Medically induced hypertension, hypervolaemia and haemodilution for the treatment and prophylaxis of vasospasm following aneurysmal subarachnoid haemorrhage: systematic review

Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes.

METHODS

A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed.

RESULTS

Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation.

CONCLUSIONS

A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

Prognostic factors affecting the ruptured intracranial aneurysms: A 9-year multicenter study in Fujian, China

BACKGROUND

A multicenter retrospective study was conducted to explore the factors affecting short-term prognosis and long-term outcomes of intracranial aneurysms (IA) rupture. Further, the prognosis prediction model was constructed based on survival analysis, contributing to the development of prevention strategies for aneurysmal subarachnoid hemorrhage.

METHODS

Data of 1280 patients with IA rupture were gathered between 2014 and 2022 in Fujian, China. Logistic regression was implemented to study the short-term prognostic factors of IA rupture. Survival analysis of 911 patients among them was performed to explore the long-term outcome status by Cox risk assessment. Nomogram prognosis models were constructed using R software.

RESULTS

The findings displayed that blood type O (OR = 1.79; P = 0.019), high systolic pressure (OR = 1.01; P < 0.001), Glasgow Coma score (GCS) 9-12 (OR = 2.73; P = 0.022), GCS < 9 (OR = 3.222; P = 0.006), diabetes (OR = 2.044; P = 0.040), and high white blood cell count (OR = 1.059, P = 0.040) were core influencing factors for poor short-term prognosis. Survival analysis revealed that age > 60 years (HR = 2.87; P = 0.001), hypertension (HR = 1.95; P = 0.001), conservative (HR = 6.89; P < 0.001) and endovascular treatment (HR = 2.20; P = 0.001), multiple ruptured IAs (HR = 2.37; P = 0.01), Fisher 3 (HR = 1.68; P = 0.09), Fisher 4 (HR = 2.75; P = 0.001), and Hunt-Hess 3 (HR = 0.55; P = 0.05) were the major risk factors for terrible long-term outcomes.

CONCLUSIONS

People over 60 years with characteristics of type O blood, high systolic pressure, diabetes, high white blood cell count, and onset GCS < 12 will have more complications and a worse short-term prognosis. Those aged > 60 years with hypertension, conservative and endovascular treatment, multiple ruptured IAs, Fisher ≥ 3 and Hunt-Hess 3 have a greater risk of poor long-term prognosis.

Management of hypertensive crisis: British and Irish Hypertension Society Position document

Patients with hypertensive emergencies, malignant hypertension and acute severe hypertension are managed heterogeneously in clinical practice. Initiating anti-hypertensive therapy and setting BP goal in acute settings requires important considerations which differ slightly across various diagnoses and clinical contexts. This position paper by British and Irish Hypertension Society, aims to provide clinicians a framework for diagnosing, evaluating, and managing patients with hypertensive crisis, based on the critical appraisal of available evidence and expert opinion.

Cerebral Perfusion Pressure-Guided Therapy in Patients with Subarachnoid Haemorrhage-A Retrospective Analysis

BACKGROUND

Prevention and treatment of haemodynamic instability and increased intracranial pressure (ICP) in patients with subarachnoid haemorrhage (SAH) is vital. This study aimed to evaluate the effects of protocolised cerebral perfusion pressure (CPP)-guided treatment on morbidity and functional outcome in patients admitted to the intensive care unit (ICU) with SAH.

METHODS

We performed a retrospective study comparing 37 patients who received standard haemodynamic treatment (control group) with 17 individuals (CPP-guided group) who were on the CPP-guided treatment aimed at maintaining CPP > 70 mmHg using both optimisations of ICP and mean arterial pressure (MAP).

RESULTS

MAP, cumulative crystalloid doses and fluid balance were similar in both groups. However, the incidence of delayed cerebral ischaemia was significantly lower in the CPP-guided group (14% vs. 64%, p < 0.01), and functional outcome as assessed by the Glasgow Outcome Scale at 30 days after SAH was improved (29.0% vs. 5.5%, p = 0.03).

