In this review, recent advances pertaining to the intensive care management of subarachnoid hemorrhage are discussed. The calcium channel blocker nimodipine has become a cornerstone of therapy for the prevention of ischemic deficits resulting from vasopasm. Recent trials suggest that nicardipine confers siimilar clinical benefits, but with more side effects. Transcranial Doppler sonography is widely used to diagnose and monitor cerebral vasopasm, but is of limited value for predicting which patients will develop ischemic deficits. Imaging modalities that reflect the adequacy of tissue perfusion or autoregulation, such as magnetic resonance spectroscopy and single photon emisson computed tomography, may eventually provide a more accurate means of identifying patients at risk for delayed ischemia. Hypertensive-hypervolemic hemodilution is widely employed to reverse cerebral ischemia from vasopasm but further studies are needed to elucidate the relative effects of hypertension, cardiac output augmentation, and hemodilution on cerebral blood flow. Neurogenic cardiac injury has become an increasingly recognized complication of acute, severe subarachnoid hemorrhage. Although significant hemodynamic instability can result, good outcomes can be achieved with aggressive intensive care unit management.
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