Treatment of patients with aneurysmal subarachnoid haemorrhage not only involves securing the aneurysm by endovascular coiling or surgical clipping but also prevention and treatment of the medical and neurological complications of the bleed. These acutely ill patients should be looked after in specialised centres by a multidisciplinary team that is available 24 h a day, 7 days a week. No medical intervention is known to improve outcome by reducing the risk of rebleeding but oral nimodipine should be standard care to prevent delayed cerebral ischaemia. For patients who develop delayed ischaemia, there is no evidence that hypervolaemia, haemodilution, hypertension, balloon angioplasty or intra-arterial vasodilating agents improve outcome. Lumbar puncture is a safe and reasonably effective way of treating those forms of acute hydrocephalus that are not caused by intraventricular obstruction.
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Competing interests: We are neurologists involved in the management of patients with aneurysmal and non-aneurysmal subarachnoid haemorrhage, and we are coordinating a trial on magnesium sulphate in patients with subarachnoid haemorrhage. We are paid by the University Medical Centre Utrecht, The Netherlands. We have had research grants from The Netherlands Heart foundation, the Hersenstichting Nederland and The Netherlands Organisation of Scientific Research–Netherlands Organisation for Health Care.