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Ditz C, Matone MV, Schwachenwald B, Küchler J. Risks of nimodipine dose reduction during the high-risk period for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2024; 47:37. [PMID: 38191859 DOI: 10.1007/s10143-023-02273-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/12/2023] [Accepted: 12/31/2023] [Indexed: 01/10/2024]
Abstract
Nimodipine dose reduction is recommended in case of high vasopressor demand after aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to assess potential adverse effects of nimodipine reduction during the high-risk period for delayed cerebral ischemia (DCI) and cerebral vasospasm (CVS) between days 5 and 10 after hemorrhage. Demographic and clinical data as well as daily nimodipine dose of aSAH patients admitted between 2010 and 2019 were retrospectively analyzed. Univariable and multivariable regression analyses were performed to identify factors associated with DCI, angiographic CVS, DCI-related infarction, and unfavorable outcome. A total of 205 patients were included. Nimodipine dose reduction occurred in 108 (53%) patients ('nimodipine reduction group'), while 97 patients (47%) received the full dose ('no nimodipine reduction group'), Patients in the 'nimodipine reduction group' had significant worse WFNS and Fisher grades and developed significantly more often DCI and angiographic CVS. DCI-related infarction and unfavorable outcome were also significantly increased in the 'nimodipine reduction group.' 'Reduced nimodipine dose' was the only independent predictor for the occurrence of DCI and angiographic CVS in multivariable regression analysis. 'Poor WFNS grade' and 'reduced nimodipine dose' were identified as independent risk factors for DCI-related infarction while 'older age,' 'poor WFNS grade,' and 'reduced nimodipine dose' were associated with unfavorable outcome at 3 months after discharge. Nimodipine dose reduction during the high-risk period of DCI and CVS between days 5 and 10 after hemorrhage might abrogate the positive prognostic effects of nimodipine and should be critically evaluated.
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Affiliation(s)
- Claudia Ditz
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Maria V Matone
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Bram Schwachenwald
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University Hospital of Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
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2
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Deem S, Diringer M, Livesay S, Treggiari MM. Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:81-90. [PMID: 37160848 DOI: 10.1007/s12028-023-01738-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 04/13/2023] [Indexed: 05/11/2023]
Abstract
One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.
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Affiliation(s)
- Steven Deem
- Neurocritical Care Unit, Swedish Medical Center, Seattle, WA, USA.
| | - Michael Diringer
- Department of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Sarah Livesay
- Department of Anesthesiology and Pain Medicine, Harborview Medical Center, University of Washington, Seattle, WA, USA
- College of Nursing, Rush University, Chicago, IL, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical School, Durham, NC, USA
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Matsumoto A, Hanayama H, Matsumoto H, Tomogane Y, Minami H, Masuda A, Yamaura I, Hirata Y, Yoshida Y. Asymmetric posterior reversible encephalopathy syndrome secondary to epilepsy occurring in the chronic phase of subarachnoid hemorrhage. Surg Neurol Int 2022; 13:129. [PMID: 35509559 PMCID: PMC9062910 DOI: 10.25259/sni_244_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 11/25/2022] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is a rare clinical syndrome that refers to a disorder with reversible subcortical vasogenic brain edema involving the parieto-occipital lobe, temporal lobe, basal ganglia, and its surroundings. Radiologically, it is characterized by symmetrical lesions; however, atypical findings have sometimes been reported. Case Description: A 79-year-old woman experienced subarachnoid hemorrhage (SAH) a year and a half previously before this hospitalization. She presented with sudden-onset coma, dacryorrhea, and moderate right hemiparesis and was taken to our hospital. Computed tomography showed no apparent abnormal acute lesions. Electroencephalography confirmed periodic lateralized epileptiform discharges in the left hemisphere. First, based on the findings, she was diagnosed with nonconvulsive status epilepticus and started antiepileptic therapy. Six days after admission, however, multiple asymmetric lesions were confirmed on magnetic resonance imaging. Considering that findings subsequently improved, we finally diagnosed her with asymmetric PRES secondary to epilepsy occurring in the chronic phase of SAH. Aphasia and right hemispatial neglect persisted as sequelae and she was transferred to a rehabilitation hospital with a modified Rankin scale of 3. Conclusion: Excessive elevation of blood flow in the hemisphere is inferred to lead to blood–brain barrier collapse and subsequent asymmetric PRES.
