures and neurosurgery or endovascular measures, preferably in a comprehensive stroke center. […] Patients with subarachnoid hemorrhage should be treated in a comprehensive stroke center whenever possible. […] Bed rest is mandatory. Restlessness and headache are treated symptomatically. Stool softeners are given to prevent constipation, which can lead to straining. […] Hypertension should be treated only if mean arterial pressure is 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for intracerebral hemorrhage. […] Vasospasm is prevented by giving nimodipine 60 mg orally every 4 hours for 21 days to prevent vasospasm, but BP needs to be maintained in the desirable range (usually considered to be a mean arterial pressure of 70 to 130 mm Hg and a systolic pressure of 120 to 185 mm Hg).

• #2 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Critical care management of patients with SAH is challenging and requires awareness of all potential medical and neurological complications, with timely intervention and treatment. Care of patients with aSAH requires a multidisciplinary team approach. […] Aims of critical care management summarised in (Fig. 2) include initial stabilisation of the patient to prevent rebleeding and allow for definite early treatment, limiting secondary neurological injury and early recognition and treatment of complications. […] Definitive treatment hinges on early securement of the aneurysm, within 72h or ideally within 48h of diagnosis. […] Following the international subarachnoid aneurysm trial (ISAT), coiling is preferred as it is associated with improved mortality and functional outcomes, with a marginally higher rate of aneurysm recurrence. […] The choice of securement method should be made after a multidisciplinary team discussion between the interventional radiologists, neurosurgeons, and neurocritical specialists.

• #2 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Additional medical management is directed to prevent and treat the following common complications of SAH: Rebleeding, Vasospasm, Hydrocephalus, Hyponatremia, Seizures, Pulmonary complications, Cardiac complications. […] Ideally, management of the complications of SAH should take place in a neurologic ICU or in an ICU similarly equipped. To minimize stimuli that may lead to an elevation of ICP, have the patient placed in a darkened, quiet, private room and given mild sedation if agitated. The head of the bed should be kept elevated at 30 to ensure optimal venous drainage. […] Blood pressure must be maintained with consideration of the patient’s neurologic status. Optimally, systolic blood pressure (SBP) of no more than 130-140 mm Hg should be the goal, unless clinical evidence of vasospasm is noted.

• #2 Subarachnoid hemorrhage (SAH)

  https://mayfieldclinic.com/pe-sah.htm

  Treatment for SAH varies, depending on the underlying cause of the bleeding and the extent of damage to the brain. Treatment may include lifesaving measures, symptom relief, repair of the bleeding vessel, and complication prevention. […] For 10 to 14 days following SAH, the patient will remain in the neuroscience intensive care unit (NSICU), where doctors and nurses can watch closely for signs of renewed bleeding, vasospasm, hydrocephalus, and other potential complications. […] Pain medication will be given to alleviate headache, and anticonvulsant medication may be given to prevent or treat seizures. […] If the SAH is from a ruptured aneurysm, surgery may be performed to stop the bleeding. Options include surgical clipping or endovascular coiling. […] If the SAH is from a bleeding arteriovenous malformation, surgery may be performed to remove the AVM.

• #2 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Patients with signs of increased ICP or herniation should be intubated and hyperventilated. Minute ventilation should be titrated to achieve a PCO2 of 30-35 mm Hg. Avoid excessive hyperventilation, which may potentiate vasospasm and ischemia. […] Other interventions for increased ICP include the following: Osmotic agents (eg, mannitol), which can decrease ICP dramatically (50% 30 minutes post administration) […] Loop diuretics (eg, furosemide) also can decrease ICP […] The use of intravenous steroids (eg, dexamethasone [Decadron]) for decreasing ICP is controversial but is recommended by some authors. […] Patients must be admitted to the intensive care unit (ICU) with strict bed rest until the etiology of hemorrhage is determined. Patients should not be allowed out of bed for any reason. All patients should receive frequent neurologic evaluation. Use sedatives and analgesics cautiously to avoid masking the neurologic examination findings.

• #2 Subarachnoid hemorrhage – Wikipedia

  https://en.wikipedia.org/wiki/Subarachnoid_hemorrhage

  If a cerebral aneurysm is identified on angiography, two measures are available to reduce the risk of further bleeding from the same aneurysm: clipping and coiling. Clipping requires a craniotomy (opening of the skull) to locate the aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the large blood vessels (endovascularly): a catheter is inserted into the femoral artery in the groin and advanced through the aorta to the arteries (both carotid arteries and both vertebral arteries) that supply the brain. […] The decision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of a neurosurgeon, neuroradiologist, and often other health professionals. […] The use of calcium channel blockers, thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for prevention. The calcium channel blocker nimodipine when taken by mouth improves outcome if given between the fourth and twenty-first day after the bleeding, even if it does not reduce the amount of vasospasm detected on angiography. It is the only Food and Drug Administration (FDA)-approved drug for treating cerebral vasospasm.

• #2 Subarachnoid Hemorrhage (SAH) – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/stroke/subarachnoid-hemorrhage-sah

  If clinical signs of acute hydrocephalus occur, ventricular drainage should be considered. […] Aneurysms are occluded to reduce risk of rebleeding. Detachable endovascular coils can be inserted during angiography to occlude the aneurysm. Alternatively, if the aneurysm is accessible, surgery to clip or stent the aneurysm can be done, especially for patients with an evacuable hematoma or acute hydrocephalus. If patients are arousable, most vascular neurosurgeons operate within the first 24 hours to minimize risk of rebleeding and risks due to angry brain. If 24 hours have elapsed, some neurosurgeons delay surgery until 10 days have passed; this approach decreases risks due to angry brain but increases risk of rebleeding and overall mortality.

• #2 Subarachnoid Hemorrhage – Harvard Health

  https://www.health.harvard.edu/a_to_z/subarachnoid-hemorrhage-a-to-z

  A subarachnoid hemorrhage frequently causes shifts in the level of blood chemicals called electrolytes. Your doctor will adjust the amount of chemicals in the intravenous fluids based upon results of daily blood tests. […] If bleeding occurred because of an abnormally formed blood vessel, you will likely need a procedure to prevent recurrent bleeding. Ideally the procedure is performed when your condition is more stable. […] For an aneurysm, your doctor may recommend endovascular coiling or aneurysm clipping. […] Endovascular coiling is a less invasive procedure. A specially trained doctor inserts a thin flexible tube (called a catheter) with a metal coil at the end into a blood vessel. The doctor threads the catheter into the brain at the site of the aneurysm. The metal coil is left behind. It blocks blood flow to the aneurysm. The pressure inside the aneurysm will be much lower and the risk of recurrent bleeding is reduced.

• #2 Subarachnoid Hemorrhage Diagnosis & Treatment – NYC | Columbia Neurosurgery in New York City

  https://www.neurosurgery.columbia.edu/patient-care/conditions/subarachnoid-hemorrhage

  The selection of and timing for each procedure depends on a great variety of factors and a comprehensive team of open surgeons and endovascular surgeons discuss each case to determine the best treatment for each individual patient. […] Doctors must also manage possible complications of subarachnoid hemorrhage. One such complication is vasospasm. […] Since vasospasm is a leading cause of poor outcome, patients generally stay in the hospital for up to three weeks after the initial subarachnoid hemorrhage so they can be monitored for vasospasm. Vasospasm can often be treated with medication. If it is resistant to medication, vasospasm may be treated with endovascular techniques. […] Treatment options for Subarachnoid Hemorrhage include Computer Assisted Surgery (CAS), Craniotomy, Embolization, Endovascular Aneurysm Treatment, Endovascular Neurosurgery, Gamma Knife Radiosurgery, Microsurgery, Stenting, and Aneurysm Clipping.

