High-yield executive summary of: Critical Care Management of Patients Following Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference {source}

1. Rebleeding: 
- TXA/aminocaproic acid- short course only, initiate on diagnosis and stop after clipping/coiling, do not start if its been more than 72 hrs or continue past that. The risk of rebleeding is highest in first 72 hrs (5-10%), so the risk-benefit does not add up after that. Watch carefully for DVTs and other clots.
- SBP < 160, MAP <110. Use nimodipine or nicardipine.
- CTA is possibly better than angiogram in the acute setting.
2. Seizures: 
- Don't use dilantin
- Seizure prophylaxis may or may not be necessary; if given, should be given in a short course (3-7 days) and not a long course.
- If they seize once, treat with keppra for 3-6 months; no need for longer unless there are multiple seizure events
- Long term EEG for patients with SAH who fail to improve or who deteriorate for an unknown reason.
3. Cardiopulmonary:
- For an unknown reason, SAH may directly lead to myocardial stunning or injury, with elevated enzymes (~1/3 of patients) wall motion abnormalities (~1/4), arrhythmias (~1/3).
- Baseline enzymes, EKG, echo for all SAH patients
- Goal euvolemia (unless there is vasospasm, then all bets are off)
- BP/MAP goals per neurological needs, not cardiac
- Monitoring: do not get a central line for the sole purpose of monitoring CVP (i.e. get it if you need a central line for other reasons).
- Do not float a swan, the harms outweigh the benefits.
4. Fluid benefits
- Prophylactic triple-H therapy - no difference in rates of clinical or radiographic vasospasm but increased risk of complications demonstrated in two separate randomized clinical trials.
5. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage : a randomized controlled trial. {Lennihan et al, Stroke. 2000}
BACKGROUND AND PURPOSE:
Cerebral blood flow (CBF) is reduced after subarachnoid hemorrhage (SAH), and symptomatic vasospasm is a major cause of morbidity and mortality. Volume expansion has been reported to increase CBF after SAH, but CBF values in hypervolemic (HV) and normovolemic (NV) subjects have never been directly compared.
METHODS:
On the day after aneurysm clipping, we randomly assigned 82 patients to receive HV or NV fluid management until SAH day 14. In addition to 80 mL/h of isotonic crystalloid, 250 mL of 5% albumin solution was given every 2 hours to maintain normal (NV group, n=41) or elevated (HV group, n=41) cardiac filling pressures. CBF ((133)xenon clearance) was measured before randomization and approximately every 3 days thereafter (mean, 4.5 studies per patient).
RESULTS:
HV patients received significantly more fluid and had higher pulmonary artery diastolic and central venous pressures than NV patients, but there was no effect on net fluid balance or on blood volume measured on the third postoperative day. There was no difference in mean global CBF during the treatment period between HV and NV patients (P=0.55, random-effects model). Symptomatic vasospasm occurred in 20% of patients in each group and was associated with reduced minimum regional CBF values (P=0.04). However, there was also no difference in minimum regional CBF between the 2 treatment groups.
CONCLUSIONS:
HV therapy resulted in increased cardiac filling pressures and fluid intake but did not increase CBF or blood volume compared with NV therapy. Although careful fluid management to avoid hypovolemia may reduce the risk of delayed cerebral ischemia after SAH, prophylactic HV therapy is unlikely to confer an additional benefit.
--Commentary: "there was no effect on net fluid balance or on blood volume measured on the third postoperative day" is an important sentence; the difference mean fluid intake between the two groups was relatively small, on the order of <1L per day, sometimes <0.5L per day.
6. Glucose: 
- Neither too high (inc risk of infection, possible increase in risk of vasospasm) nor too low (cerebral starvation, may increase risk of vasospasm).
- 80-200
7. NICE-SUGAR trial {NEJM} N=6000 ICU patients, randomized to either tight (80-110) or liberal (<180) glucose control. Those with tight sugar control had increased severe hypoglycemia (~6% vs <1%) and increased 90-day all-cause mortality.
8. Fevers:
- Common (40-70%) in SAH
- May cause increased metabolic demand of the brain, worsening infarcts.
- Treat with tyleonol/NSAIDs first line, and cooling blankets and devices secondary
- Prevent shivering (as that also increases metabolic demand)
- Look for + treat infectious source
9. DVT prophylaxis: 
- SCDs for everyone
- No chemoprophylaxis (ie. heparin/lovenox) for unruptured aneurysms that will undergo surgery
- Can be restarted 24h after surgery
- No heparin/lovenox 24 hrs before and after any intracranial procedures.
- Length of time to stay on chemoprophylaxis depends on the patient
10. Statins & SAH: 
Effects of statins-use for patients with aneurysmal subarachnoid hemorrhage: a meta-analysis of randomized controlled trials
Shao-Hua Su et al {Nature}
"...A total of 249 patients from six randomized controlled trials(RCTs) were subjected to meta-analysis. No significant decrease was found in the incidence of vasospasm(RR, 0.80; 95% CI, 0.54–1.17), with substantial heterogeneity (I2 = 49%, P = 0.08), which was verified by the further sensitivity analysis and subgroup meta-analysis. Furthermore, no significant difference was presented in the incidence of poor neurological outcome(RR, 0.94; 95% CI, 0.77–1.16), and potential side effects(RR, 2.49; 95% CI, 0.75–8.33). Nevertheless, significant difference was reported in the occurrence of DIND(RR, 0.58; 95% CI, 0.37–0.92) and mortality(RR, 0.30; 95% CI, 0.14–0.64). At present, although statins-use in the patients with aSAH should not be considered standard care at present, statins-use may have the potential effects in the prevention of mortality in patients with aSAH."