Induced Hypertension for Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage—A German Nationwide Survey

BACKGROUND: Delayed cerebral ischemia (DCI) remains a major cause of morbidity after aneurysmal subarachnoid hemorrhage (aSAH). Induced hypertension (IH) is frequently used to improve cerebral perfusion in patients with DCI, with current practice primarily supported by observational evidence with inconsistent guideline recommendations. We conducted a nationwide survey to assess current institutional approaches to IH in the management of DCI after aSAH in Germany. METHODS: An 11-item web-based questionnaire was distributed via LimeSurvey® between May and October 2025 to neurological and neurosurgical departments in Germany involved in the treatment of aSAH. The survey assessed institutional approaches to IH, monitoring and imaging strategies, and DCI treatment. RESULTS: Overall, 60/132 departments (45%) responded. IH was used by 56/59 departments (95%), predominantly in patients with suspected DCI (52/59, 88%). MAP-guided therapy was the most commonly applied IH strategy (64%), although hemodynamic targets varied substantially between departments. Noradrenaline was the primary vasopressor used for IH (98%). Transcranial doppler (TCD) ultrasonography was the predominant monitoring modality for DCI detection (93%), whereas advanced neuromonitoring techniques were used less frequently. Computed tomography (CT) perfusion (88%) and CT angiography (79%) were the most commonly applied imaging modalities in suspected DCI. IH alone (47%) or combined with intraarterial spasmolysis (36%) represented the leading first-line therapeutic approaches. CONCLUSIONS: IH remains a central component of DCI management after aSAH in Germany. Considerable variability regarding hemodynamic targets, monitoring strategies, imaging protocols, and therapeutic strategies highlights the absence of standardized evidence-based treatment approaches.