• #2 Subarachnoid Hemorrhage: Symptoms, Causes, Diagnosis, Treament

  https://www.webmd.com/stroke/subarachnoid-hemorrhage-overview

  Endovascular stent. Instead of a coil, you’ll get a tiny tube called a stent placed across the aneurysm. The stent channels the blood away from the aneurysm to prevent it from leaking or bursting. […] Clip. Your doctor will make a surgical cut (incision) in your scalp and remove a piece of your skull to reach the aneurysm. A special microscope will help your doctor find the aneurysm and fasten a tiny clip across it, replace the piece of skull, and sew up the surgical cut.

• #2 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  For prevention of vasospasm, maintenance of normovolemia, normothermia, and normal oxygenation are paramount. Volume status should be monitored closely, with avoidance of volume contraction, which can predispose to vasospasm. […] Oral nimodipine is the most studied calcium channel blocker for prevention of vasospasm after SAH. An American Heart Association/American Stroke Association guideline recommends its use for this purpose (class I, level of evidence A). […] Calcium channel blockers have been shown to reduce the incidence of ischemic neurologic deficits, and nimodipine has been shown to improve overall outcome within 3 months of aneurysmal SAH. […] Treatment for symptomatic vasospasm has traditionally involved the induction of hypertension, hypervolemia, and hemodilution, or triple H therapy. This therapy should be reserved for patients with aneurysms secured by surgical clipping or endovascular techniques in order to reduce the risk of rebleeding.

• #2 Subarachnoid Hemorrhage: ED Critical Care Management – emDocs

  https://www.emdocs.net/subarachnoid-hemorrhage-ed-critical-care-management/

  The definitive treatment for aSAH is aneurysm coiling or clipping, given that 30% of patients with untreated aSAH will rebleed in the first month following initial hemorrhage. Coiling is accomplished through endovascular means and boasts superior outcomes, while clipping is a surgical procedure available to patients that do not qualify for coiling. Patients with SAH should be transferred to facilities capable of providing these therapies even if an aneurysm isn’t initially found, as repeat angiography will often be performed several days later. […] When our case begins, the patient is hypertensive with an intact mental status. Titratable IV blood pressure agents such as labetalol, nicardipine or clevidipine should be started with a goal of lowering the systolic blood pressure to less than 160 mm Hg so long as the patient maintains consciousness. Additionally, 60 mg of nimodipine should be administered orally every 4 hours. […] In unconscious patients, support CPP with vasopressors in consultation with neurosurgery. To treat elevated ICP, use hypertonic saline. The dose is 3.2 mL/kg of 5% hypertonic saline.

• #2 Management of Aneurysmal Subarachnoid Hemorrhages

  https://www.uspharmacist.com/article/management-of-aneurysmal-subarachnoid-hemorrhages

  After securing the ruptured aneurysm, pharmacologic or mechanical venous thromboembolism (VTE) prophylaxis is strongly recommended. […] Seizure prophylaxis is not routinely recommended in aSAH. […] Effective glycemic control with strict hyperglycemia management and avoidance of hypoglycemia are reasonable.

• #2 Subarachnoid Hemorrhage (SAH) – Brain, Spinal Cord, and Nerve Disorders – MSD Manual Consumer Version

  https://www.msdmanuals.com/home/brain-spinal-cord-and-nerve-disorders/stroke/subarachnoid-hemorrhage-sah

  Medications are used to relieve the headache and to control blood pressure, and surgery is done to stop the bleeding. […] People who may have had a subarachnoid hemorrhage are hospitalized immediately. When possible, they are transported to a center that specializes in treating stroke. Bed rest with no exertion is essential. […] Anticoagulants (such as heparin and warfarin) and antiplatelet medications (such as aspirin) are not given because they make the bleeding worse. […] Pain relievers (analgesics) such as opioids are given as needed to control the severe headaches. However, aspirin and other nonsteroidal anti-inflammatory medications are not used because they can worsen the bleeding. […] Nimodipine, a calcium channel blocker, is usually given by mouth to prevent vasospasm and subsequent ischemic stroke.