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Brain Edema from a Hypertensive Emergency: A History Before the PRES Designation. Neurocrit Care 2022; 37:22-25. [PMID: 35217997 DOI: 10.1007/s12028-022-01454-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 01/18/2022] [Indexed: 10/19/2022]
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5
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cheng X, Li J, Lan Y, Liu J, Chen S, Lu G. Cerebrovascular Disease in the Setting of Posterior Reversible Encephalopathy Syndrome. Front Neurol 2021; 12:765333. [PMID: 34867751 PMCID: PMC8635685 DOI: 10.3389/fneur.2021.765333] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Accepted: 10/25/2021] [Indexed: 12/03/2022] Open
Abstract
Overlap between the pathogenesis of posterior reversible encephalopathy syndrome and that of cerebrovascular disease can confound their clinical and radiological presentations, posing a diagnostic challenge. This article presents a literature review and discussion of the clinical manifestations, pathological mechanisms, and imaging manifestations of subarachnoid hemorrhage and vasculitis leading to posterior reversible encephalopathy syndrome, coexistence of posterior reversible encephalopathy syndrome with reversible cerebral vasoconstriction syndrome, and hemorrhage and infarction secondary to posterior reversible encephalopathy syndrome. The findings show that posterior reversible encephalopathy syndrome shares some overlapping pathophysiological mechanisms with cerebrovascular disease. Importantly, neuroimaging plays an important role in identifying this entity in a timely manner and differentiating it from other diseases.
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Affiliation(s)
- XiaoQing Cheng
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - JianRui Li
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Ying Lan
- Special Medical Service, Lushan Rehabilitation and Recuperation Center of People's Liberation Army (PLA), Jiujiang, China
| | - Jia Liu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Sui Chen
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - GuangMing Lu
- Department of Medical Imaging, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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Angermann M, Jablawi F, Keulers A, Angermann M, Schubert GA, Weiss M, Reich A, Wiesmann M, Nikoubashman O. Posterior reversible encephalopathy syndrome after induced hypertension therapy for delayed cerebral ischemia after subarachnoid hemorrhage: A case-control study. J Neurol Sci 2021; 421:117313. [PMID: 33461062 DOI: 10.1016/j.jns.2021.117313] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 01/01/2021] [Accepted: 01/05/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is associated with arterial hypertension. Our aim was to investigate whether induced hypertension (IH) as therapy for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) is associated with PRES and to identify risk factors for PRES. MATERIAL AND METHODS We retrospectively searched our database for patients with SAH and IH in our institution between 2009 and 2018 and identified additional cases of PRES after SAH with IH from the literature. We then analyzed demographic findings and clinical features of these patients. RESULTS 172 patients with acute SAH received IH. PRES was diagnosed in 3/172 (1.7%) patients. Our literature search revealed 17 additional cases. The pooled PRES group (n = 20) was non-significantly older than the non-PRES group (n = 169) (median, 62.5 years vs. 52 years, p = 0.06). No significant differences were found between both groups with regard to sex (p = 0.73), Hunt & Hess-Score (p = 0.9), aneurysm treatment (p = 0.13), and time from diagnosis of SAH to the start of IH (p = 0.14). CONCLUSIONS PRES after IH in SAH patients occurred in 1.7% of our patients. Our results imply that it is important to be aware of a possible development of a PRES in older SAH patients with IH, irrespective of sex, initial clinical status, and treatment modality.
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Affiliation(s)
- Maike Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Fidaa Jablawi
- Department of Neurosurgery, Justus-Liebig-University Gießen, Germany
| | - Annika Keulers
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Manuel Angermann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Gerrit A Schubert
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, University Hospital RWTH, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH, Aachen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH, Aachen, Germany.
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Khan IR, Pai V, Mundada P, Sitoh YY, Purohit B. Detecting the Uncommon Imaging Manifestations of Posterior Reversible Encephalopathy Syndrome (PRES) in Adults: a Comprehensive Illustrated Guide for the Trainee Radiologist. Curr Probl Diagn Radiol 2020; 51:98-111. [PMID: 33257096 DOI: 10.1067/j.cpradiol.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 10/28/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) has traditionally been described as a reversible leukoencephalopathy with a distinct pattern of posteriorly distributed vasogenic oedema involving the subcortical regions of parietal and occipital lobes. PRES commonly occurs in the setting of hypertensive emergencies, pre-eclampsia/eclampsia, impaired renal function, and immunosuppressive therapy. The various clinical presentations of PRES include encephalopathy, seizures, headache, visual, and focal neurological deficits. As knowledge of this entity grows, the range of clinical, and radiological features is seen to be much broader than originally described. The brain oedema may not always be posteriorly distributed and the syndrome may not be uniformly reversible. Of special note are some uncommon imaging features (unilateral cerebral involvement, and isolated posterior fossa involvement) and also some uncommon complications (haemorrhage, cytotoxic oedema, and vasoconstriction). These red herrings may lead to potential diagnostic challenges and pitfalls especially for trainee radiologists, who often read these scans in an emergency setting. Early and accurate diagnosis is crucial for prompt optimum management, thereby avoiding residual morbidity. This review article focusses on the atypical radiological features of PRES in adults with extensive case-based imaging examples. A brief description of the pathophysiology, clinical, and classic radiological features of PRES has also been included. A tabulated summary of potential mimics with diagnostic pearls is provided to highlight pertinent take home points and to serve as an easy guide for day-to-day clinical practice.
