In aneurysmal subarachnoid hemorrhage, the initial protocol step focuses on blood pressure control — keeping systolic blood pressure below 180–200 mm Hg while avoiding hypotension (mean arterial pressure below 65 mm Hg). When this step does not achieve or maintain those target parameters, the structured protocol escalates to definitive treatment of the ruptured aneurysm.
The preceding treatment step involves frequent blood pressure monitoring and blood pressure control with short-acting medications, and emergency anticoagulation reversal in patients receiving anticoagulants. The goals of that step — avoiding severe hypertension (systolic BP exceeding 180–200 mm Hg) and avoiding hypotension (mean arterial pressure below 65 mm Hg) — were not achieved, triggering escalation to the next protocol line.
The definitive step involves a surgical or endovascular approach directed at the ruptured aneurysm, performed as early as feasible. The choice between approaches and the precise timing depend on factors not summarised here — the full structured decision pathway is available via the link below.
Complete obliteration of the ruptured aneurysm, to reduce the risk of rebleeding.
DOI: 10.1161/str.0000000000000436
For patients with aSAH, surgical or endovascular treatment of the ruptured aneurysm should be performed as early as feasible after presentation, preferably within 24 hours of onset, to improve outcome.
For patients with aSAH, complete obliteration of the ruptured aneurysm is indicated whenever feasible to reduce the risk of rebleeding and retreatment.
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