• #2 Subarachnoid Hemorrhage (SAH): Symptoms and Treatment | Ada

  https://ada.com/conditions/subarachnoid-hemorrhage/

  Subarachnoid hemorrhage treatment is a medical emergency and requires urgent medical attention and treatment. […] The aim of treatment for subarachnoid hemorrhage is to stabilize the affected person, prevent further bleeding or rebleeding from the aneurysm, which may be at risk of rupturing once again, and prevent further brain injury. […] Life-saving or supporting measures, such as help with breathing and blood pressure control, may be needed in the time directly following an SAH, especially if the bleed is big enough to cause a significant increase in the pressure inside the head. […] Some medications are given to treat subarachnoid hemorrhage and its effects in the short term. These may include: Nimodipine, which can help prevent vasospasm, a possible complication of SAH and improve blood supply to the brain, which can help improve the neurological outcome after an SAH from an aneurysm; Blood pressure medication to reduce the chances of rebleeding; Pain relief, commonly opioids and acetaminophen, not only reduce pain but also in turn reduce the chance of rebleeding, as pain leads to higher blood pressure, which can contribute to a higher chance of rebleeding; Anticonvulsants to prevent seizures; Antiemetics to stop the affected person from feeling sick and vomiting; Stool softeners, such as docusate and senna help to prevent rebleeding from increased blood pressure due to straining to pass a bowel movement; If the person suffers from coughing, antitussives, such as codeine, may be given to suppress coughs, which can help prevent rebleeding.

• #2 Tranexamic Acid Treatment Fails in Subarachnoid Hemorrhage Treatmentlogo-32logo-40logo-60NEJM Journal WatchnejmJW_1L_RGB-b

  https://www.jwatch.org/na53019/2021/01/13/tranexamic-acid-treatment-fails-subarachnoid-hemorrhage

  Tranexamic Acid Treatment Fails in Subarachnoid Hemorrhage Treatment. […] Even when treatment started at a median of about 3 hours after onset, 6-month outcomes were no better than with usual care. […] Early treatment of the aneurysm with either clipping or coiling is recommended. […] Whether antifibrinolytic treatment improves outcomes is unclear. […] The failure of TXA to improve clinical outcomes and the lack of reduction in mortality should decrease the use of this treatment option.

• #2

  https://link.springer.com/article/10.1007/s12028-023-01757-7

  The PrImary decompressive Craniectomy in AneurySmal Subarachnoid hemOrrhage (PICASSO) trial investigates whether primary decompressive craniectomy performed within 24 h in addition to best medical treatment in patients with poor-grade SAH reduces case fatality and severe disability compared with best medical treatment alone and secondary craniectomy as a therapy of last resort for elevated intracranial pressure. […] A recently ruptured aneurysm has a 40% risk of rebleeding in the first 6 weeks after ictus, and rebleeding substantially increases the risk of poor outcome. […] Although most instances of rebleeding occur within 24 h after ictus, available studies do not support that aneurysm treatment 24 h results in better outcomes compared with treatment 24-72 h after the bleeding. […] The rationale of treatment with antifibrinolytic drugs after aSAH is to improve clot stability and thereby decrease the risk of rebleeding.

• #2 Subarachnoid hemorrhage (SAH)

  https://mayfieldclinic.com/pe-sah.htm

  To prevent vasospasm, patients are given the drug nimodipine while in the hospital. Additionally, the patients blood pressure and blood volume will be increased to force blood through the narrowed arteries. […] If vasospasm is severe, patients may require an injection of medication directly into the artery to relax and stop the spasm. This is done through a catheter during an angiogram. Sometimes balloon angioplasty is used to stretch open the artery.

