Materiały źródłowe

• #1 Management of Aneurysmal Subarachnoid Hemorrhages

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

  Subarachnoid hemorrhage accounts for 5% to 10% of all strokes in the United States each year, and 50% of those without a preceding trauma are caused by the rupture of an intracranial aneurysm. […] Early repair, preferably within 24 hours of onset, of ruptured aneurysm by endovascular coiling or neurosurgical clipping is recommended to prevent rebleeding and reduce fatality. […] After securing the ruptured aneurysm, pharmacologic or mechanical venous thromboembolism (VTE) prophylaxis is strongly recommended. […] However, safety has been demonstrated with a small randomized, controlled trial, and retrospective cohort studies demonstrating no significant bleeding risk with the use of low-molecular-weight heparin after the aneurysm is secured. […] Seizure prophylaxis is not routinely recommended in aSAH. However, in those considered high risk, seizure prophylaxis may be considered, and cEEG monitoring may aid in detecting seizure.

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

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

  The majority of subarachnoid hemorrhage cases are due to head trauma and/or a ruptured brain aneurysm. Because of this, the best way you can try to avoid experiencing SAH is to manage your risk factors for these two situations. […] To try to prevent head trauma, always wear a helmet when riding a bike or motorcycle or when playing high-risk sports. Always drive safely and follow traffic laws. If you’re prone to falls, work with a physical or occupational therapist to learn how to try to prevent them and make your home safer. […] To lower your risk of developing a brain aneurysm and/or to prevent an existing aneurysm from rupturing, talk to your healthcare provider about steps you can take to stay healthy. They’ll likely recommend the following: Manage high blood pressure with medications and lifestyle changes. Quit smoking. Exercise regularly (and moderately) without excessive heavy lifting. (Heavy exertion or straining can cause an aneurysm to burst.) Eat a balanced diet. Get help for alcohol or substance use disorders and don’t use cocaine or other stimulant drugs.

• #3 Subarachnoid hemorrhage: MedlinePlus Medical EncyclopediaLock

  https://medlineplus.gov/ency/article/000701.htm

  The following measures may help prevent subarachnoid hemorrhage: […] Stopping smoking […] Treating high blood pressure […] Identifying and successfully treating an aneurysm […] Not using illicit drugs.

• #4 10. Subarachnoid Hemorrhage (SAH) | Hospital Handbook

  https://hospitalhandbook.ucsf.edu/10-subarachnoid-hemorrhage-sah/10-subarachnoid-hemorrhage-sah

  Start DVT prophylaxis 24 hours after aneurysm has been secured. […] Nimodipine 60 mg q4 hours (or 30 mg q2h if hypotensive after higher dose) for 21 days to avoid delayed cerebral ischemia from vasospasm.

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

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

  Subarachnoid hemorrhage (SAH) is relatively rare compared to other types of stroke. […] While not all subarachnoid hemorrhages (SAHs) are preventable—especially those caused by congenital conditions—some steps can help reduce your risk: Blood pressure management: High blood pressure can stress vessel walls, so keeping it under control is crucial. Avoiding tobacco: Smoking damages blood vessels and increases the risk of aneurysm formation and rupture. Moderating alcohol consumption: Excessive alcohol use can contribute to high blood pressure and vascular damage. Safety practices: Wearing seat belts and helmets and taking precautions in other high-risk activities can reduce the likelihood of head traumas that can lead to SAH. Regular medical check-ups and imaging studies, like CT scans, can help detect aneurysms early in people with a known family history or other genetic predispositions.

• #6 Brain Bleed (Intracranial Hemorrhage): Causes & Symptoms

  https://my.clevelandclinic.org/health/diseases/14480-brain-bleed-hemorrhage-intracranial-hemorrhage

  Can a brain bleed be prevented? […] You cant prevent all causes of brain bleeds, but you can take steps to reduce your risk by: […] Managing your blood pressure. […] Lowering your cholesterol level. […] Maintaining a healthy weight. […] Limiting alcohol consumption and stopping smoking. […] Eating healthy foods. […] Getting regular exercise. […] Regulating blood sugar levels if you have diabetes. […] You can also protect yourself from injury by wearing protective equipment, like a helmet, during certain activities or wearing a seatbelt in vehicles.

