BLOCK-SAH - PPF-Block for Post-SAH Headache

Inclusion criteria

• Spontaneous, non-traumatic SAH
• Subarachnoid pattern of hemorrhage warranting diagnostic DSA due to involvement of at least one of the following regions: quadrigeminal plate, prepontine cistern, perimesencephalic cistern, Sylvian fissure, or surrounding Circle of Willis
• Modified Fisher grade 1-4 (on presentation imaging)
• Hunt and Hess 1-3 or World Federation of Neurosurgeons grade 1-4 (on screening, included only if also fulfilling Glasgow Coma Scale verbal subscore ≥4)
• Minimum Glasgow Coma Scale verbal subscore of 4 (on screening)
• Able to verbalize pain scale scores according to 11-point numeric pain scale In order to be enrolled and undergo randomization in this study, an individual must meet all of the additional criteria:
• Stabilization period criteria:
• A minimum of 4 hours from DSA with clipping or coiling procedure (whenever applicable)
• Successful treatment of culprit vascular lesion (i.e., ≥90% obliteration of aneurysm), when applicable
• Requiring a minimum of 15mg OME prn for headache analgesia during any 24-hour period during eligibility period

Exclusion criteria

• An individual who meets any of the following criteria will be excluded from participation in this study:
• Premorbid conditions:
• Pre-existing neurologic, psychiatric, or other condition that would confound neurologic assessment or would make difficult/impossible to accurately assess neurologic and/or functional outcome
• Pre-existing diffuse flow-limiting narrowing of arteries in the Circle of Willis, regardless of etiology (e.g., atherosclerosis, vasculitis, Moya-Moya syndrome)
• Prior use of opioid or barbiturate analgesics for at least two-thirds of the days in previous month, regardless of indication
• Diagnosis of substance use disorder in the previous year
• Infected or wounded skin, or a skin lesion at the site of puncture for PPF- injection
• Uncorrected coagulopathy
• Platelet count \< 50,000/μL, International Normalized Ratio (INR) \> 1.7
• Requiring use of systemic anticoagulation and antiplatelet therapy (except for aspirin monotherapy).
• SAH-specific:
• Head trauma as etiology of SAH
• Infection as cause for aneurysm or SAH (i.e., mycotic aneurysms)
• Inability to successfully treat culprit vascular lesion
• Diffuse vasospasm on pre-enrollment diagnostic CTA or DSA. Vasospasm is defined as moderate-to-severe arterial narrowing on DSA or CTA not attributable to atherosclerosis, catheter-induced spasm, or vessel hypoplasia, as determined by a neuroradiologist or neurointerventionalist
• Standard pain regimen conditions
• Elevation of hepatic enzymes prohibiting use of scheduled APAP (i.e., AST or ALT \> 3x upper limit level)
• Chronic liver condition with absolute contra-indication for APAP (even at lower maximum daily doses)
• Participation in a concurrent investigational/interventional study (observational studies allowed)
• Known to be pregnant, or with a positive pregnancy test
• Allergy or intolerance to the medications used in the PPF-block (i.e., ropivacaine, dexamethasone) or standard pain regimen (APAP)
• Vulnerable populations such as prisoners and inmates (abiding GCP per the study IRB)
• Unable to receive first PPF-injection within 96 hours of ictus hemorrhage