• #2 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  Transluminal balloon angioplasty is recommended for treatment of vasospasm after failure of conventional therapy. […] Intra-arterial injection of papaverine has been reported to improve outcome, but more data are needed before its routine use can be recommended. […] Treatment for acute hydrocephalus includes external ventricular drainage, depending on the severity of clinical neurologic dysfunction or CT scan findings. […] Symptomatic cases of hydrocephalus may be managed by temporary lumbar CSF drainage, serial LPs, or placement of a permanent ventricular shunt. […] Ventriculostomy placement is associated with an increased risk for rebleeding, along with known infectious risk; therefore, patients with dilated ventricles but no compromise of level of consciousness should be treated conservatively, with close monitoring of mental status and prompt intervention in case their clinical status declines. […] Nevertheless, ventriculostomy, when done correctly, is a relatively low-risk procedure that can result in dramatic and immediate clinical improvement in about two thirds of patients.

• #2 Subarachnoid Hemorrhage (SAH): Symptoms & Treatment

  https://my.clevelandclinic.org/health/diseases/17871-subarachnoid-hemorrhage-sah

  To treat the subarachnoid hemorrhage and its cause, you may need surgery to: Remove large collections of blood or relieve pressure on your brain if the SAH is due to an injury. Repair the aneurysm if the SAH is due to an aneurysm rupture. […] The length of stay in the hospital varies based on your health status. Most people who have a subarachnoid hemorrhage are admitted to the hospital anywhere from 10 to 20 days based on their condition and their need for rehabilitation. […] These long-term complications can be managed and treated with several different types of therapies, including: Physical therapy. Occupational therapy. Speech therapy. Psychotherapy (talk therapy). Certain medications can also help. Talk to your healthcare team if you experience any of these issues.

• #2 Subarachnoid Hemorrhage – Symptoms, Diagnosis, TreatmentGroup 9Group 9Group 49Group 49

  https://www.barrowneuro.org/condition/subarachnoid-hemorrhage/

  People can recover with minimal side effects or deficits after receiving treatment for a subarachnoid hemorrhage—especially if the hemorrhage was small and quickly treated. However, others can experience lasting cognitive and physical challenges. […] Neuro-rehabilitation is key to hemorrhagic stroke and subarachnoid hemorrhage recovery. While it doesn’t reverse brain damage, neuro-rehabilitation can help patients achieve the best long-term outcome possible. […] At the Petznick Stroke Center at Barrow Neurological Institute, we’re dedicated to best-in-class stroke care and exhaustive research to find new ways to treat and prevent stroke.

• #2 Subarachnoid haemorrhage – Symptoms, diagnosis and treatment | BMJ Best Practice

  https://bestpractice.bmj.com/topics/en-gb/3000106

  Observe patients continuously for signs of acute deterioration (e.g., new focal neurological deficit, seizure, or sudden drop in the patient’s level of consciousness) or cardiac complications (e.g., arrhythmias). Neurological complications such as rebleeding, acute hydrocephalus, vasospasm, and delayed cerebral ischaemia are common and should be treated urgently.

• #2 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Hyponatraemia is commonly seen in association with aSAH. […] Therefore, in clinical practice, hyponatraemia associated with SAH management is based on maintaining euvolaemia, avoiding hypo- and hypervolaemia and repletion of volume and sodium losses. […] Management of SAH requires urgent large-scale phase three studies to establish standardised protocols and multidisciplinary neurovascular training programmes. […] The collaboration between neuroscientists, clinicians, and health policy experts will be crucial in this endeavour.

