Table 2. Basic therapeutic measures in acute subarachnoid hemorrhage (SAH) and their evidential basis.
| Goal | EL | Measure | Therapeutic intervention by means of (e.g.): | |
| Monitoring vital signs | B | Frequent GCS determinations and monitoring of basic neurologic functions as required in accordance with clinical condition (e.g., continuous, every 15 minutes, or once per hour) | ||
| Securing vital signs | A | Intubation for GCS ≤ 12, respiratory insufficiency | ||
| Demonstration of SAH | B | Noncontrast head CT | ||
| Lumbar puncture if indicated (after head CT and exclusion of elevated intracranial pressure) | ||||
| Classification of severity | B | Classification of severity according to the WFNS and H & H scales | ||
| Transfer to a neurovascular center | B | Immediate transfer to a neurosurgical/neurovascular center | ||
| Stress reduction | C | Absolute or relative bed rest (depending on hospital) | ||
| Stress reduction (limited visits of relatives, no TV, …) | ||||
| Analgesics, sedatives, and stool softeners as needed | ||||
| Minimal handling: no needle sticks in awake patients other than for intravenous access | ||||
| Sedation if needed in case of restlessness or agitation (beware of respiratory depression, hypotension, and paradoxical reactions; the patient should remain awake enough for neurological examination) | Diazepam 5 mg po or iv prn | |||
| Analgesia | B | Administration of analgesic drugs | Dexamethasone 4 mg po or iv tid | |
| Paracetamol 1 g po qid | ||||
| Morphine 10 mg po as needed (iv for intubated patients) | ||||
| Blood pressure control | B | Target range for systolic blood pressure, 100–140 mm Hg | ||
| Treatment of hypertension | Primary: | nimodipine 60 mg po or iv q4h | ||
| Secondary: | nifedipine 20 mg po tid or qid | |||
| Tertiary: | urapidil iv bolus as a test, then possibly clonidine iv infusion | |||
| Treatment of hypotension | Primary: | balanced electrolyte solution, 100–150 mL/h | ||
| Secondary: | lower nimodipine dose | |||
| Tertiary: | administration of noradrenaline only in the intensive care unit (dangerous if the aneurysm has not yet been secured; only in exceptional cases) | |||
| Prophylaxis against DCI | A | Administration of nimodipine | ||
| Ulcer prophylaxis | C | Administration of a proton-pump inhibitor | Omeprazole 40 mg qd or bid | |
| Prevention of hypertension associated with defecation | C | Administration of a stool softener | ||
| Treatment of hydrocephalus | B | Insertion of an external ventricular drain (only in neurosurgical centers) or lumbar puncture if indicated | ||
Evidence grades and definitions:
A, different patient populations studied, data from multiple prospective and randomized trials or meta-analyses;
B, limited patient population studied, data from a small number of prospective and randomized trials or from non-randomized studies;
C, very limited patient population studied, consensus opinion, single studies, standard treatment.
DCI, delayed cerebral ischemia; EL, evidence level; GCS; Glasgow Coma Scale; H & H, Hunt and Hess; WFNS, World Federation of Neurosurgical Societies