Despite recent advances, cerebral vasospasm and delayed cerebral ischemia (DCI) still represent a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). In general, aSAH affects 30,000 North Americans annually, representing 5 to 10% of all cases of stroke, primarily affecting individuals aged 40 to 60 years although it can occur at all ages. 1,2 Although aSAH is less common than ischemic forms of stroke, it commonly affects younger patients and therefore is often associated with an even greater impact in terms of productive life years lost and higher medical costs in both the acute and follow-up periods. 3,4 Although a significant portion of the morbidity and mortality associated with aSAH is related to the initial hemorrhagic ictus, cerebral vasospasm and its related cerebral injury, which typically occurs within 3 to 7 days of hemorrhage and can last through 21 days posthemorrhage, 5 is still the leading cause of poor outcomes and death in the acute posthemorrhage period, causing long-term disability or death in more than one in five of all patients who have suffered aSAH and initially survived. 6 Following aSAH, angiographically detectable vasospasm of the cerebral arteries occurs in 50 to 90% of patients. 7 Approximately two-thirds of aSAH patients will suffer from vasospasm that is at least moderate in severity. Although some of these cases will remain asymptomatic, of these, approximately half will become symptomatic and half of these will develop neuroimaging findings of cerebral infarction, correlating strongly with poor outcomes in these individuals. 8 Although recent advances in the acute management of patients following aSAH have reduced the incidence of these poor outcomes related to cerebral vasospasm, it still remains a leading cause of clinical deterioration and poor outcomes following aSAH. Most recent studies demonstrate an overall risk of death and
AbstractDespite recent advances, cerebral vasospasm and delayed cerebral ischemia (DCI) still represent a major cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Although a significant portion of the morbidity and mortality associated with aSAH is related to the initial hemorrhagic ictus, cerebral vasospasm and DCI are still the leading cause of poor outcomes and death in the acute posthemorrhage period, causing long-term disability or death in more than one in five of all patients who have suffered aSAH and initially survived. Management of patients following aSAH includes four major considerations: (1) prediction of patients at highest risk for development of DCI, (2) prophylactic measures to reduce its occurrence, (3) monitoring to detect early signs of cerebral ischemia, and (4) treatments to correct vasospasm and cerebral ischemia once it occurs. The authors review the pertinent literature related to each, including both the current management guidelines supported by the literature as well as novel management strategies that are currently being investigated.