Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

Publication Date: May 18, 2023
Last Updated: August 1, 2023

Summary of Recommendations

There is insufficient evidence to recommend a blood pressure reduction goal for the treatment of hypertension before aneurysm treatment in aSAH. Lack of evidence to recommend a specific blood pressure reduction goal does not necessarily imply that blood pressure reduction is not helpful before aneurysm treatment. (, )

We recommend against the administration of antifibrinolytic therapy to prevent rebleeding of ruptured aneurysms in patients with aSAH. (S, H)

We recommend the administration of oral nimodipine in patients with aSAH to reduce DCI and cerebral infarction, and to improve functional outcome. (S, M)

We recommend against the administration of intravenous (IV) nicardipine for the prevention of DCI because of increased risk of adverse effects. (S, M)

There is insufficient evidence to recommend for or against the administration of calcium channel blocker other than nicardipine by intravenous or intraventricular routes. (, )

We recommend against endothelin receptor antagonist administration because of lack of benefit on mortality and functional outcomes and an increased risk of adverse events. (S, H)

We recommend against starting statin treatment to reduce DCI or improve functional outcomes in aSAH because of lack of benefit. (S, H)

We recommend against the use of targeted hypermagnesemia to improve outcomes in aSAH due to lack of benefit. (S, M)

We suggest against liberal fluid administration because of an increased risk of pulmonary edema. (C, L)

We suggest using targeted fluid administration to achieve euvolemia, which may include goal directed hemodynamic therapy, to reduce the risk of pulmonary edema, prevent DCI, and improve functional outcome. (C, VL)

There are insufficient quality data to recommend for or against blood pressure or cardiac output augmentation for the prevention and treatment of DCI. Due to the associated risks, use of these interventions should be judicious and tailored to the patient’s individual hemodynamic profile. (, )

There is insufficient evidence to provide a recommendation on the optimal trigger (change in neurological exam plus findings on advanced neuroimaging versus change in exam alone) for interventional procedures for the treatment of DCI. (, )

There is insufficient evidence to support mineralocorticoid administration to maintain normal serum sodium concentrations and/or even fluid balance or to improve functional outcome. (, )

There is insufficient evidence to provide a recommendation for using a transfusion threshold higher than a hemoglobin of > 7 g/dL in patients with aSAH.
(, )

There is insufficient evidence to provide a recommendation on direct clamping versus gradual weaning strategy for EVD removal for the management of hydrocephalus in patients with aSAH. (, )

Recommendation Grading


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Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

Authoring Organization

Publication Month/Year

May 18, 2023

Last Updated Month/Year

August 8, 2023

Document Type


Country of Publication


Document Objectives

The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital, Operating and recovery room

Intended Users

Nurse, nurse practitioner, health systems pharmacist, physician, physician assistant



Diseases/Conditions (MeSH)

D013345 - Subarachnoid Hemorrhage


Aneurysmal Subarachnoid Hemorrhage, subarachnoid hemorrhage (SAH), aSAH, subarachnoid hemorrhage

Source Citation

Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care. 2023 May 18. doi: 10.1007/s12028-023-01713-5. Epub ahead of print. PMID: 37202712.

Supplemental Methodology Resources

Data Supplement, Data Supplement


Number of Source Documents
Literature Search Start Date
September 25, 2019
Literature Search End Date
April 1, 2021