• #2 Heparin in the treatment of aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis in: Neurosurgical Focus Volume 52 Issue 3 (2022) Journals

  https://thejns.org/focus/view/journals/neurosurg-focus/52/3/article-pE9.xml

  Cerebral vasospasm and the resulting infarction remain the most devastating complications of aneurysmal subarachnoid hemorrhage (aSAH). Limited treatment options are available, with nimodipine as the only approved prophylactic medication. In addition to its anticoagulant properties, heparin also has a pleiotropic and anti-inflammatory effect that could be beneficial in vasospasm. In this study, the authors sought to evaluate the efficacy and safety of heparin in the treatment of aSAH. […] Administration of intravenous UFH for more than 48 hours reduced the rate of cerebral infarction with a good safety profile. This result supports the ongoing clinical trial. […] Heparin is widely used for prophylaxis and treatment of thromboembolisms for its anticoagulant properties. Heparin also has a pleiotropic effect, with various related beneficial effects. It acts as an anti-inflammatory agent, as it alters vasomotor regulations, and recent studies have suggested its use as a potential therapeutic inhibitor of inflammation, which are all the relevant mechanisms for the treatment of aSAH-induced brain injury.

• #3 Subarachnoid Hemorrhage (SAH) – Neurologic Disorders – Merck Manual Professional Edition

  https://www.merckmanuals.com/professional/neurologic-disorders/stroke/subarachnoid-hemorrhage-sah

  Treatment is with supportive measures and neurosurgery or endovascular measures, preferably in a comprehensive stroke center. […] Patients with subarachnoid hemorrhage should be treated in a comprehensive stroke center whenever possible. […] Bed rest is mandatory. Restlessness and headache are treated symptomatically. Stool softeners are given to prevent constipation, which can lead to straining. […] Hypertension should be treated only if mean arterial pressure is 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for 130 mm Hg or systolic blood pressure (BP) is 160 mm Hg; euvolemia is maintained, and IV nicardipine is titrated as for intracerebral hemorrhage. […] Vasospasm is prevented by giving nimodipine 60 mg orally every 4 hours for 21 days to prevent vasospasm, but BP needs to be maintained in the desirable range (usually considered to be a mean arterial pressure of 70 to 130 mm Hg and a systolic pressure of 120 to 185 mm Hg).

• #3 Subarachnoid Hemorrhage – Treatment : Emergency Care BC

  https://emergencycarebc.ca/clinical_resource/clinical-summary/subarachnoid-hemorrhage-treatment/

  Neurological […] Stabilization – Initial care for patients with SAH involves ABCs and treatment of seizures. […] Intravascular volume resuscitation with isotonic fluids is recommended with a target for euvolemia (while monitoring for hyponatremia). […] Acute seizures affect 6-18% of patients with SAH and are treated with levetiracetam or benzodiazepines. Avoid phenytoin as associated with worse cognitive outcomes in patients with aneurysmal SAH. […] Pain control with short-acting opiates. […] Initial management of aneurysmal SAH includes patient stabilization, grading the severity of the SAH, and admitting the patient to an appropriate centre for SAH management. […] Admit versus transfer to expert center – Improved outcomes, including lower mortality, are associated with treating patients in centres with neurosurgical and IR capabilities.

• #3 Subarachnoid Hemorrhage Treatment

  https://www.rwjbh.org/treatment-care/neuroscience/neurosurgery/conditions-treated/subarachnoid-hemorrhage/

  When a subarachnoid hemorrhage is caused by a ruptured aneurysm, it can be treated surgically, either through an open or endovascular technique. Because the endovascular approach is less invasive, determining which treatment is best will depend on the characteristics of the aneurysm and the patients overall health. […] Open surgical techniques include: […] Clipping: Microsurgical clipping is done through craniotomy surgery. A craniotomy is performed by making an incision through the scalp to access the skull, and a piece of the skull is removed using a special, medical saw, so the neurosurgeon can access the brain. Once the brain is exposed, the neurosurgery team uses an intraoperative microscope to access the aneurysm and place a small clip around the neck of the aneurysm. Then, the portion of skull that was removed is replaced and fastened with plates and screws, and the incision is closed.

