Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with an unacceptably high rate of morbidity and mortality. For those patients who survive the initial insult of the subarachnoid hemorrhage (SAH), further neurologic deterioration or death can still occur due to early rebleeding of the ruptured aneurysm and posthemorrhagic vasospasm. Medical and surgical management is aimed at reducing the incidence of early rebleeding and symptomatic vasospasm. Unfortunately, appropriate management remains challenging. Although animal models and anecdotal experience are helpful in beginning to define appropriate treatment regimens, clinical trials of new management strategies and interventions are essential. Such trials are critical because they offer an opportunity to unequivocally evaluate whether a management scheme based on theories or animal models truly impacts and improves patient outcome. Unfortunately, despite a number of Phase 3 clinical trials, proven efficacious treatments remain minimal.

In this chapter, we critically appraise the significant clinical trials that have been published in the management of SAH and specifically evaluate the inherent strengths and limitations of these trials (including their design, outcomes assessment, and interpretation). Through such a review, we can begin to appreciate why inconsistent conclusions are being drawn regarding the appropriate management of SAH patients and how clinical trials can be used to advance the provision of care for such patients.

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