CONCLUSIONS

This preliminary analysis showed that implementing a CPP-guided treatment approach aimed at maintaining a CPP > 70 mmHg may reduce the occurrence of delayed cerebral ischaemia and improve functional outcomes in patients with SAH. This observation merits further prospective investigation of the use of CPP-guided treatment in patients with SAH.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Prospective, multicentre study of screening, investigation and management of hyponatraemia after subarachnoid haemorrhage in the UK and Ireland

BACKGROUND

Hyponatraemia often occurs after subarachnoid haemorrhage (SAH). However, its clinical significance and optimal management are uncertain. We audited the screening, investigation and management of hyponatraemia after SAH.

METHODS

We prospectively identified consecutive patients with spontaneous SAH admitted to neurosurgical units in the United Kingdom or Ireland. We reviewed medical records daily from admission to discharge, 21 days or death and extracted all measurements of serum sodium to identify hyponatraemia (<135 mmol/L). Main outcomes were death/dependency at discharge or 21 days and admission duration >10 days. Associations of hyponatraemia with outcome were assessed using logistic regression with adjustment for predictors of outcome after SAH and admission duration. We assessed hyponatraemia-free survival using multivariable Cox regression.

RESULTS

175/407 (43%) patients admitted to 24 neurosurgical units developed hyponatraemia. 5976 serum sodium measurements were made. Serum osmolality, urine osmolality and urine sodium were measured in 30/166 (18%) hyponatraemic patients with complete data. The most frequently target daily fluid intake was >3 L and this did not differ during hyponatraemic or non-hyponatraemic episodes. 26% (n/N=42/164) patients with hyponatraemia received sodium supplementation. 133 (35%) patients were dead or dependent within the study period and 240 (68%) patients had hospital admission for over 10 days. In the multivariable analyses, hyponatraemia was associated with less dependency (adjusted OR (aOR)=0.35 (95% CI 0.17 to 0.69)) but longer admissions (aOR=3.2 (1.8 to 5.7)). World Federation of Neurosurgical Societies grade I-III, modified Fisher 2-4 and posterior circulation aneurysms were associated with greater hazards of hyponatraemia.

CONCLUSIONS

In this comprehensive multicentre prospective-adjusted analysis of patients with SAH, hyponatraemia was investigated inconsistently and, for most patients, was not associated with changes in management or clinical outcome. This work establishes a basis for the development of evidence-based SAH-specific guidance for targeted screening, investigation and management of high-risk patients to minimise the impact of hyponatraemia on admission duration and to improve consistency of patient care.

Modern Imaging of Aneurysmal Subarachnoid Hemorrhage

In this review, we discuss the imaging of aneurysmal subarachnoid hemorrhage (SAH). We discuss emergency brain imaging, aneurysm detection techniques, and the management of CTA-negative SAH. We also review the concepts of cerebral vasospasm and delayed cerebral ischemia that occurs after aneurysm rupture and their impact on patient outcomes. These pathologies are distinct, and the use of multimodal imaging modalities is essential for prompt diagnosis and management to minimize morbidity from these conditions. Lastly, new advances in artificial intelligence and advanced imaging modalities such as PET and MR imaging scans have been shown to improve the detection of aneurysms and potentially predict outcomes early in the course of SAH.

Investigation and management of serum sodium after subarachnoid haemorrhage (SaSH): a survey of practice in the United Kingdom and Republic of Ireland

BACKGROUND

Hyponatraemia is a common complication of aneurysmal subarachnoid haemorrhage (SAH). We aimed to determine current neurosurgical practice for the identification, investigation and management of hyponatraemia after SAH.

METHODS

An online questionnaire was completed by UK and Irish neurosurgical trainees and consultant collaborators in the Sodium after Subarachnoid Haemorrhage (SaSH) audit.

