European Stroke Organisation (ESO), European Association of Neurosurgical Societies (EANS) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on aneurysmal subarachnoid haemorrhage.

Mervyn D I Vergouwen, Anna Ramos-Pachon, Elena-Oana Terecoasa, Nicola Willett, Elisa Cuadrado-Godia, Thomas Gaberel, Elke Ruth Gizewski, Raimund Helbok, Leonard Ho, Michael Hugelshofer, Miikka Korja, Torstein R Meling, Marios-Nikos Psychogios, Gabriel J E Rinkel, Christian A Taschner, Peter Vajkoczy, Nima Etminan

Journal: European stroke journal 2026;11(5):

PMID: 42095754

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Abstract

Aneurysmal subarachnoid haemorrhage (aSAH) results from the rupture of an intracranial aneurysm. The case-fatality after aSAH is approximately 40% and those who survive often have functional, cognitive or emotional sequelae. We prepared guidelines according to Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology, using data from meta-analyses, randomised trials, prospective observational and case-control studies, prospective registries with external validation and single-arm cohort studies with > 50 patients with aSAH. Based on high levels of evidence, we recommend oral administration of nimodipine and regular coiling over clipping if both aneurysm treatment options are equally suitable in patients who are in good clinical condition, and recommend against the routine use of antifibrinolytic drugs prior to aneurysm treatment and against the use of tirilazad, statins, magnesium sulphate or endothelin receptor antagonists. Because of lower levels of evidence, no evidence-based recommendations can be made for the prophylactic use of antiplatelet drugs or external lumbar drainage, hypertension induction, treatment of the ruptured aneurysm with endovascular devices other than coils or endovascular treatment of vasospasm. We formulated 37 expert-consensus statements, which include, among others, the suggestions to treat aSAH patients in a dedicated neuro-ICU or high care unit in a centre that treats at least 70 patients with aSAH per year or at least 35 patients with aSAH per year in geographically remote areas, and to treat the ruptured aneurysm within 24 h after ictus provided that the most dedicated team of experts is available. These guidelines present up-to-date recommendations and expert-consensus statements on key aspects in the management of aSAH patients.

Address: Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.; Department of Neurology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.; Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania.; Carol Davila University of Medicine and Pharmacy, Bucharest, Romania.; Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.; Department of Neurology, Hospital del Mar, Universitat Pompeu Fabra, Barcelona, Spain.; Department of Neurosurgery, University Hospital of Caen, Caen, France.; PhIND - Physiopathology and Imaging of Neurological Disorders, Inserm U1237, Institut Blood and Brain at Caen-Normandie, Cyceron, UNICAEN, Normandie University, Caen, France.; Department of Radiology, Medical University Innsbruck, Innsbruck, Austria.; Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria.; Clinical Research Institute for Neurosciences, Kepler University Hospital and Johannes Kepler University Linz, Linz, Austria.; European Stroke Organisation, Basel, Switzerland.; Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland.; Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.; Department of Neurosurgery, The National Hospital, Rigshospitalet, Copenhagen, Denmark.; Diagnostic and Interventional Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland.; Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.; Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany.; Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.; Department of Neurosurgery, Charite Universitätsmedizin Berlin, Berlin, Germany.

DOI: 10.1093/esj/aakag043

MeSH Terms: Humans, Subarachnoid Hemorrhage, Societies, Medical, Europe, Aneurysm, Ruptured, Intracranial Aneurysm, Endovascular Procedures, Neurosurgical Procedures