• #3 Subarachnoid hemorrhage: Symptoms, causes, and diagnosis

  https://www.medicalnewstoday.com/articles/220844

  To prevent the blood vessels near a ruptured aneurysm from going into spasm, doctors may administer a drug called nimodipine. Nimodipine treats hypertension and prevents spasms. A course of this drug may continue for around 3 weeks. […] A doctor may use morphine to treat the head pain a person experiences from a subarachnoid hemorrhage. […] Treatment can sometimes involve surgeons applying neurosurgical clipping to an aneurysm. This mechanism seals the blood vessel closed with a small metal clip. […] Endovascular coiling is another option. This procedure involves surgeons inserting a catheter or small plastic tube into an artery, usually in the groin or leg. The surgeon then threads the tube through blood vessels until it reaches the part of the brain where they have located the aneurysm. […] After this, the treating doctor threads platinum coils into the aneurysm through the tube. These stop the blood flow into the aneurysm, effectively halting the hemorrhage. […] This intervention has a better success rate when compared to neurological clipping, and people may recover more quickly.

• #3

  https://link.springer.com/article/10.1007/s00134-024-07387-7

  Criteria for admission to the intensive care unit (ICU) are not well defined but determined by the need for specialized care to manage early and delayed intracranial and extracranial complications. Management in dedicated neuroICUs has been shown to improve patient outcomes. […] Timely repair of ruptured aneurysms reduces the risk of rebleeding and allows for more targeted and safer management of DCI. […] Studies suggest that early aneurysm securement, i.e. within 24-72 h from onset of aSAH, yields better outcomes than delayed treatment after 7-10 days. […] The choice of the method to treat the ruptured aneurysm is complex and necessitates a careful balance between securing the aneurysm and the associated procedural risks. […] After aneurysm securement, the ICU management of aSAH involves close monitoring, optimization of systemic function and preventing and treating cranial and systemic complications.

• #3 Subarachnoid hemorrhage – Wikipedia

  https://en.wikipedia.org/wiki/Subarachnoid_hemorrhage

  If a cerebral aneurysm is identified on angiography, two measures are available to reduce the risk of further bleeding from the same aneurysm: clipping and coiling. Clipping requires a craniotomy (opening of the skull) to locate the aneurysm, followed by the placement of clips around the neck of the aneurysm. Coiling is performed through the large blood vessels (endovascularly): a catheter is inserted into the femoral artery in the groin and advanced through the aorta to the arteries (both carotid arteries and both vertebral arteries) that supply the brain. […] The decision as to which treatment is undertaken is typically made by a multidisciplinary team consisting of a neurosurgeon, neuroradiologist, and often other health professionals. […] The use of calcium channel blockers, thought to be able to prevent the spasm of blood vessels by preventing calcium from entering smooth muscle cells, has been proposed for prevention. The calcium channel blocker nimodipine when taken by mouth improves outcome if given between the fourth and twenty-first day after the bleeding, even if it does not reduce the amount of vasospasm detected on angiography. It is the only Food and Drug Administration (FDA)-approved drug for treating cerebral vasospasm.

• #3 Subarachnoid Hemorrhage Treatment & Management: Approach Considerations, Initial Management, Rebleeding and Clipping/Coiling Aneurysms

  https://emedicine.medscape.com/article/1164341-treatment

  For prevention of vasospasm, maintenance of normovolemia, normothermia, and normal oxygenation are paramount. Volume status should be monitored closely, with avoidance of volume contraction, which can predispose to vasospasm. […] Oral nimodipine is the most studied calcium channel blocker for prevention of vasospasm after SAH. An American Heart Association/American Stroke Association guideline recommends its use for this purpose (class I, level of evidence A). […] Calcium channel blockers have been shown to reduce the incidence of ischemic neurologic deficits, and nimodipine has been shown to improve overall outcome within 3 months of aneurysmal SAH. […] Treatment for symptomatic vasospasm has traditionally involved the induction of hypertension, hypervolemia, and hemodilution, or triple H therapy. This therapy should be reserved for patients with aneurysms secured by surgical clipping or endovascular techniques in order to reduce the risk of rebleeding.