• #7 Subarachnoid Hemorrhage and Hemorrhagic Stroke | Supreme Vascular and Interventional Clinic

  https://supremevascular.com/conditions-and-treaments/stroke-and-stroke-screening/subarachnoid-hemorrhage-and-hemorrhagic-stroke/

  Not all strokes happen because of a blood clot. A subarachnoid hemorrhage (SAH) can put someone at risk of a stroke. […] It is necessary to learn what an SAH is and how to reduce the risk of one developing. […] Protective headgear can prevent hemorrhaging when playing sports or working hazardous jobs. Managing blood pressure can limit the risk of an aneurysm-based SAH. Moderate exercise is another way to prevent a hemorrhage. Other lifestyle changes to consider are avoiding smoking and having a healthy diet. Many doctors will recommend quitting smoking as it is a significant risk factor and controlling other conditions including diabetes, high blood pressure, or high cholesterol as they may contribute to SAH.

• #8 Subarachnoid hemorrhage – Wikipedia

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

  Screening for aneurysms is not performed on a population level; because they are relatively rare, it would not be cost-effective. However, if someone has two or more first-degree relatives who have had an aneurysmal subarachnoid hemorrhage, screening may be worthwhile. […] An aneurysm may be detected incidentally on brain imaging; this presents a conundrum, as all treatments for cerebral aneurysms are associated with potential complications. The International Study of Unruptured Intracranial Aneurysms (ISUIA) provided prognostic data both in people having previously had a subarachnoid hemorrhage and people who had aneurysms detected by other means. Those having previously had a SAH were more likely to bleed from other aneurysms. In contrast, those having never bled and had small aneurysms (smaller than 10 mm) were very unlikely to have a SAH and were likely to sustain harm from attempts to repair these aneurysms.

• #9 Subarachnoid hemorrhage | Causes, Symptoms & Treatment | Britannica

  https://www.britannica.com/science/subarachnoid-hemorrhage

  Some studies have shown that screening for aneurysms is warranted if there is a family history of them. […] If an aneurysm is identified, it may then be evaluated further for the possibility of performing a procedure to reduce the risk of rupture in the future. […] These decisions are best made carefully and after direct consultation with a vascular neurosurgeon. […] Women experience subarachnoid hemorrhages more frequently than men. […] Smoking and overconsumption of alcohol have been identified as risk factors as well. […] Athletes and labourers who are at risk of head injury should wear appropriate protective head coverings.

• #10 Subarachnoid Hemorrhage – Harvard Health

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

  It is almost impossible to prevent subarachnoid hemorrhage caused by an aneurysm or AVM. These blood vessel abnormalities usually do not cause any symptoms before the hemorrhage occurs. […] Smoking has been shown to increase the risk of forming an aneurysm, so avoiding smoking may prevent some cases of hemorrhagic stroke. […] Some people have proposed screening tests, such as MRI angiography, that would identify aneurysms before they cause a problem. However, this idea has been impractical for most people, because surgery to remove an aneurysm can leave you with decreased function after your recovery. For most people, this is a risk that is not worth taking, since most aneurysms never cause serious bleeding. […] Screening and surgery are not recommended for people who have a single close relative who has a brain aneurysm or a subarachnoid hemorrhage. Screening and surgery may make sense for people who have two or more close relatives who have had bleeding, since this family is at an especially high risk. Because aneurysm screening is controversial, you should consider the risks of surgery carefully with your doctor before you ask for a screening test.

• #11

  https://step2.medbullets.com/neurology/120301/subarachnoid-hemorrhage

  risk factors […] cigarette smoking (most important preventable risk factors) […] hypertension […] polycystic kidney disease […] nimodipine indication prophylaxis to reduce the risk of delayed cerebral ischemia […] aneurysm repair indication to prevent re-rupture of the aneurysm

• #12 Management of Aneurysmal Subarachnoid Hemorrhages

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

  Subarachnoid hemorrhage accounts for 5% to 10% of all strokes in the United States each year, and 50% of those without a preceding trauma are caused by the rupture of an intracranial aneurysm. […] Early repair, preferably within 24 hours of onset, of ruptured aneurysm by endovascular coiling or neurosurgical clipping is recommended to prevent rebleeding and reduce fatality. […] After securing the ruptured aneurysm, pharmacologic or mechanical venous thromboembolism (VTE) prophylaxis is strongly recommended. […] However, safety has been demonstrated with a small randomized, controlled trial, and retrospective cohort studies demonstrating no significant bleeding risk with the use of low-molecular-weight heparin after the aneurysm is secured. […] Seizure prophylaxis is not routinely recommended in aSAH. However, in those considered high risk, seizure prophylaxis may be considered, and cEEG monitoring may aid in detecting seizure.

