The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms

Effects of induced arterial hypertension for vasospasm on unruptured and unsecured cerebral aneurysms (growth and rupture). A retrospective case-control study

OBJECTIVES

Unruptured cerebral aneurysms (UCAs) often coexist with the ruptured one but are typically left unsecured during the weeks following aneurysmal subarachnoid hemorrhage (aSAH). We compared the rate of UCAs rupture or volume growth (≥5 mm3) between patients exposed to induced arterial hypertension (iHTN) for vasospasm and those not exposed (control group).

MATERIALS AND METHODS

From 2013 to 2021, we retrospectively included consecutive adult patients with aSAH who had ≥1 UCA. Custom software for digital subtraction angiography (DSA) image analysis characterized UCAs volume, going beyond merely considering UCAs long axis.

RESULTS

We analyzed 118 patients (180 UCAs): 45 in the iHTN group (64 UCAs) and 73 in the control group (116 UCAs). Systolic blood pressure in the iHTN group was significantly higher than in the control group for several days after aSAH. During the 107 day-monitoring period [interquartile range(IQR):92;128], no UCA rupture occurred in either group. UCA volume analysis was performed in 44 patients (60 UCAs): none of the UCAs in the iHTN group and 3 out of 42 (7%) in the control group had a >5 mm3 volume growth (p=0.55). Other morphologic parameters did not exhibit any variations that might indicate an increased risk of rupture in the iHTN group compared to the control group.

CONCLUSION

iHTN did not increase the risk of rupture or volume growth of UCAs within several weeks following aSAH. These reassuring results encourage not to refrain, because of the existence of UCAs, from iHTN as an option to prevent cerebral infarction during cerebral vasospasm.

Vasopressor treatment and mortality following nontraumatic subarachnoid hemorrhage: a nationwide electronic health record analysis

OBJECTIVE

Subarachnoid hemorrhage (SAH) is a devastating cerebrovascular condition, not only due to the effect of initial hemorrhage, but also due to the complication of delayed cerebral ischemia (DCI). While hypertension facilitated by vasopressors is often initiated to prevent DCI, which vasopressor is most effective in improving outcomes is not known. The objective of this study was to determine associations between initial vasopressor choice and mortality in patients with nontraumatic SAH.

METHODS

The authors conducted a retrospective cohort study using a large, national electronic medical record data set from 2000-2014 to identify patients with a new diagnosis of nontraumatic SAH (based on ICD-9 codes) who were treated with the vasopressors dopamine, phenylephrine, or norepinephrine. The relationship between the initial choice of vasopressor therapy and the primary outcome, which was defined as in-hospital death or discharge to hospice care, was examined.

RESULTS

In total, 2634 patients were identified with nontraumatic SAH who were treated with a vasopressor. In this cohort, the average age was 56.5 years, 63.9% were female, and 36.5% of patients developed the primary outcome. The incidence of the primary outcome was higher in those initially treated with either norepinephrine (47.6%) or dopamine (50.6%) than with phenylephrine (24.5%). After adjusting for possible confounders using propensity score methods, the adjusted OR of the primary outcome was higher with dopamine (OR 2.19, 95% CI 1.70-2.81) and norepinephrine (OR 2.24, 95% CI 1.80-2.80) compared with phenylephrine. Sensitivity analyses using different variable selection procedures, causal inference models, and machine-learning methods confirmed the main findings.

CONCLUSIONS

In patients with nontraumatic SAH, phenylephrine was significantly associated with reduced mortality in SAH patients compared to dopamine or norepinephrine. Prospective randomized clinical studies are warranted to confirm this finding.

Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.

Fatal intracranial aneurysm rupture after thrombolytic treatment for ischemic stroke: a case report and literature review

Intravenous thrombolysis is a proven treatment of acute ischemic stroke. Its complications include intracranial hemorrhage; the risk may be increased in the presence of an unruptured aneurysm. We present a case report of a patient who suffered fatal subarachnoid hemorrhage after thrombolysis from a known aneurysm. A history of recent previously inexperienced headaches was revealed retrospectively, suggestive of sentinel bleedings. A similar patient was identified in the literature; we thus propose that this history should be excluded in patients harboring an aneurysm considered for thrombolytic treatment.

