Risk | 5% | 45% | 20% | 30% | 20%/50%/3% | 10% | 15% |
Mortality | 7% | 2% | 20% | 60% |
Type of treatment | Level of evidence | Authors practice |
Prevention of rebleeding | ㅤ | ㅤ |
Antifibrinolytic drugs | Cochrane review and additional trials failed to show improved clinical outcome, despite reduction in rebleeding | Never |
Blood pressure lowering | No trials available; guidelines recommend SBP < 160 (AHA), SBP < 180 (ESO), or no target (NCS) | Upper limits based on individual factors |
Prevention of DCI | ㅤ | ㅤ |
Nimodipine | Cochrane review showed improved clinical outcome for oral (not intravenous) administration | Standard oral 60 mg every 4 h starting immediately after diagnosis |
Corticosteroids | Two small RCTs found no beneficial effect on clinical outcome but an increased risk of hyperglycemia | Never |
Prevention of seizures | ㅤ | ㅤ |
Antiepileptic drugs | No evidence for seizure reduction or improved outcome from prophylactic treatment; observational study suggests worse outcome after prophylactic treatment | Only after documented seizure unrelated to (re)bleeding |
Glucose control | ㅤ | ㅤ |
Intensive insulin therapy | One trial and observational studies showed no benefit on outcome but increased risk of hypoglycemia | Insulin therapy if fasting glucose > 10 mmol/L; regular glucose control (oral diabetics and/or insulin therapy) in patients with diabetes |
Glibenclamide | One small trial found no effect on DCI or clinical outcome | Insulin therapy if fasting glucose > 10 mmol/L; regular glucose control (oral diabetics and/or insulin therapy) in patients with diabetes |
Acute hydrocephalus | ㅤ | ㅤ |
Lumbar puncture | Only observational, noncontrolled case series | If treatment is indicated we start with one or more lumbar punctures, unless the third or fourth ventricles are entirely blocked by intraventricular blood; only in these patients and in patients in whom repeated lumbar punctures are not effective in restoring consciousness we pursue external ventricular drainage |
External ventricular drainage | Only for risk of rebleeding retrospective controlled series. For clinical outcome noncontrolled series | If treatment is indicated we start with one or more lumbar punctures, unless the third or fourth ventricles are entirely blocked by intraventricular blood; only in these patients and in patients in whom repeated lumbar punctures are not effective in restoring consciousness we pursue external ventricular drainage |
- AHA: American Heart Association; DCI: delayed cerebral ischemia; ESO: European Stroke Organization; NCS: Neurocritical Care Society; RCT: randomized controlled trial; SBP: systolic blood pressure
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