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Management of aneurysmal subarachnoid hemorrhage

Section Editor(s): Sevransky, Jonathan MD, MHSDiringer, Michael N. MD, FCCM, FAHA

doi: 10.1097/CCM.0b013e318195865a
Continuing Medical Educational Article: Concise Definitive Review

Objective: Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications.

Data Sources: Source data were obtained from a PubMed search of the medical literature.

Data Synthesis and Conclusion: The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1–3 days) should take place by surgical or endovascular means. During the first 1–2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.

Professor of Neurology, Neurosurgery, Anesthesiology, and Occupational Therapy, Washington University School of Medicine, St. Louis, MO.

Supported, in part, by 5P01NS035966 from NIH.

Dr. Diringer receives research support from the NIH.

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© 2009 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins