Authors: Emma Cloud, Eric Shaw, Mallory Stringer
Contact:
[email protected]Practice Site: Memorial Health University Medical Center
Background:
Aneurysmal subarachnoid hemorrhage (aSAH) is a subtype of hemorrhagic stroke where the bleed occurs between the brain tissue and the arachnoid mater surrounding the brain. The characteristic symptom is a severe headache which patients often describe as “the worst headache of my life.” These headaches often continue to affect patients beyond the acute period and have a multifactorial etiology requiring a multimodal pain management approach. Guidelines do not have specific recommendations for headache management. Opioids, while a mainstay of treatment, have sedating effects that may confound the frequent neurological monitoring necessary for these patients. Nonsteroidal anti-inflammatory drugs carry an increased risk of bleeding and neuropathic pain medications such as gabapentin and pregabalin warrant further investigation. Butalbital has been shown to decrease pain scores secondary to aSAH and is often utilized as the combination agent acetaminophen/butalbital/caffeine (A/B/C) at our institution. Prior literature has found inconclusive results regarding the safety of A/B/C and its association with cerebral vasospasm. This study aimed to identify a potential relationship between use of A/B/C and occurrence of cerebral vasospasm in this patient population.
Methods:
This was a retrospective chart review conducted at a 711-bed academic medical center between July 2018 and September 2025. Adults admitted to the neurovascular intensive care unit with a diagnosis of non-traumatic aSAH, confirmed by diagnostic angiography, who underwent surgical fixation via clipping or coiling and received A/B/C were included. The following were exclusion criteria: pregnant, incarcerated, Hunt and Hess Score of 4 or 5, and intubated >48 hours. Patients were divided into those who had a vasospasm versus those that did not. Baseline data was analyzed using Chi-Square and Fisher’s Exact tests for categorical data and T-Test for continuous data. Primary and secondary outcomes were analyzed using Mann-Whitney U tests.
Results:
Thirty-seven patients were included in the analysis. The patient population was predominantly female (70.3%), black (48.6%), underwent coiling for surgical fixation (97%), and had an average Hunt and Hess score of 2. Baseline demographics were not significantly different between the two groups with the exception of the vasospasm group being younger (55.9 ± 10.7 vs 42.81 ± 8.6, p<0.001). There was no significant difference in A/B/C usage between patients who had a vasospasm versus those who did not have a vasospasm (2.2 ± 1.7 vs 2.3 ± 1.5; p=0.751). When looking only patients who had a vasospasm, there was no significant difference in A/B/C usage on days they had a vasospasm versus days they did not (2.4 ± 1.8 vs 2.2 ± 1.9; p = 0.955).
Conclusions:
Based off our study population, A/B/C was not associated with occurrence of cerebral vasospasm. This study was limited by variable frequency of pain score measurements across patients, small sample size, and reliance on infrequent transcranial dopplers that could lead to underreporting of vasospasm.