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Affiliation(s)
- Iram R Khan
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Vivek Pai
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Pravin Mundada
- Department of Diagnostic and Interventional Radiology, Raffles Hospital, 585 North Bridge Rd, Singapore
| | - Yih Yian Sitoh
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore
| | - Bela Purohit
- Department of Neuroradiology, National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore.
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9
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Peak blood pressure and prediction of posterior reversible encephalopathy syndrome in children. Pediatr Nephrol 2020; 35:1967-1975. [PMID: 32385528 PMCID: PMC8086820 DOI: 10.1007/s00467-020-04577-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 04/06/2020] [Accepted: 04/15/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Hypertension is a risk factor for posterior reversible encephalopathy syndrome (PRES), but the timing and severity of hypertension relative to PRES are unknown. The objective was to identify a clinically meaningful blood pressure (BP) threshold that predicts PRES development in high-risk children. METHODS We recorded peak systolic BP, diastolic BP, BP z-scores, and mean arterial pressure over the 14 days preceding clinical concern for PRES in 35 subjects who developed PRES, compared to 14 controls who had normal brain magnetic resonance imaging and similar underlying disease, renal function, and medications. We used multivariable logistic regression models adjusted for fluid overload and obesity to estimate the association of peak BP with PRES. We used receiver operating characteristic curves to determine which peak BP thresholds best predicted PRES and calculated the corresponding sensitivity, specificity, and positive and negative predictive values. RESULTS Peak systolic BP z-score was most strongly associated with PRES (OR 3.97, 95% CI 1.62-9.74), and peak systolic BP z-score ≥ 3.0 predicted PRES (area under the curve 0.95, 95% CI 0.88-1.0) with 91% sensitivity and 85% specificity, indicating 94% positive predictive value and 79% negative predictive value. CONCLUSIONS We demonstrated that peak systolic BP z-score ≥ 3.0 in the preceding 14 days predicted PRES development in cases compared with controls in children at high risk. Our study suggests that stage 2 hypertension, corresponding to a z-score ≥ 3.0, could help define hypertensive emergency in high-risk children and indicate when more aggressive treatment is warranted to prevent neurologic injury.
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Gong W, Zhang S, Li X, Shi L. Dexmedetomidine is superior to midazolam for sedation and cerebral protection in postoperative hypertensive intracerebral hemorrhage patients: a retrospective study. J Int Med Res 2020; 48:300060520957554. [PMID: 32967514 PMCID: PMC7521051 DOI: 10.1177/0300060520957554] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE Dexmedetomidine has a good sedative effect and does not affect the judgment of the patient's consciousness level. However, its effectiveness for sedation and cerebral protection after craniotomy in hypertensive intracerebral hemorrhage (HICH) patients is unknown. METHODS A retrospective study of 164 postoperative HICH patients who underwent sedation with dexmedetomidine or midazolam was conducted. The Ramsay sedation score, mean arterial pressure (MAP), heart rate (HR), pulse oxygen saturation (SpO2), and respiratory rate were measured at the indicated time points. Human soluble protein-100β (S-100β) and neuron-specific enolase (NSE) levels were also compared between the two groups. RESULTS Dexmedetomidine treatment showed a significantly better effect than midazolam on decreasing the frequency of apparent agitation. The MAP and HR, but not the SpO2, were significantly decreased and lower than those in midazolam group. Detection of plasma S-100β and NSE proteins revealed a significant decrease in the dexmedetomidine group compared with the midazolam group. The 6-month follow-up evaluation indicated a significantly better prognosis of postoperative HICH patients treated with dexmedetomidine than for those treated with midazolam. CONCLUSIONS Dexmedetomidine is effective for sedation in postoperative HICH patients and may be beneficial for their outcome.
