Fig. 1
Consensus flow chart. 1Excluding confounders such as sedation, hypo/hyperthermia, hypoxia, and hypercapnia are advisable. Contraindications to sedation hold can be only ICP instability, radiological signs of intracranial hypertension, and severe respiratory failure. 2Close to the lower limit (80 mmHg) for patients without a history of arterial hypertension and close to the upper (100 mmHg) for patients with a history of arterial hypertension. 360 mg every 4 h for 21 days after bleeding (oral or nasogastric tube); intravenous nimodipine (2 mg/h) in case of feeding intolerance. Do not utilize in hemodynamically unstable SAH patients or withheld in case of a significant drop in arterial blood pressure. 4ICP monitoring in all salvageable SAH patients in coma (GCS ≤ 8) with radiological signs of intracranial. Elevated ICP management (aneurysm/s secured) should take into account the underlying pathophysiological mechanism responsible of intracranial hypertension. CPP ≧ 70 mmHg. 5Regarding neurological examination, we consider as suggestive of DCI-related vasospasm the occurrence of a new focal or a global neurologic deficit or a decrease of 2 or more points on the GCS score that lasts for at least 1 h and cannot be explained by another cause. Regarding TCD/TCCD examination, we consider as suggestive of vasospasm an increase in mean FVMCA of more than 50 cm/s from basal over 24 h and/or a mean FVMCA of at least 120 cm/s (with a suggestive Lindegaard ratio). 6Up to 120 mmHg and targeted to the resolution of clinical symptoms and/or radiological findings taking into account the patient’s cardiovascular status to minimize the risks associated with MAP augmentation. 7Vasodilators and/or angioplasty. The treatment should be individualized after discussion with the interventional neuroradiologist. 8With advanced hemodynamic monitoring. 9If available, to utilize therapy personalization for DCI associated with cerebral vasospasm in poor-grade SAH patients where neurological assessment is not possible. Abbreviations: TCD transcranial doppler, TCCD transcranial color doppler, MAP mean arterial pressure, Mg magnesium, BCT body core temperature, Hb hemoglobin, ICP intracranial pressure, CPP cerebral perfusion pressure, DCI delayed cerebral ischemia, CTA computed tomography angiography, DSA digital subtraction angiography, IA intra-arterial, CT computed tomography, MMN multimodal neuromonitoring