RESULTS

Between August 2019 and June 2020, 43 responses were received from 31 of 32 UK and Ireland adult neurosurgical units (NSUs). All units reported routine measurement of serum sodium either daily or every other day. Most NSUs reported routine investigation of hyponatraemia after SAH with paired serum and urinary osmolalities (94%), urinary sodium (84%), daily fluid balance (84%), but few measured glucose (19%), morning cortisol (13%), or performed a short Synacthen test (3%). Management of hyponatraemia was variable, with units reporting use of oral sodium supplementation (77%), fluid restriction (58%), hypertonic saline (55%), and fludrocortisone (19%).

CONCLUSIONS

Reported assessment of serum sodium after SAH was consistent between units, whereas management of hyponatraemia varied. This may reflect the lack of a specific evidence-base to inform practice.

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.

The impact of transcranial direct current stimulation on cerebral vasospasm in a rat model of subarachnoid hemorrhage

Transcranial direct current stimulation (tDCS) has been shown to induce changes in cortical excitability and perfusion in a rat ischemic stroke model. Since perfusion disturbances are a common phenomenon, not only in ischemic but also in hemorrhagic stroke, tDCS might have a possible beneficial effect on cerebral perfusion in hemorrhagic stroke as well. We applied tDCS in a rat model of subarachnoid hemorrhage (SAH) and evaluated its impact on vasospasm. SAH was induced using the double-hemorrhage rat model. TDCS was applied on day 3 and 4. For vasospasm assessment magnetic resonance angiography was performed on day 1, day 2 and day 5. A total of 147 rats were operated, whereat 72 rats died before day 5 and 75 rats survived the whole experiment and could be analyzed. The cathodal group consisted of 26 rats, the anodal group included 24 rats. Thirteen rats served as controls without tDCS, and twelve rats underwent a sham operation. The cathodal group revealed the lowest incidence of new vasospasm on day 5 (p = 0.01), and the lowest mean number of vasospastic vessels per rat (p = 0.02). TDCS influences the vasospasm incidence in an SAH-model in rats, where cathodal-tDCS was associated with a lower vasospasm incidence and severity.

Cerebral Autoregulation in Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.

Vasospasm: Role of Imaging in Detection and Monitoring Treatment

Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) are important complications of aneurysmal subarachnoid hemorrhage (ASAH). Imaging approaches to VS monitoring include noninvasive bedside assessment with transcranial Doppler ultrasonography, angiographic evaluation with digital subtraction angiography, and computed tomography (CT) angiography. DCI is a clinical diagnosis and is not fully explained by the presence of angiographic VS. CT perfusion has shown clinical utility and implications for future research in the evaluation of DCI in patients with ASAH. This review article discusses the common approaches to diagnosis and monitoring of VS and DCI, current treatment strategies, and future research directions.

Neurovascular physiology and neurocritical care

The neurological intensive care unit plays an integral role in the management of cerebrovascular disease in the acute and perioperative period. Understanding the use of intracranial pressure (ICP) monitoring and how to apply the appropriate intervention for ICP elevation to ensure adequate cerebral perfusion is the foundation of neurocritical care. Careful management of the interplay between cerebral and systemic physiology, particularly in disorders of cerebral autoregulation, is critical in preventing secondary brain injury. Finally, understanding the cerebral pathophysiology of the underlying injured brain in acute stroke, subarachnoid hemorrhage, and arterial stenosis can help to guide the optimal use of interventional endovascular procedures in these disease states.

Duration of Vasodilatory Action After Intra-arterial Infusions of Calcium Channel Blockers in Animal Model of Cerebral Vasospasm

BACKGROUND

In medically refractory vasospasm, invasive intervention may be required. A commonly used approach is intra-arterial (IA) drug infusion. Although calcium channel blockers (CCBs) have been widely applied in this setting, studies comparing their efficacies and durations of action have been few. This study was performed to compare attributes of three CCBs (nicardipine, nimodipine, and verapamil), focusing on duration of the vasodilatory action based on angiography.