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Affiliation(s)
- Weiyi Gong
- Department of Neurosurgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, P.R. China
| | - Shuguang Zhang
- Department of Neurosurgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, P.R. China
| | - Xiaoliang Li
- Department of Neurosurgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, P.R. China
| | - Lei Shi
- Department of Neurosurgery, Affiliated Kunshan Hospital of Jiangsu University, Suzhou, P.R. China
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11
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Elsamadicy AA, Koo AB, Reeves BC, Sujijantarat N, David WB, Malhotra A, Gilmore EJ, Matouk CC, Hebert R. Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 143:e309-e323. [PMID: 32721559 DOI: 10.1016/j.wneu.2020.07.135] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients. METHODS We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. RESULTS The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved. CONCLUSION IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.
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Affiliation(s)
- Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nanthiya Sujijantarat
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Wyatt B David
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily J Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA; Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA.
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Symptomatic Cerebral Hyperperfusion After Cerebral Vasospasm Associated with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 137:379-383. [DOI: 10.1016/j.wneu.2020.02.092] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 02/16/2020] [Indexed: 11/22/2022]
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13
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Hernández-Durán S, Mielke D, Rohde V, Malinova V. Does Nimodipine Interruption due to High Catecholamine Doses Lead to a Greater Incidence of Delayed Cerebral Ischemia in the Setting of Aneurysmal Subarachnoid Hemorrhage? World Neurosurg 2019; 132:e834-e840. [DOI: 10.1016/j.wneu.2019.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2019] [Revised: 07/31/2019] [Accepted: 08/01/2019] [Indexed: 10/26/2022]
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Effect of HHH-Therapy on Regional CBF after Severe Subarachnoid Hemorrhage Studied by Bedside Xenon-Enhanced CT. Neurocrit Care 2019; 28:143-151. [PMID: 28983856 PMCID: PMC5948237 DOI: 10.1007/s12028-017-0439-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background Management of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH) is difficult and still carries controversies. In this study, the effect of therapeutic hypervolemia, hemodilution, and hypertension (HHH-therapy) on cerebral blood flow (CBF) was assessed by xenon-enhanced computerized tomography (XeCT) hypothesizing an increase in CBF in poorly perfused regions. Methods Bedside XeCT measurements of regional CBF in mechanically ventilated SAH patients were routinely scheduled for day 0–3, 4–7, and 8–12. At clinical suspicion of DCI, patients received 5-day HHH-therapy. For inclusion, XeCT was required at 0–48 h before start of HHH (baseline) and during therapy. Data from corresponding time-windows were also collected for non-DCI patients. Results Twenty patients who later developed DCI were included, and twenty-eight patients without DCI were identified for comparison. During HHH, there was a slight nonsignificant increase in systolic blood pressure (SBP) and a significant reduction in hematocrit. Median global cortical CBF for the DCI group increased from 29.5 (IQR 24.6–33.9) to 38.4 (IQR 27.0–41.2) ml/100 g/min (P = 0.001). There was a concomitant increase in regional CBF of the worst vascular territories, and the proportion of area with blood flow below 20 ml/100 g/min was significantly reduced. Non-DCI patients showed higher CBF at baseline, and no significant change over time. Conclusions HHH-therapy appeared to increase global and regional CBF in DCI patients. The increase in SBP was small, while the decrease in hematocrit was more pronounced, which may suggest that intravascular volume status and rheological effects are of importance. XeCT may be potentially helpful in managing poor-grade SAH patients.
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Acar S, Kavlak ME, Demir B, Ozkan P, Polat KY, Akyildiz M, Arikan C. Posterior Reversible Encephalopathy Syndrome in a Five-Year-Old Child: A Case Report. Transplant Proc 2019; 51:2495-2497. [PMID: 31351771 DOI: 10.1016/j.transproceed.2019.01.186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/28/2019] [Indexed: 10/26/2022]
Abstract
Posterior reversible encephalopathy syndrome (PRES) is a neuroradiologic syndrome. The etiology of PRES is still unclear. Some factors were described. We present a case of a pediatric patient with liver transplant who developed PRES following blood transfusion while receiving tacrolimus therapy. A 5½-year-old boy who underwent living donor liver transplantation, and PRES developed on the sixth day post transplant under tacrolimus treatment after 6 hours of red blood transfusion. PRES is a rare condition; it should be kept in mind about patients who have received organ transplants and develop sudden neurologic symptoms.
