Subarachnoid Hemorrhage: Drug Therapy

Therapeutic targets

  • Safeguarding or stabilization of vital functions (respiration, body temperature, circulation).
  • Avoidance of recurrent hemorrhage (new bleeding/post-bleeding) (often in the first 24 hours).
  • Reduction of intracranial pressure
  • Avoidance of complications, v. a. hydrocephalus (pathological dilation of the fluid spaces (cerebral ventricles) of the brain filled with cerebrospinal fluid), vasospasms (vascular spasms) and epileptic seizures (convulsions)

Therapy recommendations

  • Sedation (immobilization of the patient)
  • Analgesia (pain relief)
  • Blood pressure management
    • Target range for normotensive patients: 120-140 mmHg.
    • Target range for hypertensive patients: 130-160 mmHg
    • The following agents are suitable:
      • Primary nimodipine, secondary nifedipine, tertiary urapidil (possibly clonidine as perfusor/syringe pump).
      • Cave: sodium nitroprusside is not suitable because it can lead to an increase in intracranial pressure (ICP; intracranial pressure)!
  • Intracranial pressure reduction:
    • Upper body elevation (10-30°).
    • Osmotherapy with mannitol (4 to 6 times 80 ml/day) or glycerol (2 to 3 times 250 ml).
    • CSF drainage through ventricular catheter.
  • Neuroprotective measures:
    • Compensation of electrolyte disturbances, v. a. hyponatremia (sodium deficiency).
    • Normoglycemia (normalization of blood glucose levels).
    • Normothermia (< 37.5 ° C)
    • Normovolemia (normal blood volume) → isotonic solutions.
  • Avoidance of actions that involve pushing:
  • In hydrocephalus (pathological dilation of the fluid spaces (cerebral ventricles) of the brain filled with cerebrospinal fluid):
    • In occlusive hydrocephalus (hydrocephalus occlusus): CSF drainage via external ventricular drainage (EVD).
    • In chronic occlusive hydrocephalus: surgical insertion of a ventriculoperitoneal (drainage into the abdominal cavity) or ventriculoartial (drainage into the right atrium) shunt
  • If epileptic symptoms are present: anticonvulsive therapy (“anti-seizure” drug therapy).
  • In case of hematoma (subdural or intraparenchymatous): neurosurgical hematomevacuation (hematoma evacuation).
  • Prophylaxis of:
  • Caveat: Prophylactic administration of glucocorticoids and antifibrinolytics is not indicated!
  • Low-dose (75-300 mg/day) continuous medication with acetylsalicylic acid (ASA; antiplatelet agent), as prescribed in primary and secondary prevention of vascular events, does not increase the risk of intracranial hemorrhage. In fact, a protective (protective) effect was observed for subarachnoid hemorrhage.