**4.4 Management**

Once the patient has been diagnosed with an SAH, treatment should focus on limiting secondary neurologic injuries to improve the patient's functional outcome.


#### **4.5 Pharmacologic treatments**

#### *4.5.1 Antiepileptic drugs*

In patients with a suspected ruptured aneurysm, seizures can lead to aneurysmal rebleeding and result in intracranial hypertension and herniation, the

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*Endovascular Treatment of Brain Aneurysms DOI: http://dx.doi.org/10.5772/intechopen.88964*

antiepileptic drugs in SAH [87].

*Flowchart of management aSAH [1, 10–12].*

**4.7 Blood pressure management**

agents recommended by the ASA [86].

only level IA evidence recommended by the ASA [86].

**4.6 Nimodipine**

**Figure 5.**

risk of being highest in patients with poor Hunt and Hess grade and those with thick subarachnoid blood [85]. Routine prophylactic antiepileptic drug use in patients with SAH is a common practice despite limited evidence The American Stroke Association (ASA) guideline recommends consideration of short-term prophylactic antiepileptic drug use in the immediate post hemorrhage period [86]. No randomized controlled trials have investigated the safety and effectiveness of

Delayed cerebral ischemia (DCI) is one of the most serious complications associated with SAH, occurring in one-third of patients surviving the initial hemorrhage and results in poor outcome in half of the patients with this complication [86]. Nimodipine is a calcium antagonist that is thought to reduce the rate of cerebral vasospasm by reducing the influx of calcium into the vascular smooth muscle cells. The administration of nimodipine to reduce the risk of poor outcome and DCI is the

There is general consensus that hypertension should be controlled after SAH and until the ruptured aneurysm is secured. However, specific parameters for blood pressure have not been defined and data are sparse. Early retrospective studies suggest a higher rate of rebleeding with SBP greater than 160 mm Hg and severity of initial hemorrhage [88]. Therefore, the ASA and Neurocritical Care Society recommend maintaining SBP less than 160 mm Hg and mean arterial pressure less than 110 mm Hg before the ruptured aneurysm is secured to reduce the risk of rebleeding [86, 87, 89, 90]. The ideal antihypertensive to use in SAH would be a parenteral agent that produces a rapid and reproducible dose response while concurrently minimizing adverse cerebral effects. Labetalol, nicardipine, and clevidipine are

*New Insight into Cerebrovascular Diseases - An Updated Comprehensive Review*

**Grade Glasgow coma scale (GCS) Neurological exam** 15 No motor deficit 13–14 No motor deficit 13–14 Motor deficit 7–12 With/without motor deficit 5–6 With/without motor deficit

Once the patient has been diagnosed with an SAH, treatment should focus on limiting secondary neurologic injuries to improve the patient's functional outcome.

**Grade Criteria Survival** I Asymptomatic, mild headache, slight nuchal rigidity 70%

*World Federation of Neurological Surgeons Grading System for Subarachnoid Hemorrhage - (WFNS) scale.*

cranial nerve palsy

III Drowsiness/confusion and mild focal neurological deficit 50% IV Stupor, moderate to severe hemiparesis 20% V Coma, decerebrate positioning 10%

**Grade Appearance of blood on CT Risk of cerebral** 

(VH)

 Minimal SAH, No VH in 2 lateral ventricles 6% Minimal SAH, VH in 2 lateral ventricles 14% Large SAH, No VH in 2 lateral ventricles 12% Large SAH, VH in 2 lateral ventricles 28%

60%

**hemorrhage**

0%

II Moderate to severe headache, nuchal rigidity, no neurological deficit other than

• Resuscitation of a patient with SAH should follow all established protocols

• After stabilization of the airway and circulation, treatments specific to SAH

In patients with a suspected ruptured aneurysm, seizures can lead to aneurysmal rebleeding and result in intracranial hypertension and herniation, the

with immediate attention to airway and circulatory support.

0 No sub arachnoid hemorrhage (SAH) or ventricular hemorrhage

**192**

**4.4 Management**

*Modified fisher grading system [82].*

**Table 2.**

**Table 1.**

**Table 3.**

*Hunt and Hess scale.*

can begin.

*4.5.1 Antiepileptic drugs*

**4.5 Pharmacologic treatments**

#### **Figure 5.** *Flowchart of management aSAH [1, 10–12].*

risk of being highest in patients with poor Hunt and Hess grade and those with thick subarachnoid blood [85]. Routine prophylactic antiepileptic drug use in patients with SAH is a common practice despite limited evidence The American Stroke Association (ASA) guideline recommends consideration of short-term prophylactic antiepileptic drug use in the immediate post hemorrhage period [86]. No randomized controlled trials have investigated the safety and effectiveness of antiepileptic drugs in SAH [87].
