Cardiac and central vascular functional alterations in the acute phase of aneurysmal subarachnoid hemorrhage

The Relationship Between Intraoperative Surrogates of Vascular Stiffness, Cerebral Aneurysms, and Surgical Outcomes

OBJECTIVE

Increased arterial stiffness has been linked to aneurysm formation in the systemic and cerebral circulations, though the role played by arterial stiffness in the cerebral vasculature continues to be refined. This study assesses whether intraoperative surrogates of arterial stiffness differ between patients with cerebral aneurysms and controls, and the extend that these indices relate to outcomes following open surgical treatment.

METHODS

We evaluated patients in a prospectively maintained database who underwent cerebral aneurysm surgery, and compare them to controls without cerebral aneurysms. Arterial stiffness was estimated using the intraoperative ambulatory arterial stiffness index (AASI) and average pulse pressure (PP).

RESULTS

We analyzed 214 cerebral aneurysm patients and 234 controls. Patients in the aneurysm group were predominantly female and had a higher incidence of hypertension, diabetes mellitus, and vascular disease. They also demonstrate elevated AASI and average PP. When stratified by the occurrence of subarachnoid hemorrhage (SAH) or unfavorable neurological outcome, the AASI and average PP were not highly associated with the occurrence of SAH but were highly associated with unfavorable neurological outcomes. After multivariable analysis, both the AASI and average PP were no longer associated with unfavorable neurological outcomes, however elevated age, strongly linked with arterial stiffness, become a key predictive variable.

CONCLUSION

Readily obtained intraoperative surrogates of arterial stiffening demonstrates its presence in those with cerebral aneurysm disease and the extent that it does it may meaningfully direct their clinical course. However, multivariable analysis demonstrates limitations of using arterial stiffness measures to predict clinical outcomes.

The Role of Serum Monocytes and Tissue Macrophages in Driving Left Ventricular Systolic Dysfunction and Cardiac Inflammation Following Subarachnoid Hemorrhage

BACKGROUND

Neurocardiogenic injury is common after aneurysmal subarachnoid hemorrhage (aSAH) despite low prevalence of preexisting cardiac disease. Potential mechanisms include autonomic dysregulation due to excess catecholamines as well as systemic inflammation. Understanding how inflammation contributes to cardiac dysfunction may aid in identifying novel therapeutic strategies. Here, we investigated serum leukocytes as predictors of left ventricular systolic dysfunction in patients with aSAH. We also investigated increased cardiac macrophages in an animal model of SAH and whether immunomodulatory treatment could attenuate this inflammatory response.

METHODS

We retrospectively analyzed 256 patients with aSAH admitted to University of Illinois Hospital between 2013 and 2019. Our inclusion criteria included patients with aSAH receiving an echocardiogram within 72 h of admission. Our primary outcome was echocardiographic evidence of systolic dysfunction. We performed multinomial regression and receiver operating curve analysis. We also used the endovascular perforation model of SAH in male Sprague-Dawley rats to assess for myocardial inflammation. Two days after surgery, hearts were collected and stained for the macrophage marker Iba-1. We compared the presence and morphology of macrophages in cardiac tissue isolated from SAH animals and sham controls treated with and without the immunomodulatory agent fingolimod.

RESULTS

Of 256 patients with aSAH, 233 (91.0%) underwent echocardiography within 72 h of admission. Of 233, 81 (34.7%) had systolic dysfunction. Patients had baseline differences in the presence of hypertension, alcohol use, and admission Glasgow Coma Scale and Hunt-Hess score. On multivariable analysis, total leukocytes (odds ratio 1.312, p < 0.001), neutrophils (odds ratio 1.242, p = 0.012), and monocytes (odds ratio 6.112, p = 0.008) were independent predictors of reduced systolic function, whereas only monocytes (odds ratio 28.014, p = 0.030) predicted hyperdynamic function. Within the rodent heart, there were increased macrophages after SAH relative to controls, and this was attenuated by fingolimod treatment (p < 0.0001).

