Clinical Disease

critical-care

Must-have

Aneurysmal SAH Vasospasm & Delayed Cerebral Ischemia

Recognition, prophylaxis, and ICU management of cerebral vasospasm and DCI days 3-14 after aneurysmal subarachnoid hemorrhage

Cerebral vasospasm is delayed arterial narrowing of the circle of Willis 3-14 days after aneurysmal SAH, producing BP-dependent neurologic deficits and progressing to delayed cerebral ischemia (DCI) if untreated; prophylaxis centers on oral nimodipine, euvolemia, and avoidance of hypotension and hyponatremia.

If you forget

Headline: Nimodipine 60 mg PO/NG q4h x 21 days is the only proven DCI prophylaxis — start early and tolerate mild hypotension.

Board trap

A patient on day 6 post-SAH with new aphasia — resident wants to start Triple-H immediately. Classic trap: confirm the aneurysm is secured first (clip vs coil, residual on DSA). Inducing hypertension/hypervolemia on an unsecured aneurysm re-bleeds the patient. Always check securing status before any hemodynamic escalation.

Key numbers

Nimodipine 60 mg PO/NG q4h x 21 days (360 mg/day total)
Nicardipine IV 0.075-0.15 mg/kg/hr when PO nimodipine not tolerated
Vasospasm window: days 3-14 post-SAH; peak DCI day 4-10
Modified Triple-H hemodilution target Hct 30-35%
TCD sensitivity 90%, NPV 92% for DCI prediction
Antiseizure medication duration ≤7 days for onset seizures

Reviewed Sep 24, 2026 for clinical accuracy by BoardsBridge Editorial Process

Uri Rozen, MD — Licensed Physician, Israel

Source guidelines: SNACC Neuroanesthetic Emergencies 2020 · AHA SAH 2023

Re-review cadence: 12 months from reviewed date.

Drill this as a SOE stem →

Related on BoardsBridge

Card ID: sah-vasospasm · Path: aba.critical-care.neurocritical-care.sah-vasospasm