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Affiliation(s)
- Sencan Acar
- Department of Gastroenterology and Organ Transplant Center, Sakarya University School of Medicine, Sakarya, Turkey.
| | - Mustafa Emre Kavlak
- Department of Anesthesiology and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Baris Demir
- Department of Family Practice and Organ Transplant Center, Koc University School of Medicine, Istanbul, Turkey
| | - Perihan Ozkan
- Department of Radiology, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Kamil Yalcin Polat
- Department of General Surgery and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Murat Akyildiz
- Department of Gastroenterology and Organ Transplant Center, Memorial Atasehir Hospital, Istanbul, Turkey
| | - Cigdem Arikan
- Department of Pediatric Gastroenterology and Organ Transplant Center, Koc University School of Medicine, Istanbul, Turkey
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Chihara H, Hatano T, Ando M, Takita W, Tokunaga K, Hashikawa T, Funakoshi Y, Kamata T, Higashi E, Nagata I. A Case of Posterior Reversible Encephalopathy Syndrome After Surgical Clipping of Unruptured Cerebral Aneurysm. World Neurosurg 2019; 124:323-327. [PMID: 30660882 DOI: 10.1016/j.wneu.2019.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Revised: 01/02/2019] [Accepted: 01/05/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on imaging examinations, along with symptoms of altered consciousness disorder and seizures. Various factors associated with PRES have been reported. However, we encountered a very rare case that developed after clipping surgery for unruptured cerebral aneurysm. CASE DESCRIPTION A 74-year-old man with a history of hypertension presented with an unruptured right middle cerebral artery aneurysm and underwent cranial clipping surgery. After surgery, he developed consciousness disorder and epilepsy after delayed awakening from general anesthesia. Radiological examinations revealed multiple edematous lesions, strongly suggesting PRES, and excluding asymmetry consistent with the area of craniotomy. With conservative treatment, symptoms and radiological findings almost disappeared. Symptoms and imaging findings remaining at the area of craniotomy were attributed to the severe difference in cerebral perfusion pressure due to craniotomy. CONCLUSIONS Based on the literature, this case was considered to represent PRES caused by rapid blood pressure fluctuations accompanying general anesthesia for clipping surgery. Practitioners must keep PRES in mind as a rare complication after clipping for unruptured cerebral aneurysms. PRES developing after craniotomy shows unilaterality and may become severe in the craniotomy area and leave sequelae.
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Allen ML, Kulik T, Keyrouz SG, Dhar R. Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study. Neurosurgery 2018; 85:223-230. [DOI: 10.1093/neuros/nyy240] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 05/10/2018] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Induced hypertension (IH) remains the mainstay of medical management for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). However, raising blood pressure above normal levels may be associated with systemic and neurological complications, of which posterior reversible encephalopathy syndrome (PRES) has been increasingly recognized.
OBJECTIVE
To ascertain the frequency and predisposing factors for PRES during IH therapy.
METHODS
We identified 68 patients treated with IH from 345 SAH patients over a 3-yr period. PRES was diagnosed based on clinical suspicion, confirmed by imaging. We extracted additional data on IH, including baseline and highest target mean arterial pressure (MAP), comparing PRES to IH-treated controls.
RESULTS
Five patients were diagnosed with PRES at median 6.6 d (range 1-8 d) from vasopressor initiation. All presented with lethargy, 3 had new focal deficits, and 1 had a seizure. Although baseline MAP (prior to DCI) did not differ between cases and controls, both MAP immediately prior to IH (112 vs 90) and highest MAP targeted were greater (140 vs 120 mm Hg, both P < .01). Magnitude of MAP elevation was greater (54 vs 34 above baseline, P = .004) while degree of IH was not (37 vs 38 above pre-IH MAP). All 4 surviving PRES patients had complete resolution with IH discontinuation.
CONCLUSION
PRES was diagnosed in 7% of SAH patients undergoing IH therapy, most often when MAP was raised well above baseline to levels that exceed traditional autoregulatory thresholds. High suspicion for this reversible disorder appears warranted in the face of unexplained neurological deterioration during aggressive IH.
