Characteristics of Blood Pressure Profiles After Endovascular Coiling as Predictors of Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage

Factors affecting 30-day mortality in poor-grade aneurysmal subarachnoid hemorrhage: a 10-year single-center experience

Background

The management of patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is burdened by an unfavorable prognosis even with aggressive treatment. The aim of the present study is to investigate the risk factors affecting 30-day mortality in poor-grade aSAH patients.

Methods

We performed a retrospective analysis of a prospectively collected database of poor-grade aSAH patients (World Federation of Neurosurgical Societies, WFNS, grades IV and V) treated at our institution from December 2010 to December 2020. For all variables, percentages of frequency distributions were analyzed. Contingency tables (Chi-squared test) were used to assess the association between categorical variables and outcomes in the univariable analysis. Multivariable analysis was performed by using the multiple logistic regression method to estimate the odds ratio (OR) for 30-day mortality.

Results

A total of 149 patients were included of which 32% had WFNS grade 4 and 68% had WFNS grade 5. The overall 1-month mortality rate was 21%. On univariable analysis, five variables were found to be associated with the likelihood of death, including intraventricular hemorrhage (IVH ≥ 50 mL, p = 0.005), the total amount of intraventricular and intraparenchymal hemorrhage (IVH + ICH ≥ 90 mL, p = 0.019), the IVH Ratio (IVH Ratio ≥ 40%, p = 0.003), posterior circulation aneurysms (p = 0.019), presence of spot sign on initial CT scan angiography (p = 0.015).Nonetheless, when the multivariable analysis was performed, only IVH Ratio (p = 0.005; OR 3.97), posterior circulation aneurysms (p = 0.008; OR 4.05) and spot sign (p = 0.022; OR 6.87) turned out to be independent predictors of 30-day mortality.

Conclusion

The risk of mortality in poor-grade aSAH remains considerable despite maximal treatment. Notwithstanding the limitations of a retrospective study, our report highlights some neuroradiological features that in the emergency setting, combined with leading clinical and anamnestic parameters, may support the multidisciplinary team in the difficult decision-making process and communication with family members from the earliest stages of poor-grade aSAH. Further prospective studies are warranted.

Blood pressure variability and prognosis in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

INTRODUCTION

The subarachnoid hemorrhage due to a ruptured brain aneurysm is a neurological emergency with high mobility and mortality. Hypertensive states are related to a bad prognosis and a higher risk of a ruptured aneurysm. However, the relationship between the blood pressure variability with the aneurysmal subarachnoid hemorrhage and its prognosis is quite unknown.

EVIDENCE ACQUISITION

A systematic review was performed across the databases. The following descriptors and related were used for the search: blood pressure, arterial pressure, variability, subarachnoid hemorrhage, hemorrhage, aneurysmal, aneurysmal subarachnoid hemorrhage. The following data were extracted: Glasgow Outcome Scale or Modified Rankin Scale, and blood pressure variabilities to categorize the prognosis.

EVIDENCE SYNTHESIS

Five studies were selected. The blood pressure variability and the related outcome were assessed by mean systolic blood pressure and minimum systolic blood. The meta-analysis of mean systolic blood pressure (cut-off >95.3 mmHg) showed an odds ratio of 11.23 (95% CI: 4.423 to 28.537) (P≤0.001), predicting the good outcome after the aneurysmal subarachnoid hemorrhage. The pooled analysis revealed AUC of the ROC predicting the good outcome was statistically significant (AUC: 0.85, P<0.001). The pooled data analysis of minimum systolic blood pressure revealed an odds ratio of 6.43 (95% CI: 2.834-14.589, P<0.001) and AUC of the pooled ROC 0.931 (95% CI: 0.851 to 1.000, P<0.001) to predict poor outcome. The funnel plot through Egger's test for the analysis showed different grades of asymmetry.

CONCLUSIONS

The blood pressure variability (mean and minimum systolic blood pressure) is a good predictor and parameter in the aneurysmal subarachnoid hemorrhage prognosis and outcome prediction.

Comparison of neostigmine and sugammadex for hemodynamic parameters in neurointerventional anesthesia

Introduction

Hemodynamic stability is important during neurointerventional procedures. However, ICP or blood pressure may increase due to endotracheal extubation. The aim of this study was to compare the hemodynamic effects of sugammadex and neostigmine with atropine in neurointerventional procedures during emergence from anesthesia.

Methods

Patients undergoing neurointerventional procedures were allocated to the sugammadex group (Group S) and the neostigmine group (Group N). Group S was administered IV 2 mg/kg sugammadex when a train-of-four (TOF) count of 2 was present, and Group N was administered neostigmine 50 mcg/kg with atropine 0.2 mg/kg at a TOF count of 2. We recorded heart rate, systolic blood pressure, diastolic blood pressure, mean blood pressure (MAP), and peripheral arterial oxygen saturation during administration of the reverse agent and at 2, 5, 10, 15, 30, 120 min, and 24 h thereafter. The primary outcome was blood pressure and heart rate change after the reversal agent was given. The secondary outcomes were systolic blood pressure variability standard deviation (a measure of the amount of variation or dispersion of a set of values), systolic blood pressure variability-successive variation (square root of the average squared difference between successive blood pressure measurements), nicardipine use, time-to-TOF ratio ≥0.9 after the administration of reversal agent, and time from the administration of the reversal agent to tracheal extubation.

