This patient should receive oral nimodipine. Nimodipine is an L-type calcium channel blocker that has reduced the incidence of vasospasm in clinical trials involving patients with subarachnoid hemorrhage; morbidity and mortality also were reduced, even among patients who did not have cerebral vasospasm. Nimodipine may improve outcomes by preventing vasospasm and by a neuroprotective mechanism, particularly because calcium influx into neurons is a common pathway of cell injury in ischemia. Administration of oral nimodipine for 21 days after the hemorrhage is indicated in all patients with aneurysmal subarachnoid hemorrhage. This patient had an aneurysmal subarachnoid hemorrhage that was appropriately treated. In the first 48 hours after subarachnoid hemorrhage, rebleeding and hydrocephalus can cause neurologic worsening that is associated with significant morbidity and mortality.

Because the patient has no evidence of cerebral artery vasospasm, such as deterioration in level of consciousness or new focal neurologic deficits, treatment with intravenous dopamine is inappropriate. Vasospasm with subsequent cerebral ischemia is a significant contributor to neurologic worsening and poor long-term outcomes in patients with aneurysmal hemorrhage. Patients with a thick clot in the base of the brain are at higher risk of vasospasm, which can be detected before symptom onset on a transcranial Doppler ultrasound. This patient, however, has no clinical, objective, or imaging signs of vasospasm that would warrant prophylactic treatment with a vasopressor.

Intravenous insulin should not be given to this patient. Her blood glucose levels are mildly elevated, but acute management of mild hyperglycemia has not shown benefit in patients with all stroke subtypes. Because of the risk of hypoglycemia, the American College of Physicians (ACP) and other organizations recommend not using intensive insulin therapy to normalize blood glucose levels in critically ill patients with or without diabetes mellitus. If insulin therapy is required, the ACP recommends target blood glucose levels of 140 mg/dL to 200 mg/dL (7.8-11.1 mmol/L).

The efficacy of statins for secondary stroke prevention or as a neuroprotective agent in subarachnoid hemorrhage has not been established. Statins are indicated for secondary stroke prevention in patients with ischemic stroke or transient ischemic attack of a presumed atherosclerotic subtype.