Medical management of patients with aneurysmal subarachnoid haemorrhage

Treating patients with aneurysmal subarachnoid haemorrhage is taking care of acutely ill patients, and should be performed in centres where a multidisciplinary team is available 24 hours a day 7 days a week, and where enough patients are managed to maintain and improve standards of care. There is no medical management that improves outcome by reducing the risk of rebleeding, therefore occlusion of the aneurysm, nowadays preferably by means of coiling, remains an important goal in treating patients with aneurysms. Because the poor outcome after subarachnoid haemorrhage is caused to a large extent by complications other than rebleeding, proper medical management to prevent and treat these complications is therefore essential. On basis of the available evidence, oral (not intravenous) nimodipine should be standard care in patients with subarachnoid haemorrhage. It is rational to refrain from treating hypertension unless cardiac failure develops and to aim for normovolaemia, even in case of hyponatraemia. There is no evidence for prophylactic hypervolaemia, and the strategy of hypervolaemia and hypertension in patients with secondary cerebral ischaemia is based on case reports and uncontrolled observational series of patients. Magnesium sulphate and statins are promising therapies, and large trials on effectiveness in improving clinical outcome are underway. There is no evidence for prophylactic use of anti epileptic drugs, and routine use of corticosteroids should be avoided.