Acute care of aneurysmal subarachnoid hemorrhage: practical consensus statement from a multidisciplinary group of German-speaking neurointensivists and neuroradiologists on behalf of the DIVI neurology section

Background: Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition requiring multidisciplinary management, particularly in the intensive care setting. Despite existing guidelines, gaps in evidence and variability in practice remain, necessitating practical, consensus-driven recommendations for acute care and management. Objective To develop comprehensive, practical consensus statement for the acute management of aSAH, addressing high- and low-evidence areas, through a modified Delphi consensus approach among German-speaking neurointensivists and neuroradiologists. Methods: Senior experts from neurology, neurosurgery, neurocritical care, and interventional neuroradiology were selected for their academic and clinical expertise. The consensus process included iterative rounds of Delphi surveys, a face-to-face meeting, and online discussions. Consensus statements were formulated based on literature review, expert input, and iterative validation, with a consensus threshold of ≥ 70% agreement. Results: The group reached consensus on key aspects of aSAH management, including diagnostic protocols, invasive monitoring, blood pressure and temperature control, prophylactic and therapeutic measures for vasospasm and delayed cerebral ischemia, nutrition, and mobilization. Specific guidance was provided for early surgical/endovascular intervention, invasive hemodynamic monitoring, enteral nutrition initiation, and fever prevention. The consensus emphasized evidence-informed strategies where available and expert-derived recommendations in areas lacking robust data, such as therapeutic hypothermia and multimodal monitoring. Conclusion: This practical consensus statement provides a standardized approach to aSAH management, balancing guideline-based evidence with expert consensus to address clinical uncertainties. Due to the used methods and composition of the group, the results should be considered as a multi-institutional protocol of an experienced neurointensivist group, but certainly not as evidence based-guidelines. Adoption of this consensus may improve outcomes and harmonize care in the intensive management of aSAH.