Initial Management

The main aim in the early management of SAH is stabilization of the patient, with optimization for aneurysm obliteration, together with the prevention of secondary cerebral insults. Initial priorities include adequate ventilation and oxygenation, normovolemia and hemodynamic stability and control of intracranial pressure (ICP).

In all patients, bedrest is recommended until aneurysm obliteration can be undertaken. Frequent neurological examination is required in order to identify any neurological deterioration requiring further investigation or management. The prophylactic use of nimodipine, at a dose of 60 mg 4-hourly, is used in most centers, as it has been shown to improve outcome [12]. With an unsecured aneurysm, gentle volume expansion with slight hemodilution may help to return the circulating volume to normal and prevent or minimize the effects of vasospasm; however, hypertension should be avoided. Some authors recommend central venous pressure measurement in all SAH patients to allow accurate assessment of the hydration of the patient, although this is not routine practice in all units.

Aggressive peri- and post-operative intensive care may be associated with improved outcome, with a decrease in the incidence of medical complications and secondary cerebral insults. SAH is a complex pathophysiological event, which results in a number of systemic and intracranial alterations. These changes are more prevalent in poor-grade patients and are often associated with subsequent DID.

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