Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2025 Apr;42(2):668-679.
doi: 10.1007/s12028-024-02111-1. Epub 2024 Sep 12.

The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review

James Then  1 , Samuel Tawfik  2 , Timothy Law  3 , Alastair Brown  3   4   5 , Vanessa Carnegie  6 , Andrew Udy  7 , Toby Jeffcote  7
Affiliations

The Impact of Sedative Choice in the Management of Aneurysmal Subarachnoid Hemorrhage: A Scoping Review

James Then et al. Neurocrit Care. 2025 Apr.

Abstract

Aneurysmal subarachnoid hemorrhage (aSAH) is characterized by high mortality and morbidity. This scoping review assesses the current evidence regarding the use of sedatives and analgesics in the acute intensive care unit management of aSAH. We conducted a systematic search of Ovid MEDLINE, Ovid Embase, Ovid EmCare, APA PsycInfo, CINAHL, and the Cochrane Database of Systematic Reviews from inception to June 2023. Studies were included if they enrolled intensive care unit patients aged 18 or older with a significant proportion (> 20%) who had aSAH and evaluated the impact of one or more commonly used analgosedatives on physiological parameters in the management of aSAH. The methodological quality of the studies was assessed using the Methodological Index for Nonrandomized Studies score. Of 2,583 articles, 11 met the inclusion criteria. The median sample size was 47 (interquartile range 10-127), and the median Methodological Index for Nonrandomized Studies score was 9.5 (interquartile range 8-11). The studies' publication years ranged from 1980 to 2023. Dexmedetomidine and ketamine showed potential benefits in reducing the incidence of cortical spreading depolarization and delayed cerebral ischemia. Propofol and opioids appeared safe but lacked robust evidence for efficacy. Benzodiazepines were associated with increased delayed cerebral ischemia-related cerebral infarctions and cortical spreading depolarization events. The evidence available to guide the use of analgosedative medications in aSAH is critically inadequate. Dexmedetomidine and ketamine warrant further exploration in large-scale prospective studies because of their potential benefits. Improved study designs with consistent definitions and a focus on patient-centered outcomes are necessary to inform clinical practice.

Keywords: Adrenergic alpha agonist; Barbituarates; Benzodiazepines; Clonidine; Conscious sedation; Deep sedation; Dexmedetomidine; Diazepam; Fentanyl; Ketamine; Medetomidine; Midazolam; Morphine; Opiate; Opioid; Phenobarbital; Ruptured intracranial aneurysm; Subarachnoid hemorrhage; Thiopental.

PubMed Disclaimer

Conflict of interest statement

Conflicts of interest: The authors have disclosed that there are no conflicts of interest. Ethical Approval/Informed Consent: This study adheres to ethical guidelines. As this is a scoping review, no institutional review board approval or informed consent was required. However, all included studies were reviewed for adherence to ethical standards.

Figures

Fig. 1
Fig. 1
Search strategy
Fig. 2
Fig. 2
Timeline and quality of publication
Fig. 3
Fig. 3
PRISMA flow diagram
Fig. 4
Fig. 4
Boxplot of sample size and MINORS score of different drug class
See this image and copyright information in PMC

References

    1. Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, et al. Diagnosis and management of subarachnoid haemorrhage. Nat Commun. 2024;15(1):1850. - PMC - PubMed
    1. Rowland MJ, Hadjipavlou G, Kelly M, Westbrook J, Pattinson KT. Delayed cerebral ischaemia after subarachnoid haemorrhage: looking beyond vasospasm. Br J Anaesth. 2012;109(3):315–29. - PubMed
    1. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke. 2007;38(8):2315–21. - PubMed
    1. Geraghty JR, Testai FD. Delayed cerebral ischemia after subarachnoid hemorrhage: beyond vasospasm and towards a multifactorial pathophysiology. Curr Atheroscler Rep. 2017;19(12):50. - PubMed
    1. Macdonald RL, Higashida RT, Keller E, Mayer SA, Molyneux A, Raabe A, et al. Clazosentan, an endothelin receptor antagonist, in patients with aneurysmal subarachnoid haemorrhage undergoing surgical clipping: a randomised, double-blind, placebo-controlled phase 3 trial (CONSCIOUS-2). Lancet Neurol. 2011;10(7):618–25. - PubMed

Publication types

MeSH terms

LinkOut - more resources