• #13 Subarachnoid hemorrhage – Wikipedia

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

  On the basis of the ISUIA and other studies, it is now recommended that people are considered for preventive treatment only if they have a reasonable life expectancy and have aneurysms that are highly likely to rupture. Moreover, there is only limited evidence that endovascular treatment of unruptured aneurysms is actually beneficial. […] Management involves general measures to stabilize the person while also using specific investigations and treatments. These include the prevention of rebleeding by obliterating the bleeding source, prevention of a phenomenon known as vasospasm, and prevention and treatment of complications. […] Efforts to keep a person’s systolic blood pressure somewhere between 140 and 160 mmHg are generally recommended. Medications to achieve this may include labetalol or nicardipine.

• #14 Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy | AJA Asian Journal of Anesthesiology

  http://www.aja.org.tw/articles/content.php?id=156&jid=21&continue=Y&sub=29&flag=2

  According to the 2012 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the AHA/ASA, some important recommendations are as follows: (1) surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Class I; Level of Evidence B); (2) complete obliteration of the aneurysm is recommended whenever possible (Class I; Level of Evidence B); (3) for patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of Evidence B); and (4) microsurgical clipping may receive increased consideration in patients presenting with large (50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms.

• #14 Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy | AJA Asian Journal of Anesthesiology

  http://www.aja.org.tw/articles/content.php?id=156&jid=21&continue=Y&sub=29&flag=2

  Aneurysmal subarachnoid hemorrhage (aSAH) is a serious and debilitating condition that leads to the development of many complications, which are followed by mortality and morbidity. […] The purpose of this article is to review recent advances and future perspectives in the treatment of aSAH, early brain injury, and cerebral vasospasm. […] Endovascular management of intracranial aneurysms is likely to progress rapidly and has emerged as the first-line intervention for medical treatment failure patients. […] Delayed cerebral ischemia (DCI) as a result of CVS is the most common cause of death and disability after aSAH. Nimodipine has been shown to improve CVS in controlled trials. […] The choice of interventional treatment following a ruptured aneurysm is either endovascularly coiling or surgically clipping.

• #15 Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy | AJA Asian Journal of Anesthesiology

  http://www.aja.org.tw/articles/content.php?id=156&jid=21&continue=Y&sub=26&flag=2

  According to the 2012 Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals from the AHA/ASA, some important recommendations are as follows: (1) surgical clipping or endovascular coiling of the ruptured aneurysm should be performed as early as feasible in the majority of patients to reduce the rate of rebleeding after aSAH (Class I; Level of Evidence B); (2) complete obliteration of the aneurysm is recommended whenever possible (Class I; Level of Evidence B); (3) for patients with ruptured aneurysms judged to be technically amenable to both endovascular coiling and neurosurgical clipping, endovascular coiling should be considered (Class I; Level of Evidence B); and (4) microsurgical clipping may receive increased consideration in patients presenting with large (50 mL) intraparenchymal hematomas and middle cerebral artery aneurysms.

• #15 Review of aneurysmal subarachnoid hemorrhage—Focus on treatment, anesthesia, cerebral vasospasm prophylaxis, and therapy | AJA Asian Journal of Anesthesiology

  http://www.aja.org.tw/articles/content.php?id=156&jid=21&continue=Y&sub=26&flag=2

  Recommendations from the AHA/ASA are as follows: (1) oral nimodipine should be administered to all patients with aSAH (Class I; Level of Evidence A); (2) maintenance of euvolemia and normal circulating blood volume is recommended to prevent DCI (Class I; Level of Evidence B); (3) prophylactic hypervolemia or balloon angioplasty prior to the development of angiographic spasm is not recommended (Class III; Level of Evidence B); (4) transcranial Doppler is reasonable to monitor for the development of CVS (Class IIa; Level of Evidence B); (5) cerebral angioplasty and/or selective intra-arterial vasodilator therapy is reasonable in patients with symptomatic CVS, particularly in those who are not responding rapidly to hypertensive therapy (Class IIa; Level of Evidence B).

