Pre-Operative Management

Aneurysm rebleeding within the first 2 to 12 hours of the rupture is associated with high mortality and long term morbidity. Every effort will be made to treat the aneurysm as soon as possible with either surgical clipping or endovascular coiling.

In this early period, before the aneurysm can be clipped or coiled, hypertension is believed to present a significant risk for rebleeding. Unfortunately, blood pressure parameters during this period have not been standardized.


Severe acute hypertension may be an autoregulating response to cerebral ischemia caused by increased intracranial pressure resulting from the aSAH. If systolic pressure is excessive and antihypertensive medications are required, an arterial pressure line may be necessary to monitor mean arterial pressure (MAP). Antihypertensives medication must be titrated carefully to avoid cerebral ischemia caused by inadequate cerebral perfusion pressure (CPP).

Titratable medications including nicardipine, and in some instances labetalol or sodium nitroprusside may be used to balance CPP with systolic blood pressure <160 mm Hg. Clevidipine, a very short-acting calcium channel blocker may be also used to control acute hypertension (Connolly et al., 2012; McNett & Koren, 2016).

Oral nimodipine is a Class I; Level of Evidence A, American Heart Association/American Stroke Association recommendation for all patients with aSAH. "It should be noted that this agent has been shown to improve neurological outcomes but not cerebral vasospasm. The value of other calcium antagonists, whether administered orally or intravenously, remains uncertain (Connolly et al., 2012)."

Antifibrinolytic (Connolly et al., 2012)

Antifibrinolytic, therapy with tranexamic acid or aminocaproic acid is reasonable to reduce the short-term (<72 hours) risk of early aneurysm rebleeding if there are no thromboembolic contraindications and if the aneurysm ablation must be delayed. Patients should be screen for contraindications and DVT risk. Antifibrolytics should be discontinuation 2 hours prior to planned endovascular aneurysm ablation. (Neither aminocaproic acid nor tranexamic acid are FDA aapproved for prevention of aneurysm rebleeding.)