Delayed Ischemic Neurologic Deficit after Aneurysmal Subarachnoid Hemorrhage

Delayed ischemic neurologic deficit (DIND) is the main preventable cause of poor outcomes in aneurysmal subarachnoid hemorrhage (SAH) patients. Of 50% of survivors from a SAH, approximately 30% of patients will present clinical vasospasm (VS). The cornerstone of the DIND management comprises prevention and early identification. Several diagnostic methods have been proposed differing in efficacy, invasiveness, and costs. Serial neurological examination is the most reliable method to detect a new neurological deficit. On the other hand, comatose patients require advanced monitoring methods which identify changes in the microcirculatory environment, brain autoregulation, and spreading depolarization. Multimodality monitoring with continuous electroencephalography, microdialysis, and intracranial pressure monitoring represents altogether the current state-of-art technology for the intensive care of SAH patients. Moreover, advances in genetic biomarkers to predict clinical VS have shown consistent accuracy which may in the near future allow the early prediction of DIND through a simple blood test. Several clinical trials have tested drugs with theoretical effects on DIND prevention or treatment. Nevertheless, nimodipine remains the Holy Grail in the prevention of clinical VS. Among rescue therapies, the endovascular treatment through intra-arterial vasodilator (verapamil or nicardipine) infusion is the most employed method for DIND reversal; however, there is no good quality evidence comparing results of intra-arterial infusion of vasodilators versus balloon angioplasty. Although we have addressed the most refined technology in the management of SAH and DIND, the clinical experience and strict follow-up in neurointensive care will be determinant for favorable long-term outcomes.

Improvement in Sonographic Vasospasm Following Intravenous Milrinone in a Subarachnoid Hemorrhage Patient with Normal Cardiac Function

Cerebral vasospasm and delayed cerebral ischemia are well-known complications of an aneurysmal subarachnoid hemorrhage (aSAH), generally occurring days to weeks after hemorrhagic ictus. Management strategies for these complications are controversial and vary in efficacy. There is a growing interest in supporting the use of intravenous (IV) milrinone to manage vasospasm. A 31-year-old male presented to the hospital after being found down outside his home. Computed tomography (CT) of the head and subsequent CT angiogram revealed a Fisher Grade 4 aneurysmal subarachnoid hemorrhage (aSAH). Six hours after admission, he became hypotensive and his neurological examination declined. A repeat CT head showed a new, left frontoparietal intracerebral hemorrhage (ICH) along with increasing SAH. He was stabilized with vasopressors and underwent emergent decompressive hemicraniectomy with subsequent clipping of the aneurysm. Approximately one week later, transcranial Doppler (TCD) showed increasing mean flow velocities in the bilateral anterior and middle cerebral arteries consistent with cerebral vasospasm. He was treated with intravenous milrinone. Repeat TCD 6.5 hours after the initial TCD showed improved mean flow velocities. His cardiac function by echocardiogram assessment was normal. The decrease in TCD velocity following treatment with milrinone indicates an improvement in the cerebral vasospasm regardless of cardiac output in a patient with subarachnoid hemorrhage. This case suggests that augmenting cardiac output may not be the only mechanism for the therapeutic benefit of milrinone.

Postinterventional critical care management of aneurysmal subarachnoid hemorrhage

PURPOSE OF REVIEW

Subarachnoid hemorrhage from a ruptured aneurysm (aSAH) is a complex disorder with the potential to have devastating effects on the brain as well as other organ systems. After more than 3 decades of research, the underlying pathophysiologic mechanisms remain incompletely understood and important questions remain regarding the evaluation and management of these patients. The purpose of this review is to analyze the recent literature and improve our understanding of certain key clinical aspects.

