Removal of subarachnoid hemorrhage as soon as possible.
Instillation of thrombolytic agents (e.g. urokinase).
Antiinflammatory agents (steroids or NSAIDs).
The ultimate goal in the treatment of cerebral vasospasm after subarachnoid hemorrhage is to avoid DIND by reducing ICP, optimizing the rate of cerebral oxygen demand, and improving cerebral blood flow. Given these goals, early aneurysm treatment and ventriculostomy placement for patients with elevated intracranial pressure is a necessity. Early aneurysm treatment allows the treatment team to be more aggressive with further vasospasm treatment over the course of care.
Triple H therapy controversial
Pulmonary edema, myocardial ischemia, rebleeding, rupture of new aneurysm, vasogenic edema/hemorrhagic infarction insetting of compromised BBB.
Selective intra-arterial verapamil, papaverine, or nitroprusside or Angioplasty.
Hemodynamic strategies and endovascular procedures may be considered for the treatment of cerebral vasospasm.
To date, the current therapeutic interventions remain ineffective being limited to the manipulation of systemic blood pressure, variation of blood volume and viscosity, and control of arterial carbon dioxide tension.In this scenario, the hormone erythropoietin (EPO), has been found to exert neuroprotective action during experimental SAH when its recombinant form (rHuEPO) is systemically administered. However, recent translation of experimental data into clinical trials has suggested an unclear role of recombinant human EPO in the setting of SAH 3).
The use of intravascular papaverine as an alternative treatment for reversible vasospasm is associated with various side effects including hemodynamic instability like bradycardia and hypotension. Some recent studies have pointed that washing aneurysmal arteries and subarachnoid space with papaverine may not have many complications and hemodynamic disorders besides preventing aneurysmal vasospasm 4)
Washing with papaverine significantly reduces cerebral blood flow and relieves vasospasm 5).
A substantial body of evidence supports the idea that CSF diversion could prevent VS, even if this issue is still much debated. External ventricular drainage (EVD) is the recommended procedure for posthemorrhagic hydrocephalus.
VS occurred in 8.75% of cases (7 patients) in the first groups, while in 22.95% (14 patients) in the second group. In addition, patients not treated with EVD display a prevalence of VS in lower Fisher grades compared to the other group.