METHODS

Vasospasm was produced in New Zealand white rabbits (N = 22) through experimentally induced subarachnoid hemorrhage and confirmed in each via conventional angiography, grouping them by IA-infused drug. After chemoangioplasty, angiography was performed hourly for 5 h to compare dilated and vasospastic arterial diameters. Drug efficacy, duration of action, and changes in mean arterial pressure (relative to baseline) were analyzed by group.

RESULTS

Effective vasodilation was evident in all three groups immediately after IA drug infusion. The vasodilative effects of nimodipine and nicardipine peaked at 1 h and were sustained at 2 h, returning to initial vasospastic states at 3 h. In verapamil recipients, effects were more transient by comparison, entirely dissipating at 1 h. Only the nicardipine group showed a significant 3-h period of lowered blood pressure.

CONCLUSIONS

Although nimodipine and nicardipine proved longer acting than verapamil in terms of vasodilation, their effects were not sustained beyond 2 h after IA infusion. Further study is required to confirm the vasodilatory duration of IA CCB based on perfusion status, and an effort should be made to find new alternative to extend the duration.

A Questionnaire Survey of Management of Patients with Aneurysmal Subarachnoid Haemorrhage in Poland

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) remains a potentially devastating threat to the brain with a serious impact on mortality and morbidity. We attempted to investigate correspondence between the current guidelines for aSAH management and real clinical practice in Poland.

METHODS

A web-based questionnaire was performed between 03.2019 and 06.2019. Centres performing neuro-interventional radiology procedures and neuro-critical care were included (n = 29). One response from each hospital was recorded.

RESULTS

In three (10.4%) centres, there was no clear protocol for an interventional treatment plan. Endovascular embolisation was predominantly used in 11 (37.9%) hospitals, and microsurgical clipping, in 10 (34.5%). A written protocol for standard anaesthetic management was established only in six (20.7%) centres for coiling and in five (17.2%) for microsurgical clipping. The diagnosis of cerebral vasospasm was based on transcranial Doppler as the first-choice method in seven (24.1%) units. "3-H therapy" was applied by 15 (51.8%) respondents, and "2-H therapy", by four (13.8%) respondents. In only eight (27.6%) centres were all patients with aSAH being admitted to the ICU.

CONCLUSION

Many discrepancies exist between the available guidelines and clinical practice in aSAH treatment in Poland. Peri-procedural management is poorly standardised. Means must be undertaken to improve patient-oriented treatment and care.

A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage.

OBJECTIVE

To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era.

METHODS

A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage.

RESULTS

Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy.

CONCLUSIONS

Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.

The Management of Hypertension in Pre-Aneurysmal Treatment Subarachnoid Hemorrhage Patients

BACKGROUND

Management of hypertension in subarachnoid hemorrhage patients within the preaneurysmal treatment period remains ambiguous, in part due to the lack of high-level, evidence-based guidelines. Despite this, current recommendations offer guidance regarding certain parameters (e.g., mean arterial pressure, systolic blood pressure). However, managing hypertension within this critical period is difficult because a fine balance must be achieved between lowering blood pressure enough to minimize the risk of rebleeding and preventing reduced cerebral perfusion and subsequent ischemic damage. Furthermore, the different causes of hypertension within the preaneurysmal treatment period are polyfactorial and include pathophysiologic responses, sympathetic nervous system activation, and iatrogenic from hyperdynamic therapy and vasopressors, which requires consideration for these patients to receive optimal management. Other factors including loss of autoregulation and concomitant conditions must also be considered when deciding whether to start antihypertensive therapy.

METHODS

We review the literature and provide a comprehensive update on management of hypertension within the preaneurysmal treatment period, which we hope stresses the need for better evidence-based guidelines that will in turn help manage this cohort.

RESULTS

Thorough review revealed no high-grade, evidence-based guidelines to manage these patients, which results in variation in clinical practice among different clinicians and institutions. Despite this, current recommendations seem reasonable until such guidelines are established.

CONCLUSIONS

It is clear that further, larger studies are warranted in order to clarify the effect of antihypertensive therapy on patient outcome and what the BP thresholds are, along with establishing the best treatment, for commencing antihypertensive therapy.