CONCLUSIONS

Increased serum leukocytes are associated with abnormal left ventricular systolic function following aSAH. The strongest independent predictor of both reduced and hyperdynamic systolic function was increased monocytes. Increased cardiac macrophages after experimental SAH can also be targeted by using immunomodulatory drugs.

Cardiac dysfunction in patients affected by subarachnoid haemorrhage affects in-hospital mortality: A systematic review and metanalysis

BACKGROUND

Subarachnoid haemorrhage (SAH) is a life-threatening condition with associated brain damage. Moreover, SAH is associated with a massive release of catecholamines, which may promote cardiac injury and dysfunction, possibly leading to haemodynamic instability, which in turn may influence a patient's outcome.

OBJECTIVES

To study the prevalence of cardiac dysfunction (as assessed by echocardiography) in patients with SAH and its effect on clinical outcomes.

DESIGN

Systematic review of observational studies.

DATA SOURCES

We performed a systematic search over the last 20 years on MEDLINE and EMBASE databases.

ELIGIBILITY CRITERIA

Studies reporting echocardiography findings in adult patients with SAH admitted to intensive care. Primary outcomes were in-hospital mortality and poor neurological outcome according to the presence or absence of cardiac dysfunction.

RESULTS

We included a total of 23 studies (4 retrospective) enrolling 3511 patients. The cumulative frequency of cardiac dysfunction was 21% (725 patients), reported as regional wall motion abnormality in the vast majority of studies (63%). Due to the heterogeneity of clinical outcome data reporting, a quantitative analysis was carried out only for in-hospital mortality. Cardiac dysfunction was associated with a higher in-hospital mortality [odds ratio 2.69 (1.64 to 4.41); P < 0.001; I2 = 63%]. The GRADE of evidence assessment resulted in very low certainty of evidence.

CONCLUSION

About one in five patients with SAH develops cardiac dysfunction, which seems to be associated with higher in-hospital mortality. The consistency of cardiac and neurological data reporting is lacking, reducing the comparability of the studies in this field.

Prehospital misdiagnosis of acute cerebral disease for acute coronary syndrome: a retrospective study

OBJECTIVE

In cerebrovascular accidents symptoms, laboratory results and electrocardiogram (ECG) changes can mimic acute coronary syndrome (ACS) and is subsumed as neurogenic stunned myocardium. So far, data regarding the frequency of cerebrovascular accidents misdiagnosed for ACS in a prehospital setting are missing. This study aims to quantify misdiagnoses and discover discriminating features.

METHODS

In a retrospective cohort study, prehospital and hospital medical records of all patients treated by physician-staffed emergency medical teams in the city of Bonn (Germany) with suspected ACS in 2018 were evaluated regarding medical history, prehospital symptoms and findings as well as hospital diagnoses.

RESULTS

From 758 patients admitted for presumed ACS, 9 patients (1.2%, 95% CI: 0.5-2.2%) suffered from acute cerebral disease (ACD group). Mainly, diagnoses were cerebrovascular accidents and one case of neuroborreliosis. A history of intracranial haemorrhage was found more often in the ACD group compared to the remaining cohort (OR 19, p = 0.01), while a history of arterial hypertension was less frequent (OR 0.22, p = 0.03). Presentation with headaches (OR 10.1, p = 0.03) or neurological symptoms (OR 16.9, p = 0.01) occurred more frequent in the ACD group. ECG changes were similar between groups.

CONCLUSION

Acute cerebral disease misdiagnosed for ACS seems more common than assumed. Out of 758 patients with presumed ACS, 9 patients (1.2%) suffered from ACD, which were cerebrovascular accidents mainly. This is highly relevant, since prehospital treatment with heparin and acetylsalicylic acid is indicated in ACS but contraindicated in cerebrovascular accidents without further diagnostics. Thus, discriminating these patients is crucial. An attentive patient history and examination may be the key to differentiating ACD. Due to small ACD group size, further studies are needed.

