Critical care of patients with subarachnoid hemorrhage.

Critical care of a patient with SAH should focus on the prevention or immediate treatment of the common sequelae of this disorder that adversely affect outcome: vasospasm, rebleeding, hydrocephalus, seizures, and associated medical problems. The frequency of rebleeding can be lessened by early surgical or endovascular intervention. The extent of SAH on the CT scan can identify those patients at highest risk for vasospasm, and all patients must be closely monitored in the ICU with serial neurological examinations and transcranial Doppler studies. Regional CBF examinations and continuous EEG may also be helpful. Calcium channel blocking agents and volume expansion are recommended prophylatically for all patients. Aggressive hypertensive, hemodilutional, hypervolemic therapy (including pulmonary artery catheter placement) is indicated for symptomatic vasospasm. Transluminal angioplasty can be used in selected patients with vasospasm refractory to these measures. Hydrocephalus can occur in the days, weeks, or months following SAH and is treated effectively with external (acute hydrocephalus) or internal cerebrospinal fluid diversion. Seizures, which can cause intracranial and systemic hypertension, high cerebral metabolic demand, and delayed neurological injury, should be prevented with prophylactic use of anticonvulsants. In addition, early recognition and treatment of associated medical complications are critical. Novel endovascular approaches, meticulous surgical technique, and aggressive ICU care will undoubtedly lead to improved outcome following aneurysmal SAH.