• #16 Delayed cerebral ischemia and therapeutic approaches after subarachnoid hemorrhage

  https://www.explorationpub.com/Journals/ent/Article/100426

  Delayed cerebral ischemia after subarachnoid hemorrhage is one of the most important causes of mortality and poor functional outcome in patients. […] The main treatment strategies in the prevention and treatment of delayed cerebral ischemia are the regulation of blood pressure and the use of calcium channel blockers, especially nimodipine. […] To prevent the development of DCI and improve its prognosis, the underlying etiological factors should be recognized. Evidence-based scientific methods should be applied to prevent the development of DCI. […] It is essential to provide SAH stabilization and hemorrhage control. For this, the blood pressure must first be stabilized at the beginning. […] Nimodipine, a calcium channel blocker of the dihydropyridine group, is one of the major treatments that prevent the progression of vasospasm.

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

  https://practicalneurology.com/articles/2019-jan/subarachnoid-hemorrhage-vasospasm-and-delayed-cerebral-ischemia

  Prevention, effective monitoring, and early detection are the keys to successful management after subarachnoid hemorrhage. […] Prevention of rebleeding by early repair of any ruptured aneurysm and advances in neurocritical care contribute to this improved outcome. […] 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. […] For many years, prophylactic or therapeutic use of induced hypertension, hypervolemia, and hemodilution—triple-H therapy—was 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.

• #18 Management of delayed cerebral ischemia after subarachnoid hemorrhage | Critical Care | Full Text

  https://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1447-6

  DCI prevention has been the Holy Grail of SAH research for decades, but few options are available and unfortunately most attempts have yielded disappointing results. Nimodipine, a dihydropyridine calcium channel antagonist, is the only pharmacologic intervention so far associated with better outcome in SAH patients. Multiple trials have demonstrated a benefit, with the seminal trial showing an impressive reduction in cerebral infarction, poor neurological outcome, and death with oral nimodipine 60 mg given every 4 hours for 21 days. This is now the recommended regimen, although intravenous nimodipine is approved as an alternative in Europe. […] Hyponatremia and hypovolemia occur frequently after SAH due to physiological changes favoring excessive natriuresis and inappropriate antidiuretic hormone elevation, and have been associated with impending DCI. Retrospective data indicate that fluid restriction, the typical treatment for syndrome of inappropriate antidiuretic hormone (SIADH), can be deleterious and increases the risk of DCI due to aggravation of hypovolemia. Isotonic crystalloid fluid resuscitation targeting normal serum sodium values and euvolemia is presently the favored fluid management strategy for preventing DCI. […] Based on the best available evidence, nimodipine administration and maintenance of euvolemia are the surest way to prevent DCI.

• #19 Subarachnoid hemorrhage secondary prevention – wikidoc

  https://www.wikidoc.org/index.php/Subarachnoid_hemorrhage_secondary_prevention

  Use of fludrocortisone acetate and hypertonic saline solution is reasonable for preventing and correcting hyponatremia[10] […] Careful glucose management with strict avoidance of hypoglycemia[11] […] Use of packed red blood cell transfusion to treat anemia in order to reduced the risk of cerebral ischemia[12][13] […] Treatment of high blood pressure with antihypertensive medication is recommended to prevent ischemic stroke, intracerebral hemorrhage, and cardiac, renal, and other end-organ injury(Level of Evidence: A) […] Hypertension should be treated, and such treatment may reduce the risk of aSAH(Level of Evidence: B) […] Tobacco use and alcohol misuse should be avoided to reduce the risk of aSAH(Level of Evidence: B) […] After any aneurysm repair, immediate cerebrovascular imaging is generally recommended to identify remnants or recurrence of the aneurysm that may require treatment(Level of Evidence: B)

• #20 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. […] Prevention of rebleeding by early repair of any ruptured aneurysm and advances in neurocritical care contribute to this improved outcome. […] 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. […] For many years, prophylactic or therapeutic use of induced hypertension, hypervolemia, and hemodilution—triple-H therapy—was 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.

• #21 Magnesium infusion for vasospasm prophylaxis after subarachnoid hemorrhage in: Journal of Neurosurgery Volume 105 Issue 5 (2006) Journals

  https://thejns.org/view/journals/j-neurosurg/105/5/article-p723.xml

  Despite the application of current standard therapies, vasospasm continues to result in death or major disability in patients treated for ruptured aneurysms. […] The authors investigated the effectiveness of continuous MgSO4 infusion for vasospasm prophylaxis. […] Symptomatic vasospasm was present at a significantly lower frequency in patients who received MgSO4 infusion (18%) compared with patients who did not receive MgSO4 (42%) (p = 0.025). […] Analysis of the results suggests that MgSO4 infusion may have a role in cerebral vasospasm prophylaxis if therapy is initiated within 48 hours of aneurysm rupture.

