Authors: Argyro Zoumprouli et al.
Source: Current Opinion in Anesthesiology 38(5):541–546, October 2025.
This review summarizes recent advances in the intensive care management of aneurysmal subarachnoid hemorrhage (aSAH), emphasizing updates from the past 18 months. The authors outline current best practices for preventing rebleeding, mitigating delayed cerebral ischemia (DCI), managing hydrocephalus, refining transfusion thresholds, and optimizing temperature regulation in the critical care setting.
Recent Findings
Emerging data reinforce strict systolic blood pressure control below 160 mmHg prior to aneurysm securing to reduce the risk of rebleeding. Frailty indices and quantitative imaging platforms are showing promise as prognostic tools for individualized risk stratification. Prophylactic lumbar drainage has been associated with reduced DCI rates and improved neurological outcomes, while ongoing studies explore milrinone infusions and computed tomography perfusion-guided therapy for cerebral vasospasm. Transfusion strategies now favor maintaining hemoglobin above 9 g/dl, striking a balance between oxygen delivery and transfusion risk. For temperature management, maintaining normothermia (36.0–37.5°C) is supported as the safest approach, although therapeutic hypothermia remains unproven.
Summary
Contemporary aSAH care increasingly incorporates precision medicine, quantitative imaging, and artificial intelligence to guide individualized interventions. Multidisciplinary, protocol-driven approaches remain essential, while multicenter trials are needed to validate optimal targets for hemodynamic, hematologic, and temperature management, as well as to define the evolving role of novel DCI therapies.
What You Should Know
• Maintain systolic BP <160 mmHg prior to securing the aneurysm.
• Hemoglobin threshold of 9 g/dl appears optimal.
• Normothermia should be maintained; avoid therapeutic hypothermia outside of trials.
• Prophylactic lumbar drainage may reduce DCI.
• New tools like AI-based imaging and frailty scoring improve individualized risk assessment.
Thank you to Current Opinion in Anesthesiology for publishing this timely update on critical care management of aneurysmal subarachnoid hemorrhage.