RECENT FINDINGS

Growing body of evidence highlights the usefulness of CT perfusion scans in the diagnosis of vasospasm and delayed cerebral ischemia (DCI). Hypervolemia leads to worse cardiopulmonary outcomes and does not improve DCI. The traditional triple H therapy is falling out of favor with hemodynamic augmentation alone now considered the mainstay of medical management. Randomized controlled trials have shown that simvastatin and intravenous magnesium do not prevent DCI or improve functional outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Emerging data using multimodality monitoring has further advanced our understanding of the pathophysiology of DCI in poor grade aSAH.

SUMMARY

The brief review will focus on the postinterventional care of aSAH patients outlining the recent advances over the past few years.

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

PURPOSE

Arterial vasospasm is a major cause of death and long-term disability following subarachnoid haemorrhage (SAH). The use of medically induced hypertension, hypervolaemia and/or haemodilution is widely practiced for prophylaxis and treatment of vasospasm following SAH. We aimed to determine if the quality of available research is adequate to inform use of haemodynamic management strategies to prevent or treat vasospasm following SAH.

METHODS

Individual searches of the following databases were conducted: The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and OpenSIGLE. Pertinent randomised clinical trials and cohort studies comparing any element or combination thereof: medically induced hypertension, hypervolaemia, and haemodilution were included. Data were extracted using standardised proformas and risk of bias assessed using a domain-based risk of bias assessment tool.

RESULTS

348 study reports were identified by our literature search. Eight studies were included, three of which examined both volume expansion and medically induced hypertension. Three randomised clinical trials and two cohort studies examining prophylactic volume expansion were included. Two trials of prophylactic medically induced hypertension and two cohort studies were included. One trial and one cohort study of medically induced hypertension for treatment of established vasospasm was included. These trials demonstrated no significant difference in any of the clinical outcome measures studied. No trials of blood transfusion were included.

CONCLUSIONS

There is currently insufficient evidence to determine the efficacy or non-efficacy of intravenous volume expansion, medically induced hypertension or blood transfusion for the treatment or prophylaxis of vasospasm following SAH. All of these approaches have been associated with adverse events, of unclear incidence. The current evidence base therefore cannot be used to reliably inform clinical practice. This is a priority for further research.

The Extracranial Consequences of Subarachnoid Hemorrhage

BACKGROUND

Subarachnoid hemorrhage (SAH) is managed across the full spectrum of healthcare, from clinical diagnosis to management of the hemorrhage and associated complications. Knowledge of the pathogenesis and pathophysiology of SAH is widely known; however, a full understanding of the underlying molecular, cellular, and circulatory dynamics has still to be achieved. Intracranial complications including delayed ischemic neurologic deficit (vasospasm), rebleed, and hydrocephalus form the targets for initial management. However, the extracranial consequences including hypertension, hyponatremia, and cardiopulmonary abnormalities can frequently arise during the management phase and have shown to directly affect clinical outcome. This review will provide an update on the pathophysiology of SAH, including the intra- and extracranial consequences, with a particular focus on the extracranial consequences of SAH.

METHODS

We review the literature and provide a comprehensive update on the extracranial consequences of SAH that we hope will help the management of these cohort of patients.

RESULTS

In addition to the pathophysiology of SAH, the following complications were examined and discussed: vasospasm, seizures, rebleed, hydrocephalus, fever, anemia, hypertension, hypotension, hyperglycemia, hyponatremia, hypernatremia, cardiac abnormalities, pulmonary edema, venous thromboembolism, gastric ulceration, nosocomial infection, bloodstream infection/sepsis, and iatrogenic complications.

CONCLUSIONS

Although the intracranial complications of SAH can take priority in the initial management, the extracranial complications should be monitored for and recognized as early as possible because these complications can develop at varying times throughout the course of the condition. Therefore, a variety of investigations, as described by this article, should be undertaken on admission to maximize early recognition of any of the extracranial consequences. Furthermore, because the extracranial complications have a direct effect on clinical outcome and can lead to and exacerbate the intracranial complications, monitoring, recognizing, and managing these complications in parallel with the intracranial complications is important and would allow optimization of the patient's management and thus help improve their overall outcome.