• #22 Therapeutic hypercapnia for prevention of secondary ischemia after severe subarachnoid hemorrhage: physiological responses to continuous hypercapnia | Scientific Reports

  https://www.nature.com/articles/s41598-021-91007-7

  Temporary hypercapnia has been shown to increase cerebral blood flow (CBF) and might be used as a therapeutical tool in patients with severe subarachnoid hemorrhage (SAH). […] It is concluded that 45 min might be the optimum duration for a therapeutic use and may provide an optimal balance between the benefits of hypercapnia and risks of a negative rebound effect after return to normal ventilation parameters. […] The optimum duration of controlled hypercapnia and its effects on CBF and brain tissue oxygen saturation (StiO2) as a therapeutic tool against DCI are not clarified. […] The present study was planned as a dose optimization study in order to identify the time-point at which CBF reaches a maximum. […] The rationale behind intermittent controlled hypercapnia is to temporarily increase a critically reduced CBF so that energy stores can recover. […] We conclude that 45 min of controlled hypercapnia might be the most suitable duration regarding the CBF-increasing effect, the patients safety and the feasibility in an intensive care setting.

• #23 Seizure Prophylaxis in the Immediate Post-Hemorrhagic Period in Patients with Aneurysmal Subarachnoid Hemorrhage

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5805895/

  Seizures are a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) and occur most commonly in the immediate posthemorrhagic period. Most commonly used antiepileptic drugs (AEDs) for seizure prophylaxis in aSAH include phenytoin and levetiracetam. There is no reliable data available on the safety and efficacy of restricting AED prophylaxis only till the aneurysm is secured. […] Stopping the AED prophylaxis immediately after aneurysm coiling is not associated with increased risk of seizures. […] Both phenytoin and levetiracetam are well tolerated in patients with aSAH when limited to the immediate posthemorrhagic period. […] Most commonly used AEDs for seizure prophylaxis in patients with aSAH include phenytoin and levetiracetam. […] NCS guidelines recommend against the use of phenytoin for seizure prophylaxis in patients with aSAH, while the AHA recommends the use of AEDs in such patients without specifying the drug of choice.

• #24

  https://journals.lww.com/md-journal/fulltext/2024/07120/use_of_antiepileptic_medications_for_seizures_.30.aspx

  The use of prophylactic antiepileptic drugs (AEDs) post-subarachnoid hemorrhage (SAH), particularly aneurysmal SAH, is controversial, with limited data available. […] Our findings support the 2023 AHA/ASA guideline recommendation to avoid using routine AEDs for prophylaxis for all SAH patients. Proper and careful stratification methods should be implemented in each given scenario. […] The associated negative adverse effects of phenytoin and the lack of randomized clinical trials that support using antiepileptics, particularly those with a good safety profile, led to the most recent AHA/ASA guidelines for the management of aneurysmal SAH against using antiepileptic medications as seizure prophylaxis. […] Despite the common practice of administering the new AEDs, particularly levetiracetam, as seizure prophylactics in patients with SAH, certainly aneurysmal SAH, the efficacy of such prophylaxis is not guaranteed, and the safety of possible death and a longer hospital stay could be a critical concern. In conclusion, our findings support the 2023 AHA/ASA guideline recommendations to avoid using routine AEDs for prophylaxis in all SAH cases.

• #25 Long-Versus Short-Term Seizure Prophylaxis After Craniotomy for Clipping in Aneurysmal Subarachnoid Hemorrhage; A Retrospective Cohort Study

  https://brieflands.com/articles/ans-68108

  Seizures are quite common following subarachnoid hemorrhage (SAH) and due to increased mortality and morbidity in this setting, thus seizure prophylaxis is introduced as a common neurosurgical practice. […] Although short-term 1-month seizure prophylaxis with phenytoin provides adequate seizure control for most individuals after SAH, perioperative seizures necessitate a longer course of 3 – 6 month seizure prophylaxis. […] Despite recent efforts to introduce a guideline for seizure prophylaxis in SAH patients, a consensus regarding a uniform protocol for all of these patients has not been achieved. […] According to this survey, we believe that a short-term 1-month administration of phenytoin provides adequate seizure prophylaxis, confirming that the continuation of prophylaxis beyond this time is unnecessary.

