Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is a common and often devastating occurrence; each year approximately 30 000 Americans have nontraumatic SAH.1 Despite considerable advances in diagnostic techniques, surgical, and anesthetic techniques and perioperative management, the outcome for patients with SAH remains poor, with overall mortality rates of 25% and significant morbidity among approximately 50% of survivors.2 The evolution of treatment protocols for patients with subarachnoid hemorrhage has been influenced considerably by large, multicenter prospective cohort analyses and, more recently, multicenter prospective, randomized trials. Nevertheless, several accepted treatment modalities have not been substantiated by rigorous clinical scientific assessment. In many cases specific treatments for SAH are not amenable to testing by randomized, prospective trials because of practical or ethical considerations. To address these issues, the Stroke Council of the American Heart Association formed a task force to develop practice guidelines for the management of aneurysmal subarachnoid hemorrhage. A consensus committee reviewed existing data in this field and prepared recommendations. The database for this review was the existing literature regarding SAH assembled by the committee; a formal literature review was not conducted. The reports reviewed were selected on the basis of study design, sample size, and relevance to the issue involved. Each report was graded according to existing criteria of scientific merit,3 and a grading scale derived from these data (Table 1). Recommendations