Proposal of an Institutional Protocol for the Management of Aneurysmal Subarachnoid Hemorrhage in a Tertiary Neurocritical Care Center
Mariana Rodrigues Martino, MD1*; Michel Franco Figueiredo, MD1; Bárbara Cozaro Valentim, MD1; Lucas Thodoro Kruze, MD1; Pedro Vicente Mesquita de Souza, MD1; Maria Eugênia Babbini Valentino Rosa, MD1; Fernando de Melo Filho, MD1
1Neurosurgery resident, Department of Neurosurgery, Hospital PUC Campinas, São Paulo, Brazil.
2Assistant Professor of Neurosurgery, Hospital PUC Campinas, São Paulo, Brazil.
*Corresponding Author: Mariana Rodrigues Martino, Department of Neurosurgery, Hospital PUC Campinas, São Paulo, Brazil.
DOI: https://doi.org/10.58624/SVOANE.2026.07.010
Received: March 05, 2026
Published: March 25, 2026
Citation: Martino MR, Figueiredo MF, Valentim BC, Kruze LT, Souza PVM, Rosa MEBV, Filho FM. Proposal of an Institutional Protocol for the Management of Aneurysmal Subarachnoid Hemorrhage in a Tertiary Neurocritical Care Center. SVOA Neurology 2026, 7:2, 59-66. doi. 10.58624/SVOANE.2026.07.010
Abstract
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a severe neurological emergency characterized by high early mortality and substantial long-term disability. Beyond the initial hemorrhage, secondary mechanisms including delayed cerebral ischemia (DCI), vasospasm, hydrocephalus, and systemic complications significantly influence prognosis.
Objective: To propose a structured institutional protocol for the management of aSAH based on contemporary high-impact literature and international guideline recommendations.
Methods: A structured narrative review was conducted using PubMed and Scopus databases covering publications from 2020 to 2025. In addition, foundational references directly informing endovascular management principles were included regardless of publication year. Search terms included “aneurysmal subarachnoid hemorrhage,” “vasospasm,” “delayed cerebral ischemia,” “lumbar drainage,” “nimodipine,” and “neurocritical care protocol.” Inclusion criteria comprised international guidelines, randomized clinical trials, systematic reviews, and high-impact observational studies. Case reports, pediatric-only studies, and animal studies were excluded. Foundational guideline documents and landmark trials directly informing protocol construction were incorporated. Evidence was synthesized into a phase-based multidisciplinary institutional care pathway.
Results: Evidence synthesis supported inclusion of early imaging confirmation, structured severity grading, strict pre-occlusion blood pressure control, universal nimodipine therapy, selective seizure prophylaxis, systematic transcranial Doppler surveillance, individualized early lumbar drainage, criteria-based external ventricular drainage, metabolic optimization, and tiered escalation strategies including induced hypertension, endovascular intervention, and intravenous milrinone in refractory vasospasm.
Conclusion: Institutional standardization grounded in contemporary evidence may reduce variability in care delivery and promote consistent neurocritical management of patients with aSAH.
Keywords: Aneurysmal Subarachnoid Hemorrhage; Delayed Cerebral Ischemia; Vasospasm; Lumbar Drainage; Neurocritical Care; Protocol Proposal.
