Subarachnoid Hemorrhage

In patients with ruptured and unsecured aneurysms and in good grade, blood pressure should be controlled and maintained at normal or slightly reduced values to reduce the risk of re-bleeding. Labetalol and beta-blockers have no effect on CBF and are the hypotensive agents of choice. In patients refractory to this treatment, the addition of clonidine or enlapril generally would control the blood pressure. In difficult cases, intravenous sodium nitroprus-side may be necessary. Agents such as nitro-prusside, hydralazine and nicardipine are cerebral vasodilators, and thus must be used with caution in patients with poor intracranial compliance or increased ICP. Continuous monitoring of ICP will enhance safety in these patients. In patients with elevated ICP and in poor grades, ongoing cerebral ischemia is an important consideration and blood pressure may have to be maintained at normal levels appropriate for the patient, albeit at the expense of increased risk of bleeding. Prompt surgical treatment will minimize this complication.

Patients in vasospasm will require hypertensive therapy to improve cerebral perfusion. The optimal blood pressure should be guided by the patient's clinical conditions and the magnitude of vasospasm. In general, systolic blood pressure of 140-160 mmHg is maintained for patients with mild vasospasm, and 160-180 mmHg for patients with evidence of moderate-to-severe vasospasm. Occasionally, even higher blood pressure may be required. A therapeutic dilemma occurs when vasospasm occurs in patients with unsecured aneurysms. However, therapeutic hypertensive therapy should not be withheld in these patients as the risk of hemorrhage appears to be very small.

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