• #26 Long-Versus Short-Term Seizure Prophylaxis After Craniotomy for Clipping in Aneurysmal Subarachnoid Hemorrhage; A Retrospective Cohort Study

  https://brieflands.com/articles/ans-68108

  However, patients with perioperative seizures tend to experience a higher rate of late seizures if the medication is discontinued early within one month. […] The most recent recommendations applied by many academic centers for seizure prophylaxis in SAH are as follow: Prophylaxis should be initiated in patients under the following conditions: Hunt Hess grade 4 or 5, Fisher grade III or IV, Modified Fisher grade II-IV, Concomitant intracerebral hemorrhage, MCA aneurysm, History of hypertension. […] Although short-term 1-month prophylaxis with phenytoin provides efficient seizure control following SAH, a history of perioperative seizures necessitates a longer course of seizure prophylaxis.

• #27 Seizure Prophylaxis in the Immediate Post-Hemorrhagic Period in Patients with Aneurysmal Subarachnoid Hemorrhage

  https://pmc.ncbi.nlm.nih.gov/articles/PMC5805895/

  Importantly, no reliable data or guidelines are available regarding the safety and efficacy of stopping AED prophylaxis once the aneurysm is secured. […] No difference was noted between phenytoin and levetiracetam usage. […] Stopping AED prophylaxis immediately after the aneurysm is secured and is not associated with increased risk of seizures or other worse outcomes.

• #28

  https://journals.lww.com/neurosurgery/fulltext/2007/12000/three_day_phenytoin_prophylaxis_is_adequate_after.51.aspx

  We read with interest the recent article by Chumnanvej et al. on the adequacy of 3-day phenytoin prophylaxis after subarachnoid hemorrhage (SAH). The authors conclude that a prophylactic 3-day phenytoin regimen is adequate to prevent seizures after SAH when compared with long-term anticonvulsant administration, with less potential for phenytoin toxicity and related hypersensitivity reactions. […] In our unit, for over 10 years it has been the senior author’s (KAC) policy not to administer any anticonvulsant prophylaxis to patients presenting with SAH. […] Although we do not disagree with the authors’ suggestions that a longer-term anticonvulsant prophylaxis after SAH may be overkill, from our observations, we contend that routine anticonvulsant prophylaxis is unnecessary altogether in SAH patients, even those with a high risk of seizures.

• #29

  https://journals.lww.com/neurosurgery/fulltext/2007/12000/three_day_phenytoin_prophylaxis_is_adequate_after.51.aspx

  We believe that the literature does not provide robust and unequivocal support for prophylactic anticonvulsant therapy, and that the risk of seizure may, in fact, be overestimated. […] We think that universal phenytoin prophylaxis in all patients with SAH on empiric grounds is unwarranted. […] We congratulate the authors for their timely study and for opening up this important debate that we hope, in the future, results in abolishing altogether the practice of administering routine anticonvulsant prophylaxis.

• #30 Seizure prophylaxis following aneurysmal subarachnoid haemorrhage (SPSAH): study protocol for a multicentre randomised placebo-controlled trial of short-term sodium valproate prophylaxis in patients with acute subarachnoid haemorrhage | BMJ Open

  https://bmjopen.bmj.com/content/12/5/e057917

  Seizures are a common complication that leads to neurological deficits and affects outcomes after aneurysmal subarachnoid haemorrhage (aSAH). However, whether to use prophylactic anticonvulsants in patients with aSAH remains controversial. […] Our study aims to determine whether short-term (7days) sodium valproate could prevent seizure occurrence and improve neurological function in patients with SAH caused by anterior circulation aneurysm rupture and treated with clipping. […] This study will be conducted according to the principles of Declaration of Helsinki and good clinical practice guidelines. […] Although seizure prophylaxis after aSAH is controversial with little clinical evidence available, it is a common practice in SAH management. […] Sodium valproate, which has been introduced into clinical practice for more than 50 years, is a mainstay of anticonvulsant therapy because of its effectiveness for a wide range of seizures as well as epileptic syndromes. […] Therefore, we choose sodium valproate as the anticonvulsant drug in our study.