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Affiliation(s)
- Michelle L Allen
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Tobias Kulik
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Salah G Keyrouz
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Rajat Dhar
- Department of Neurology (Division of Neurocritical Care), Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Murphy A, de Oliveira Manoel AL, Macdonald RL, Baker A, Lee TY, Marotta T, Montanera W, Aviv R, Bharatha A. Changes in Cerebral Perfusion with Induced Hypertension in Aneurysmal Subarachnoid Hemorrhage: A Pilot and Feasibility Study. Neurocrit Care 2018; 27:3-10. [PMID: 28244000 DOI: 10.1007/s12028-017-0379-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The effects of induced hypertension (IH) on cerebral perfusion after subarachnoid hemorrhage (SAH) are unclear. The objectives of this investigation are to: (1) determine whether there are differences in cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) measured with computed tomography perfusion (CTP) before and after IH; (2) evaluate differences in the presence of infarction and clinical outcome between patients with and without IH. METHODS We performed a retrospective cohort analysis of 25 aneurysmal SAH patients. IH was initiated as per the standard institutional protocol when patients showed clinical symptoms of delayed cerebral ischemia (DCI). Differences in CBF, CBV, and MTT between early (<72 h after aneurysm rupture) and late (7-10 days after aneurysm rupture) CTP were quantified in patients with (n = 13) and without IH (n = 12). Outcome measures included cerebral infarction and clinical outcome at 3 months. RESULTS Early MTT was significantly greater in the IH group compared to the no-IH group. There was no difference in early or late CBV or CBF between the two groups. In patients that received IH, there was a significant decrease in MTT between the early (7.0 ± 1.2 s) and late scans (5.8 ± 1.6 s; p = 0.005). There was no difference in the incidence of infarction (5/13 vs. 2/11) or poor outcome (3/11 vs. 6/13) between the IH and no-IH groups, respectively (p > 0.05). CONCLUSIONS Elevated MTT is a significant factor for the development of DCI in patients eventually requiring IH therapy and is improved by IH treatment. Therapies to prevent DCI and improve clinical outcome may need to be initiated earlier, when cerebral perfusion abnormalities are first identified.
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Affiliation(s)
- Amanda Murphy
- Department of Medical Imaging, University of Toronto, 30 Bond Street, Room 3-077CC, Toronto, ON, M5B 1W8, Canada.
| | | | - R Loch Macdonald
- Department of Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew Baker
- Department of Critical Care, St. Michael's Hospital, Toronto, ON, Canada
| | | | - Tom Marotta
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Walter Montanera
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
| | - Richard Aviv
- Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Aditya Bharatha
- Department of Medical Imaging, St. Michael's Hospital, Toronto, ON, Canada
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19
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Diringer MN. Hemodynamic Therapy for Delayed Cerebral Ischemia in SAH. Neurocrit Care 2018; 28:152-153. [DOI: 10.1007/s12028-018-0529-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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20
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Chaudhry SR, Stoffel-Wagner B, Kinfe TM, Güresir E, Vatter H, Dietrich D, Lamprecht A, Muhammad S. Elevated Systemic IL-6 Levels in Patients with Aneurysmal Subarachnoid Hemorrhage Is an Unspecific Marker for Post-SAH Complications. Int J Mol Sci 2017; 18:ijms18122580. [PMID: 29194369 PMCID: PMC5751183 DOI: 10.3390/ijms18122580] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 11/22/2017] [Accepted: 11/23/2017] [Indexed: 12/31/2022] Open
Abstract
Background: Aneurysmal subarachnoid hemorrhage (aSAH) is still a fatal and morbid disease, although bleeding aneurysms can be secured in almost all cases. Occurrence of post-SAH complications including cerebral vasospasm, delayed cerebral ischemia, hydrocephalus, epilepsy, and infections are the main determinants of clinical outcome. Hence, it is important to search for early predictors for specific post-SAH complications to treat these complications properly. Both cellular and molecular (cytokines) inflammation play a key role after aSAH during the phase of occurrence of post-SAH complications. Interleukin-6 (IL-6) is a well-known cytokine that has been extensively analyzed in cerebrospinal fluid (CSF) of patients after aSAH, but detailed studies exploring the role of systemic IL-6 in aSAH associated complications and its impact on early clinical outcome prediction are lacking. The current study aims to analyze the systemic IL-6 levels over two weeks after bleeding and its role in post-SAH complications. Methods: We recruited 80 aSAH patients prospectively who underwent peripheral venous blood withdrawal in serum gel tubes. The blood was centrifuged to harvest the serum, which was immediately frozen at −80 °C until analysis. Serum IL-6 levels were quantified using Immulite immunoassay system. Patient records including age, gender, post-SAH complications, aneurysm treatment, and clinical outcome (modified Rankin scale and Glasgow outcome scale) were retrieved to allow different subgroup analysis. Results: Serum IL-6 levels were significantly raised after aSAH compared to healthy controls over the first two weeks after hemorrhage. Serum IL-6 levels were found to be significantly elevated in aSAH patients presenting with higher Hunt and Hess grades, increasing age, and both intraventricular and intracerebral hemorrhage. Interestingly, serum IL-6 was also significantly raised in aSAH patients who developed seizures, cerebral vasospasm (CVS), and chronic hydrocephalus. IL-6 levels were sensitive to the development of infections and showed an increase in patients who developed pneumoniae. Intriguingly, we found a delayed increase in serum IL-6 in patients developing cerebral infarction. Finally, IL-6 levels were significantly higher in patients presenting with poor clinical outcome in comparison to good clinical outcome at discharge from hospital. Conclusion: Serum IL-6 levels were elevated early after aSAH and remained high over the two weeks after initial bleeding. Serum IL-6 was elevated in different aSAH associated complications, acting as a non-specific marker for post-SAH complications and an important biomarker for clinical outcome at discharge.