• #3

  https://link.springer.com/article/10.1007/s12028-023-01757-7

  Although observations that treatment of hypertension may reduce the risk of rebleeding have existed for decades, there is no evidence from randomized trials that this treatment strategy improves outcome after aSAH. […] A randomized clinical trial is required to answer the question of whether blood pressure lowering before aneurysm occlusion, and to which target, decreases the risk of rebleeding and improves outcome after aSAH. […] Acute hydrocephalus may result from intraventricular obstruction through intraventricular extension of the hemorrhage, from compression of the ventricular system by an intracerebral hematoma or from obstruction of the flow of the cerebrospinal fluid at the level of the tentorial hiatus in patients in whom all cisterns around the brainstem are filled with blood.

• #3 Diagnosis and management of subarachnoid haemorrhage | Nature Communications

  https://www.nature.com/articles/s41467-024-46015-2

  Hyponatraemia is commonly seen in association with aSAH. […] Therefore, in clinical practice, hyponatraemia associated with SAH management is based on maintaining euvolaemia, avoiding hypo- and hypervolaemia and repletion of volume and sodium losses. […] Management of SAH requires urgent large-scale phase three studies to establish standardised protocols and multidisciplinary neurovascular training programmes. […] The collaboration between neuroscientists, clinicians, and health policy experts will be crucial in this endeavour.

• #3 Subarachnoid Hemorrhage – Harvard Health

  https://www.health.harvard.edu/a_to_z/subarachnoid-hemorrhage-a-to-z

  Aneurysm clipping requires brain surgery. The brain surgeon places a small metal clip across the base of the aneurysm. […] An AVM sometimes can be destroyed by a carefully directed beam of radiation or can be removed through surgery. Another technique is called embolization. A catheter is threaded through a blood vessel and guided to the AVM. The doctor injects special material or a chemical into the AVM to block off blood supply. […] Occupational and physical therapy will likely be needed if neurological impairment has occurred. The therapists are professionals who help the person improve daily function and regain strength after brain injury. Commonly, hospitalization is followed by a period of residence at a rehabilitation center, where additional intensive therapy may be provided. The goal of rehabilitation is to help the patient recover as much physical and speaking function as possible.

• #4 Subarachnoid Hemorrhage, Vasospasm, and Delayed Cerebral Ischemia

  https://practicalneurology.com/diseases-diagnoses/stroke/subarachnoid-hemorrhage-vasospasm-and-delayed-cerebral-ischemia/30142/

  Prevention, effective monitoring, and early detection are the keys to successful management after subarachnoid hemorrhage. […] Oral nimodipine is the only agent approved for DCI prophylaxis. […] A Cochrane review of 16 studies showed that oral nimodipine significantly reduces risk of poor outcome and secondary ischemia after SAH with a number needed to treat (NNT) of 19, although this was not the case for other calcium antagonists or intravenous nimodipine. […] For many years, prophylactic or therapeutic use of induced hypertension, hypervolemia, and hemodilutiontriple-H therapywas the principal approach of restoring impaired cerebral perfusion in patients with DCI after SAH. […] A systematic literature review showed no evidence from controlled trials for a positive effect of triple-H therapy.

• #4

  https://link.springer.com/article/10.1007/s12028-023-01757-7

  The most often applied method is external ventricular drainage. […] If an external ventricular drain is placed before occlusion of the ruptured aneurysm, concerns have been raised regarding an increased risk of rerupture of the aneurysm, but in a study with controls matched for interval since aneurysmal rupture and duration of exposure, such a risk could not be confirmed. […] Thus, the benefits of this procedure outweigh the risks, although large volumes of drainage should probably be avoided. […] In patients with hydrocephalus and severe intraventricular extension of the hemorrhage, intraventricular fibrinolysis after treatment of the ruptured aneurysm to resolve the clot and prevent drain obstruction has been found safe in preliminary randomized trials, but the effect on clinical outcome is unclear.

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