Results

A total of 31 patients were randomized to sugammadex, and 30 patients were randomized to neostigmine. Except for anesthesia time, there were no significant differences in any of the clinical characteristics between the two groups. The results demonstrated that the increase in MAP from period A to B was significantly greater in Group N than in Group S (regression coefficient = -10, 95% confidence interval = -17.3 to -2.7, P = 0.007). The MAP level was significantly increased from period A to B in the neostigmine group (95.1 vs. 102.4 mm Hg, P = 0.015), but it was not altered in Group S. In contrast, the change in HR from periods A to B was not significantly different between groups.

Conclusion

We suggest that sugammadex is a better option than neostigmine in interventional neuroradiological procedures due to the shorter extubation time and more stable hemodynamic change during emergence.

Blood Pressure Variability After Cerebrovascular Events—A Possible New Therapeutic Target: A Narrative Review

Blood pressure variability, the variation of blood pressure during a certain period, results from the interaction of hemodynamic, neuronal, humoral, behavioral, and environmental factors. Cerebral autoregulation is impaired in acute cerebrovascular disease. In these patients, increased blood pressure variability may provoke or exacerbate secondary brain injury. In fact, available data showed that increased Blood pressure variability is associated with worse outcomes after acute ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Consequently, blood pressure variability may represent a usual modifiable therapeutic target. This concept this particularly attractive because reduction of blood pressure variability can be feasible in regions with lower resources and can be applicable to patients with various forms of acute stroke. Prospective studies are needed to further clarify the relationship between blood pressure variability and secondary brain damage, and the determinants of blood pressure variability in different clinical populations. Ultimately, cerebrovascular disease-specific randomized controlled trials aimed at reducing blood pressure variability, irrespective of the absolute blood pressure values, are needed to determine if reduction of blood pressure variability can improve outcomes in patients with acute cerebrovascular disease.

Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism

BACKGROUND AND PURPOSE

Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients.

MATERIALS AND METHODS

We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients.

RESULTS

Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension.

CONCLUSIONS

Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.

Nimodipine-Induced Blood Pressure Changes Can Predict Delayed Cerebral Ischemia

Background: Early diagnosis of delayed cerebral ischemia (DCI) in patients after aneurysmal subarachnoid hemorrhage (aSAH) still poses a leading problem in neurointensive care. The aim of this study was to analyze the effect of oral Nimodipine administration on systemic blood pressure in patients with evolving DCI compared to patients without DCI.

Methods: Systolic (SBP), mean (MAP), and diastolic (DBP) blood pressures were analyzed at the time of Nimodipine administration and additionally 30, 60, and 120 min thereafter on days 1, 3, and 5 after aSAH. Additionally, the 24 h period preceding DCI and in patients without DCI day 10 after aSAH were analyzed. Statistical analysis was performed for SBP, MAP and DBP at time of Nimodipine administration and for the maximal drop in blood pressure after Nimodipine administration.

Results: Thirty patients with aSAH were retrospectively analyzed with 17 patients developing DCI (“DCI”) and 13 patients who did not (“Non-DCI”). DCI patients showed a more pronounced rise in MAP and DBP over the examined time period as well as a higher decrease in SBP following Nimodipine administration. A fall of 18 mmHg in SBP after Nimodipine administration showed a sensitivity of 82.4% and specificity of 92.3% for occurrence of DCI.

Conclusion: An increase of MAP and DBP after aSAH and a heightened sensitivity to Nimodipine administrations may serve as additional biomarkers for early detection of evolving DCI.

Heart rate variability after endovascular coiling is associated with short-term outcomes in patients with subarachnoid hemorrhage

OBJECTIVE

to evaluate whether postoperative heart rate variability (HRV) predicts short-term outcomes in patients undergoing coil embolization of ruptured aneurysms.

METHODS

Consecutive patients receiving endovascular coiling to treat aneurysmal subarachnoid hemorrhage (SAH) were retrospectively reviewed between November 2011 and December 2014 in the authors' institution. Heart rate (HR) and blood pressure (BP) recorded in the initial 24 h after endovascular treatment were extracted along with other clinical data. HR variability (HRV) and BP variability (BPV) were determined as standard deviation (SD) and successive variation (SV) of every 2-h HR and BP. The correlation between HRV and clinical outcomes as assessed by Glasgow Outcome Scale (GOS) scores at discharge were analyzed statistically.

RESULTS

Compared to the 310 patients with favorable outcomes (GOS 4-5), the 35 with unfavorable outcomes (GOS 1-3) had significantly higher HR, HRV, and BPV in the first postoperative day. Furthermore, HRV-SD remained to be an independent predictor of unfavorable recovery in multivariate logistic analysis (OR = 1.14; 95% CI, 1.02-1.29; P = 0.026) after adjusting for age, postoperative fever, and Glasgow Coma Scale scores on admission, which have been identified as predictors of poor prognosis. The area under the receiver operating characteristic curves for HRV-SD and BPV-SV were found to be 0.745 (95% CI, 0.658-0.833) and 0.633 (95% CI, 0.524-0.741), respectively (P < 0.05).

CONCLUSIONS

Higher HRV in the first day after coil embolization was associated with unfavorable outcomes in patients with SAH. Early detection and appropriate treatment of the overactive sympathetic activity might promote functional recovery after SAH. Abbreviation: BP: Blood pressure; CI: Confidence interval; DBP: Diastolic blood pressure; GCS: Glasgow coma scale; GOS: Glasgow outcome scale; HR: Heart rate; HRV: Heart rate variability; OR: Odds ratio; ROC: Receiver operating characteristics; SD: Standard deviation; SAH: Subarachnoid hemorrhage; SV: Successive variation; SBP: Systolic blood pressure.