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Affiliation(s)
- Shafqat Rasul Chaudhry
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
- Department of Pharmaceutics, University of Bonn, D-53121 Bonn, Germany.
| | - Birgit Stoffel-Wagner
- Department of Clinical Chemistry and Clinical Pharmacology, University Hospital Bonn, D-53127 Bonn, Germany.
| | - Thomas Mehari Kinfe
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
| | - Dirk Dietrich
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
| | - Alf Lamprecht
- Department of Pharmaceutics, University of Bonn, D-53121 Bonn, Germany.
| | - Sajjad Muhammad
- Department of Neurosurgery, University Hospital Bonn, D-53127 Bonn, Germany.
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21
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Hayman EG, Wessell A, Gerzanich V, Sheth KN, Simard JM. Mechanisms of Global Cerebral Edema Formation in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2017; 26:301-310. [PMID: 27995510 DOI: 10.1007/s12028-016-0354-7] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A growing body of clinical literature emphasizes the impact of cerebral edema in early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Aneurysm rupture itself initiates global cerebral edema in up to two thirds of cases. Although cerebral edema is not a universal feature of aSAH, it portends a poor clinical course, with quantitative analysis revealing a direct correlation between cerebral edema and poor outcome, including mortality and cognitive deficits. Mechanistically, global cerebral edema has been linked to global ischemia at the time of aneurysm rupture, dysfunction of autoregulation, blood breakdown products, neuroinflammation, and hyponatremia/endocrine abnormalities. At a molecular level, several culprits have been identified, including aquaporin-4, matrix metalloproteinase-9, SUR1-TRPM4 cation channels, vascular endothelial growth factor, bradykinin, and others. Here, we review these cellular and molecular mechanisms of global cerebral edema formation in aSAH. Given the importance of edema to the outcome of patients with aSAH and its status as a highly modifiable pathological process, a better understanding of cerebral edema in aSAH promises to hasten the development of medical therapies to improve outcomes in this frequently devastating disease.
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Affiliation(s)
- Erik G Hayman
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Aaron Wessell
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Volodymyr Gerzanich
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, New Haven, CT, USA.,Department of Neurosurgery, Yale New Haven Hospital, New Haven, CT, USA
| | - J Marc Simard
- Department of Neurosurgery, University of Maryland School of Medicine, 22 S. Greene St., Suite S12D, Baltimore, MD, 21201-1595, USA. .,Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA. .,Department of Physiology, University of Maryland School of Medicine, Baltimore, MD, USA.
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22
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Niwa R, Oya S, Nakamura T, Hana T, Matsui T. Rapid intracranial pressure drop as a cause for posterior reversible encephalopathy syndrome: Two case reports. Surg Neurol Int 2017; 8:103. [PMID: 28695050 PMCID: PMC5473084 DOI: 10.4103/sni.sni_55_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Accepted: 02/23/2017] [Indexed: 01/12/2023] Open
Abstract
Background: Posterior reversible encephalopathy syndrome (PRES) is characterized by reversible edematous lesions on radiological examinations as well as symptoms of altered consciousness and seizures. To date, the underlying mechanism remains largely unknown. Case Descriptions: Case 1 is a 72-year-old man with a history of hypertension presented with a subarachnoid hemorrhage. Fourteen days after the successful clipping of a ruptured aneurysm; he experienced inadvertent overdrainage via the intraventricular drain. Nine hours later, he started to have seizures followed by disturbances in consciousness. An emergency magnetic resonance imaging showed multiple high-intensity lesions in the frontal, temporal, parietal, and occipital lobes, basal ganglia, brainstem, and cerebellar hemispheres bilaterally, which are compatible with typical magnetic resonance findings in PRES patients. He was treated conservatively and recovered well. Case 2 is a 68-year-old woman with a mild history of hypertension and a ventriculo-peritoneal shunt for obstructive hydrocephalus, who underwent a cysto-peritoneal shunt placement because of an enlarging symptomatic arachnoid cyst. Immediately following surgery, she experienced disturbances in consciousness and developed status epilepticus. Radiological examinations revealed remarkable shrinkage of the arachnoid cyst and multiple edematous lesions, which led us to strongly suspect PRES. With conservative treatment, her symptoms and the radiological abnormalities disappeared. Conclusion: Based on the previous literature and our cases, we believe that the association between rapid reduction of intracranial pressure (ICP) and the development of PRES should be recognized because most neurosurgical procedures such as craniotomy or cerebrospinal fluid diversion present a potential risk of rapid reduction of ICP.