An Unusual Etiology: Subarachnoid Hemorrhage Resulting in Transient Apical Ballooning Syndrome

Intracranial bleeds, such as subarachnoid hemorrhage, carry high morbidity and mortality rates. Often intracranial hemorrhages result in debilitating residual neurological symptoms but can be so extensive that cardiac complications can also be seen. We present a rare case of a patient who was found to have a subarachnoid hemorrhage that incited the development of Takotsubo cardiomyopathy, which subsequently progressed to an acute myocardial infarction. The aim of this case report is to explore the underlying pathophysiology of how cerebral hemorrhage can result in apical ballooning of the left ventricle through various mechanisms including sympathetic-induced surge in catecholamines and neurogenic damage to the myocardium. We also intend to highlight the importance for clinicians to consider brain bleeds in the differential diagnosis when a patient presents with an acute myocardial infarction as treatment with heparin is generally contraindicated.

Hemorrhagic Cerebral Insults and Secondary Takotsubo Syndrome: Findings in a Novel In Vitro Model Using Human Blood Samples

Intracranial hemorrhage results in devastating forms of cerebral damage. Frequently, these results also present with cardiac dysfunction ranging from ECG changes to Takotsubo syndrome (TTS). This suggests that intracranial bleeding due to subarachnoid hemorrhage (SAH) disrupts the neuro-cardiac axis leading to neurogenic stress cardiomyopathy (NSC) of different degrees. Following this notion, SAH and secondary TTS could be directly linked, thus contributing to poor outcomes. We set out to test if blood circulation is the driver of the brain-heart axis by investigating serum samples of TTS patients. We present a novel in vitro model combining SAH and secondary TTS to mimic the effects of blood or serum, respectively, on blood-brain barrier (BBB) integrity using in vitro monolayers of an established murine model. We consistently demonstrated decreased monolayer integrity and confirmed reduced Claudin-5 and Occludin levels by RT-qPCR and Western blot and morphological reorganization of actin filaments in endothelial cells. Both tight junction proteins show a time-dependent reduction. Our findings highlight a faster and more prominent disintegration of BBB in the presence of TTS and support the importance of the bloodstream as a causal link between intracerebral bleeding and cardiac dysfunction. This may represent potential targets for future therapeutic inventions in SAH and TTS.

The value of early CT perfusion parameters for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Delayed cerebral ischemia (DCI) is a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). We aim to investigate the efficacy of early CT perfusion (CTP) parameters for predicting DCI in patients with aSAH. The search was conducted in five databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and China Biology Medicine database). Studies were reviewed by two independent authors, and the included studies were assessed for methodological quality. Fifteen studies with 882 participants were included for the final analysis. The meta-analysis of quantitative parameters showed that mean transit time represented the most valuable predictor when the calculation of the mean value was uniformed (MD 0.30 s, 95% CI: 0.10 to 0.49 s, P = 0.003). Semi-quantitative parameters using relative values or index scores were also widely used to minimize undue variations derived from patients, operators, machines, and software. Studies also demonstrated that these relative parameters had better predictive accuracy than corresponding absolute parameters. Perfusion thresholds in each study were incomparable, and the results warranted further validation. The best threshold for the prediction was 0.9 using the relative cerebral blood flow parameter (sensitivity 97% and specificity 89%). We conclude that CTP in the early phase is a promising tool for predicting DCI in aSAH patients. However, the parameters require standardization. Future studies with prospective, multi-centered design and large sample size are needed to validate the thresholds and optimize the parameters.

Levosimendan in the modern treatment of patients with acute heart failure of various aetiologies

Acute decompensated heart failure (ADHF) is a common clinical problem associated with a high mortality rate. Because ADHF has various aetiologies, there are a range of therapeutic options, among others, positive inotropes (inotropic drugs). As an inotropic agent whose mechanism is different than that of "classical" medicines, levosimendan (LSM) is one of the most common therapeutic options. Despite many publications on LSM, some issues related to its application remain unclear. The authors of this paper have attempted to summarise expert recommendations and reports available in the literature.