• #31 Management of Aneurysmal Subarachnoid Hemorrhages

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

  Subarachnoid hemorrhage accounts for 5% to 10% of all strokes in the United States each year, and 50% of those without a preceding trauma are caused by the rupture of an intracranial aneurysm. […] Early repair, preferably within 24 hours of onset, of ruptured aneurysm by endovascular coiling or neurosurgical clipping is recommended to prevent rebleeding and reduce fatality. […] After securing the ruptured aneurysm, pharmacologic or mechanical venous thromboembolism (VTE) prophylaxis is strongly recommended. […] However, safety has been demonstrated with a small randomized, controlled trial, and retrospective cohort studies demonstrating no significant bleeding risk with the use of low-molecular-weight heparin after the aneurysm is secured. […] Seizure prophylaxis is not routinely recommended in aSAH. However, in those considered high risk, seizure prophylaxis may be considered, and cEEG monitoring may aid in detecting seizure.

• #32 Management of Aneurysmal Subarachnoid Hemorrhages

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

  Per guidelines, effective glycemic control with strict hyperglycemia management and avoidance of hypoglycemia are reasonable. […] Nimodipine is the only current therapy approved to help reduce the incidence and severity of vasospasm leading to DCI. […] Current Joint Commission National Quality Measures recommend administering nimodipine within 24 hours of arrival to the hospital, and pharmacists can help ensure appropriate medication timing and administration.

• #33 Prevention of Intracerebral and Subarachnoid Haemorrhage (Chapter 22) – Stroke Prevention and Treatment

  https://www.cambridge.org/core/books/stroke-prevention-and-treatment/prevention-of-intracerebral-and-subarachnoid-haemorrhage/B6BC6A7DCB2BA3F4461A6AF64078C171

  Intracerebral haemorrhage and subarachnoid haemorrhage are associated with considerable morbidity and mortality. […] Medical therapies to control hypertension, achieve tobacco abstinence, and avoid excessive alcohol consumption can confer broad reductions in haemorrhage risk across pathophysiological subtypes. […] Judicious restriction of antiplatelet and anticoagulant therapies to only those individuals and those intensities for which they are indicated also can substantially reduce haemorrhagic stroke frequency. […] Specific endovascular and surgical therapies, judiciously employed, will further reduce risk of first or recurrent haemorrhage from structural vascular anomalies, including arteriovenous malformation, cavernous malformations, and saccular aneurysms. […] For unruptured intracranial aneurysms, features that favour consideration of preventive occlusion include include younger patient age, prior subarachnoid haemorrhage from a different aneurysm, familial intracranial aneurysms, large aneurysm size, irregular shape, basilar or vertebral artery location, and aneurysm growth on serial imaging. […] Among individuals who are technical candidates for either coiling or clipping, endovascular coiling is associated with a reduction in procedural morbidity and mortality but has a higher risk of recurrence.

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

  https://practicalneurology.com/articles/2019-jan/subarachnoid-hemorrhage-vasospasm-and-delayed-cerebral-ischemia

  The HIMALAIA trial was designed to assess the effectiveness of induced hypertension on clinical outcome in patients with DCI, but it was terminated prematurely because of a lack of efficacy on cerebral perfusion and slow recruitment. […] In the authors’ current clinical practice, we find it reasonable to treat patients who develop DCI with stepwise blood pressure augmentation and simultaneous neurologic assessment at each mean arterial pressure level. […] When hemodynamic management fails to reverse a focal neurologic deficit consistent with vasospasm or is contraindicated, endovascular management is preferred. […] Endovascular therapy combines mechanical balloon angioplasty for accessible lesions and vasodilator infusion for distal vessels and microvascular beds. […] Vasospasm and DCI contribute substantially to mortality and morbidity of patients who experienced SAH. Prevention, effective monitoring, and early detection are the keys to successful management.

• #35

  https://scholars.duke.edu/publication/1527718

  Cerebral vasospasm remains a devastating medical complication of aneurysmal subarachnoid hemorrhage (SAH). […] This topic review collects the relevant literature on clinical trials investigating prophylactic therapies for cerebral vasospasm in patients with aneurysmal SAH and emphasizes the need for large clinical trials to confirm the results derived from clinical experience. […] In addition, it points out some experimental therapies that may hold promise in future clinical trials to prevent the occurrence of vasospasm.

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