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Affiliation(s)
- Ryoko Niwa
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Soichi Oya
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Takumi Nakamura
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Taijun Hana
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Toru Matsui
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Saitama, Japan
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23
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Prognosis of neurologic complications in critical illness. HANDBOOK OF CLINICAL NEUROLOGY 2017. [PMID: 28190446 DOI: 10.1016/b978-0-444-63599-0.00041-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/12/2023]
Abstract
Neurologic complications of critical illness require extensive clinical and neurophysiologic evaluation to establish a reliable prognosis. Many sequelae of intensive care unit (ICU) treatment, such as delirium and ICU-acquired weakness, although highly associated with adverse outcomes, are less suitable for prognostication, but should rather prompt clinicians to seek previously unnoticed persisting underlying illnesses. Prognostication can be confounded by drug administration particularly because its clearance is abnormal in critical illness. Some neurological complications are severe, and can last for months or years after discharge from ICU. The most important ethical aspects regarding neurologic complications in critically ill patients are prevention, recognition, and identification, and prevention of self-fulfilling prophecies. This chapter summarizes the tool of prognostication of major neurological complications of critical illness.
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Increased Perioperative Crystalloid Transfusion Is Associated with Better Outcomes After Spontaneous Hypertensive Putamen Hemorrhage: A Retrospective Study. World Neurosurg 2017; 98:140-145. [DOI: 10.1016/j.wneu.2016.10.115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 10/23/2016] [Accepted: 10/24/2016] [Indexed: 11/23/2022]
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25
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Brown RJ, Kumar A, McCullough LD, Butler K. A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage. Int J Neurosci 2016; 127:51-58. [PMID: 26822716 DOI: 10.3109/00207454.2016.1138952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpose/aim: Blood pressure (BP) regulation is recommended following aneurysmal subarachnoid hemorrhage (aSAH) to prevent re-bleeding and to treat delayed cerebral ischemia. However, optimal BP thresholds are not well established. There is also variation with regard to the BP component (e.g. systolic vs. mean) that is targeted or manipulated. MATERIALS AND METHODS An 18-question survey was distributed to physicians and advanced practitioner members of the Neurocritical Care Society. Respondents were asked which BP parameter they manipulated and what their thresholds were in different clinical scenarios. They were also asked whether they were influenced by the presence of incidental aneurysms. Answers were analyzed for differences in training background and treatment setting. RESULTS There were 128 responses. The majority were neurointensivists (47 neurology and 37 non-neurology) and treated patients in dedicated neurointensive care units (n = 98). Systolic BP (SBP) was preferred over mean arterial pressure (MAP). Prior to aneurysm treatment, SBP limits ranged from 140 to 180 mm Hg. After aneurysm treatment, SBP limits ranged from 160 to 240 mm Hg. The maximum and minimum MAPs varied by as much as 50%. Nearly two-thirds of the respondents were influenced by the presence of incidental aneurysms. Training background influenced tolerance to BP limits with neurology-trained neurointensivists accepting higher BP limits when treating delayed ischemia ( p = .018). They were also more likely to follow SBP ( p = .018) and have a limit of 140 mm Hg prior to aneurysm treatment ( p = .001). CONCLUSIONS There is large practice variability in BP management following aSAH. There is also uncertainty over the importance of incidental aneurysms. Further research could evaluate whether this variability has clinical significance.
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Affiliation(s)
- Robert J Brown
- a Department of Surgery, Division of Critical Care , Hartford Hospital , Hartford , CT , USA
| | - Abhay Kumar
- b Department of Neurology and Psychiatry , Saint Louis University , SaintLouis , MO , USA
| | - Louise D McCullough
- c Department of Neurology , University of Connecticut School of Medicine , Farmington , CT , USA
| | - Karyn Butler
- a Department of Surgery, Division of Critical Care , Hartford Hospital , Hartford , CT , USA
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