Real-Time Non-invasive Assessment of Cerebral Hemodynamics With Diffuse Optical Spectroscopies in a Neuro Intensive Care Unit: An Observational Case Study

Prevention of secondary damage is an important goal in the treatment of severe neurological conditions, such as major head trauma or stroke. However, there is currently a lack of non-invasive methods for monitoring cerebral physiology. Diffuse optical methods have been proposed as an inexpensive, non-invasive bedside monitor capable of providing neurophysiology information in neurocritical patients. However, the reliability of the technique to provide accurate longitudinal measurement during the clinical evolution of a patient remains largely unaddressed. Here, we report on the translation of a hybrid diffuse optical system combining frequency domain diffuse optical spectroscopy (FD-DOS) and diffuse correlation spectroscopy (DCS) for real-time monitoring of cerebral physiology in a neuro intensive care unit (neuro-ICU). More specifically, we present a case study of a patient admitted with a high-grade aneurysmal subarachnoid hemorrhage, who was monitored throughout hospitalization. We show that the neurophysiological parameters measured by diffuse optics at the bedside are consistent with the clinical evolution of the patient at all the different stages following its brain lesion. These data provide support for clinical translation of DOS/DCS as a useful biomarker of neurophysiology in the neuro-ICU, particularly in locations where other clinical resources are limited.

Takotsubo Cardiomyopathy Secondary to Ruptured Supraclinoid Internal Carotid Artery Aneurysm

A 41-year-old lady who presented with sudden-onset severe headache diagnosed to have ruptured supraclinoid internal carotid artery (ICA) aneurysm. Her cardiac echocardiography showed features of Takotsubo cardiomyopathy. After stabilizing her cardiac condition, she underwent craniotomy and clipping of aneurysm. Both cardiac and neurological catastrophes were managed by the joint team with excellent outcome. This paper emphasizes the need for high-quality combined care.

Speckle tracking analysis allows sensitive detection of stress cardiomyopathy in severe aneurysmal subarachnoid hemorrhage patients

PURPOSE

Stress cardiomyopathy is a common life-threatening complication after aneurysmal subarachnoid hemorrhage (SAH). We hypothesized that left ventricular (LV) longitudinal strain alterations assessed with speckle tracking could identify early systolic function impairment.

METHODS

This was an observational single-center prospective pilot controlled study conducted in a neuro-intensive care unit. Forty-six patients with severe SAH with a World Federation of Neurological Surgeons grade (WFNS) ≥ III were included. Transthoracic echocardiography (TTE) was performed on day 1, day 3, and day 7 after the patient's admission. A cardiologist blinded to the patient's management analyzed the LV global longitudinal strain (GLS). The control group comprised normal subjects matched according to gender and age.

RESULTS

On day 1 median (25th-75th percentile) GLS was clearly impaired in SAH patients compared to controls [-16.7 (-18.7/-13.7) % versus -20 (-22/-19) %, p < 0.0001], whereas LVEF was preserved [65 (59-70) %]. GLS was severely impaired in patients with a WFNS score of V versus III-IV [-15.6 (-16.9/-12.3) % versus -17.8 (-20.6/-15.8) %, p = 0.008]. Seventeen (37 %) patients had a severe GLS alteration (>- 16 %). In these patients, GLS improved from day 1 [-12.4 (-14.8/-10.9) %] to last evaluation [-16.2 (-19/-14.6) %, p = 0.0007] in agreement with the natural evolution of stress cardiomyopathy.

CONCLUSIONS

On the basis of LV GLS assessment, we demonstrated for the first time that myocardial alteration compatible with a stress cardiomyopathy is detectable in up to 37 % of patients with severe SAH while LVEF is preserved. GLS could be used for sensitive detection of stress cardiomyopathy. This is critical because cardiac impairment remains a major cause of morbidity and mortality after SAH.

