Neurocritical Care

iv.

Abrupt withdrawal of statins in patients who were taking statins before SAH may result in a

withdrawal effect and increase the risk of vasospasm.

Magnesium – No usefulness in attaining magnesium concentrations 3–4 mEq/L. Maintaining

magnesium at normal concentrations (i.e., preventing hypomagnesemia) is advisable.

ii.

Clazosentan – No usefulness in blocking endothelin-1

iii.

Albumin – Not beneficial and may be associated with an increase in pulmonary edema

Treatment of vasospasm

Intra-arterial therapies (see Table 14)

Triple-H therapy (hypertension, hypervolemia, hemodilution)

No longer recommended in the traditional format. Euvolemia is better than hypervolemia –

Similar outcomes in clinical trials, less pulmonary edema

ii.

Hemodilution has not been shown beneficial.

Hyperperfusion therapy

Better descriptor for the goal of therapy

ii.

Vasospasm causes distal vasoconstriction to the point of ischemia.

iii.

Maximizing cerebral blood flow mitigates ischemia.

Euvolemia

ii.

Vasopressors (blood pressure targets are ill defined, but are also typically patient- and

symptom-dependent)

iii.

Inotropes (milrinone)

iv.

Superselective intra-arterial vasodilators (e.g., verapamil, nicardipine)

Headache

“Worst headache of my life” is the typical chief concern for an aneurysmal SAH.

Multimodality treatment will be needed to improve patient satisfaction during hospital admission

(which may be up to 14–21 days).

Optimal choice of agents is not well known.

Common analgesics such as acetaminophen, nonsteroidal anti-inflammatory drugs (if

aneurysm is secured)

ii.

Other therapies such as magnesium, corticosteroids, or gabapentin may be helpful.

iii.

Agents that contain caffeine are often used for headache but may not be appropriate, given the

risk of cerebral vasospasm after SAH.

iv.

Opioids may be needed, but use should be limited to avoid sedation and inability to monitor

neurologic examination.

Nonpharmacologic therapies like warm compresses on the back of the neck, minimization of

noise, and minimization of bright light may also be useful.

Seizure prophylaxis (Stroke 2023;54:314-70)

Use of anticonvulsants for seizure prophylaxis is controversial after SAH.

For new-onset seizures after aSAH, treatment with antiseizure medication for 7 days is

recommended.

Prophylactic antiseizure medication should not be routinely used but can be considered in high-risk

patients (with ruptured middle cerebral artery aneurysm, ICH, high-grade aSAH, hydrocephalus,

or cortical infarction).