Ultrasound in cardiac trauma

In the perioperative period, the emergency department or the intensive care unit accurate assessment of variable chest pain requires meticulous knowledge, diagnostic skills, and suitable usage of various diagnostic modalities. In addition, in polytrauma patients, cardiac injury including aortic dissection, pulmonary embolism, acute myocardial infarction, and pericardial effusion should be immediately revealed and treated. In these patients, arrhythmias, mainly tachycardia, cardiac murmurs, or hypotension must alert physicians to suspect cardiovascular trauma, which would potentially be life threatening. Ultrasound of the heart using transthoracic and transesophageal echocardiography are valuable diagnostic tools that can be used interchangeably in conjunction with other modalities such as the electrocardiogram and computed tomography for the diagnosis of cardiovascular abnormalities in trauma patients. Although ultrasound of the heart is often underused in the setting of trauma, it does have the advantages of being easily accessible, noninvasive, and rapid bedside assessment tool. This review article aims to analyze the potential cardiac injuries in trauma patients, and to provide an elaborate description of the role of echocardiography for their accurate diagnosis.

Radiographic and Clinical Predictors of Cardiac Dysfunction Following Isolated Traumatic Brain Injury

Introduction:

Although cardiac dysfunction after traumatic brain injury (TBI) has been described, there is little data regarding the association of radiographic severity and particular lesions of TBI with the development of cardiac dysfunction. We hypothesize that the Rotterdam or Marshall scores and particular TBI lesions are associated with the development of cardiac dysfunction after isolated TBI.

Methods:

We performed a retrospective cohort study. Adult patients with isolated TBI who underwent echocardiography between 2003 and 2010 were included. A board-certified neuroradiologist assessed the first computed tomography head, assigning the Rotterdam and Marshall scores and the type of TBI. Cardiac dysfunction was defined as either systolic or all cause based on the first echocardiogram after TBI. Demographic, radiological, and clinical variables were used in our analysis.

Results:

A total of 139 patients were identified, with 20 having isolated systolic dysfunction. The Marshall and Rotterdam scores were not associated with the development of cardiac dysfunction. Only head Abbreviated Injury Scale was found to be an independent predictor of systolic cardiac dysfunction (relative risk: 2.70, 95% confidence interval: 1.19-6.13; P = .02).

Conclusions:

No specific radiographic variable was found to be an independent predictor of cardiac dysfunction. Further study into clinical or radiological features that would warrant an echocardiogram is warranted, as it may direct patient management.

Advanced monitoring of systemic hemodynamics in critically ill patients with acute brain injury

Hemodynamic monitoring is widely used in critical care; however, the impact of such intervention in patients with acute brain injury (ABI) remains unclear. Using PubMed, a systematic review was performed (1966-August 2013), and 118 studies were included. Data were extracted using the PICO approach. The evidence was classified, and recommendations were developed according to the GRADE system. Electrocardiography and invasive monitoring of arterial blood pressure should be the minimal hemodynamic monitoring required in unstable or at-risk patients in the intensive care unit. Advanced hemodynamic monitoring (i.e., assessment of preload, afterload, cardiac output, and global systemic perfusion) could help establish goals that take into account cerebral blood flow and oxygenation, which vary depending on diagnosis and disease stage. Choice of techniques for assessing preload, afterload, cardiac output, and global systemic perfusion should be guided by specific evidence and local expertise. Hemodynamic monitoring is important and has specific indications among ABI patients. Further data are necessary to understand its potential for therapeutic interventions and prognostication.

A case of subarachnoid hemorrhage revealed by an acute coronary syndrome (ACS)

The subarachnoid hemorrhage (SAH) is definitely the best descriptive model of the interaction between cardiovascular system and cerebral damage. The underlying mechanism of cardiovascular alterations after SAH is linked to the adrenergic discharge related to aneurysm rupture. Cardiac and pulmonary complications are common after severe brain injury, especially the aneurismal subarachnoid hemorrhage. Acute neurogenic pulmonary edema is not exceptional; it may occur in 20% of cases and commonly follows a severe subarachnoid hemorrhage. Severe myocardial damage with cardiogenic shock may possibly reveal the SAH (3% of cases) and mislead to wrong diagnosis of ACS with dramatic therapeutic consequences. The contribution of CT and cerebral angiography is essential for diagnosis and treatment. Surgical or endovascular treatment depends on location, size and shape of the aneurysm, on patient's age, neurological status and existence of concomitant diseases. We report the case of a 58 years old patient, with a past medical history of diabetes and hypertension, admitted for acute pulmonary edema with cardiogenic shock. This case illustrates an unusual presentation of aneurismal SAH in a patient presenting with an acute coronary syndrome.

Takotsubo cardiomyopathy secondary to intracranial hemorrhage

Patients suffering from aneurysmal subarachnoid hemorrhage often present with electrocardiogram (ECG) abnormalities that mimic cardiac ischemia, but documented left ventricular regional wall-motion dysfunction has rarely been reported. This report is intended to raise the awareness of possible ECG changes secondary to subarachnoid hemorrhage (SAH). We cared for a 55-year-old female with an acute aneurysmal subarachnoid hemorrhage, whose evaluation was delayed and complicated by the presence of Takotsubo cardiomyopathy (TCM). Aneurysmal subarachnoid hemorrhage may induce Takotsubo cardiomyopathy that can present as an acute ST-elevation myocardial infarction. Physicians need to be aware of this possibility since it can lead to significant delays and treatment options for the patient.

The role of nuclear cardiac imaging in redefining neurogenic stunned myocardium in subarachnoid hemorrhage: a deeper look into the heart

Subarachnoid hemorrhage may be complicated by neurogenic stunned myocardium, a catecholamine-induced transient cardiomyopathy that displays a wide clinical spectrum of cardiac abnormalities, including electrocardiographic changes, arrhythmias, myocardial necrosis, and left ventricular systolic and diastolic dysfunction. However, less is known about the cardiac metabolic consequences of acute subarachnoid hemorrhage. Prunet and coworkers' recent study provides scintigraphic evidence suggesting that glucose metabolism and sympathetic cardiac innervation are severely and globally depressed during the acute phase of the disease. Metabolic and innervation abnormalities are largely overlapped and are probably not causally related to myocardial ischemia, suggesting that impaired glucose metabolism is probably neurogenic in nature. The scintigraphic defects seem to reverse slowly, within months of the onset of cerebral bleeding. Interestingly, scintigraphic evidence of metabolic myocardial alterations may exist even in the absence of clinical features of cardiac disease, possibly representing a subclinical type of neurogenic stunned myocardium.

The harmful effects of subarachnoid hemorrhage on extracerebral organs

Subarachnoid hemorrhage (SAH) is a devastating neurological disorder. Patients with aneurysmal SAH develop secondary complications that are important causes of morbidity and mortality. Aside from secondary neurological injuries, SAH has been associated with nonneurologic medical complications, such as neurocardiogenic injury, neurogenic pulmonary edema, hyperglycemia, and electrolyte imbalance, of which cardiac and pulmonary complications are most common. The related mechanisms include activation of the sympathetic nervous system, release of catecholamines and other hormones, and inflammatory responses. Extracerebral complications are directly related to the severity of SAH-induced brain injury and indicate the clinical outcome in patients. This review provides an overview of the extracerebral complications after SAH. We also aim to describe the manifestations, underlying mechanisms, and the effects of those extracerebral complications on outcome following SAH.

Impairment of cardiac metabolism and sympathetic innervation after aneurysmal subarachnoid hemorrhage: a nuclear medicine imaging study

Introduction

Although aneurysmal subarachnoid hemorrhage (SAH) is often complicated by myocardial injury, whether this neurogenic cardiomyopathy is associated with the modification of cardiac metabolism is unknown. This study sought to explore, by positron emission tomography/computed tomography, the presence of altered cardiac glucose metabolism after SAH.

Methods

During a 16-month period, 30 SAH acute phase patients underwent myocardial ¹⁸ F- fluorodesoxyglucose positron emission tomography (¹⁸F-FDGPET), ^99mTc-tetrofosmin and ¹²³I-meta-iodobenzylguanidine (¹²³I-mIBG) scintigraphy, respectively, assessing glucose metabolism, cardiac perfusion, and sympathetic innervation. Patients with initial abnormalities were followed monthly for two months for ¹⁸F-FDG, and six months later for ¹²³I-mIBG.

Results

In this SAH population, acute cardiac metabolic disturbance was observed in 83% of patients (n = 25), and sympathetic innervation disturbance affected 90% (n = 27). Myocardial perfusion was normal for all patients. The topography and extent of metabolic defects and innervation abnormalities largely overlapped. Follow-up showed rapid improvement of glucose metabolism in one or two months. Normalization of sympathetic innervation was slower; only 27% of patients (n = 8) exhibited normal ¹²³I-mIBG scintigraphy after six months. Presence of initial altered cardiac metabolism was not associated with more unfavorable cardiac or neurological outcomes.

Conclusions

These findings support the hypothesis of neurogenic myocardial stunning after SAH. In hemodynamically stable acute phase SAH patients, cardiomyopathy is characterized by diffuse and heterogeneous ¹⁸F-FDG and ¹²³I-mIBG uptake defect.

Trial registration

Clinicaltrials.gov NCT01218191. Registered 6 October 2010.

Dobutamine-induced high cardiac index did not prevent vasospasm in subarachnoid hemorrhage patients: a randomized controlled pilot study

BACKGROUND

Prevention of vasospasm is a challenging issue in subarachnoid hemorrhage (SAH) patients and the objective is to compare high dobutamine-induced cardiac index (CI) and high norepinephrine-induced hypertension for the prevention of vasospasm in SAH patients.

METHODS

Single center, single blind, controlled randomized study. Patients hospitalized in intensive care unit (ICU) for a moderate to severe SAH (WFNS grade ≥2) were randomized to receive dobutamine to reach a 25 % increase in cardiac index or norepinephrine to reach a mean arterial pressure ≥100 mmHg. Norepinephrine could be used in the dobutamine group to maintain a cerebral pressure perfusion ≥60 mmHg. Primary endpoint was the incidence of angiographic vasospasm in the first 14 days in the ICU setting, which was upheld by a cerebral arteriography. Secondary endpoints were the incidence of delayed ischemic deficits, duration of mechanical ventilation, and ICU length of stay (LOS).

RESULTS

During the 3-year study, 41 patients were randomized. Six patients were excluded--3 because of consent withdrawal and 3 who did not receive the assigned treatment. Respectively, 17 and 18 patients in the dobutamine and the norepinephrine group were kept in analysis. Five (28 %) patients in the dobutamine group and 5 (27 %) patients in the norepinephrine group developed vasospasm in ICU (p = 1). Seven (41 %) patients presented a delayed ischemic deficit in the dobutamine group and 9 (50 %) in the norepinephrine group (p = 0.24). Duration of mechanical ventilation was 8 [0.5-11.5] days in the dobutamine group and 19 [2.7-23] days in the norepinephrine group (p = 0.01). ICU LOS was 11 [6-15] days in the dobutamine group and 21 [9-28] days in the norepinephrine group (p = 0.01).

CONCLUSION

As compared to norepinephrine-induced hypertension, dobutamine-induced high CI did not reduce the rate of vasospasm in SAH patients. Dobutamine may reduce durations of mechanical ventilation and ICU LOS.