Accuracy in Identifying the Source of Subarachnoid Hemorrhage in the Setting of Multiple Intracranial Aneurysms

BACKGROUND

Subarachnoid hemorrhage cases with multiple cerebral aneurysms frequently demonstrate a hemorrhage pattern that does not definitively delineate the source aneurysm. In these cases, rupture site is ascertained from angiographic features of the aneurysm such as size, morphology, and location.

OBJECTIVE

To examine the frequency with which such features lead to misidentification of the ruptured aneurysm.

METHODS : Records of patients who underwent surgical clipping of a ruptured aneurysm at our institution between 2004 and 2014 and had multiple aneurysms were retrospectively reviewed. A blinded neuroendovascular surgeon provided the rupture source based on the initial head computed tomography scans and digital subtraction angiography images. Operative reports were then assessed to confirm or refute the imaging-based determination of the rupture source.

RESULTS

One hundred fifty-one patients had multiple aneurysms. Seventy-one patients had definitive hemorrhage patterns on initial computed tomography scans and 80 patients had nondefinitive hemorrhage patterns. Thirteen (16.2%) of the cases with nondefinitive hemorrhage patterns had discordance between the imaging-based determination of the rupture source and intraoperative findings of the true ruptured aneurysm, yielding an imperfect positive predictive value of 83.8%. Of all multiple aneurysm cases with subarachnoid hemorrhage treated by surgical or endovascular means at our institution, 4.3% (13 of 303) were misidentified.

CONCLUSION

Morphological features cannot reliably be used to determine rupture site in cases with nondefinitive subarachnoid hemorrhage patterns. Microsurgical clipping, confirming obliteration of the ruptured lesion, may be preferentially indicated in these patients unless, alternatively, all lesions can be contemporaneously and safely treated with endovascular embolization.

Management of delayed cerebral ischemia after subarachnoid hemorrhage

For patients who survive the initial bleeding event of a ruptured brain aneurysm, delayed cerebral ischemia (DCI) is one of the most important causes of mortality and poor neurological outcome. New insights in the last decade have led to an important paradigm shift in the understanding of DCI pathogenesis. Large-vessel cerebral vasospasm has been challenged as the sole causal mechanism; new hypotheses now focus on the early brain injury, microcirculatory dysfunction, impaired autoregulation, and spreading depolarization. Prevention of DCI primarily relies on nimodipine administration and optimization of blood volume and cardiac performance. Neurological monitoring is essential for early DCI detection and intervention. Serial clinical examination combined with intermittent transcranial Doppler ultrasonography and CT angiography (with or without perfusion) is the most commonly used monitoring paradigm, and usually suffices in good grade patients. By contrast, poor grade patients (WFNS grades 4 and 5) require more advanced monitoring because stupor and coma reduce sensitivity to the effects of ischemia. Greater reliance on CT perfusion imaging, continuous electroencephalography, and invasive brain multimodality monitoring are potential strategies to improve situational awareness as it relates to detecting DCI. Pharmacologically-induced hypertension combined with volume is the established first-line therapy for DCI; a good clinical response with reversal of the presenting deficit occurs in 70 % of patients. Medically refractory DCI, defined as failure to respond adequately to these measures, should trigger step-wise escalation of rescue therapy. Level 1 rescue therapy consists of cardiac output optimization, hemoglobin optimization, and endovascular intervention, including angioplasty and intra-arterial vasodilator infusion. In highly refractory cases, level 2 rescue therapies are also considered, none of which have been validated. This review provides an overview of current state-of-the-art care for DCI management.

Poor outcome is associated with less negative fluid balance in patients with aneurysmal subarachnoid hemorrhage treated with prophylactic vasopressor-induced hypertension

Background

Aneurysmal subarachnoid hemorrhage (SAH) is a serious condition associated with high mortality rates and long-term disability. We investigated the impact of fluid balance on neurologic outcome after adjustment for possible confounders related to intensive care therapy and extra-cerebral organ failure during the early phase after SAH.

Methods

In this retrospective study, we analyzed data from all 142 adult patients admitted to our university hospital surgical intensive care unit (ICU) with SAH between March 2004 and November 2010.

Results

The mean patient age was 54 ± 14 years, 62.7 % were female, and the median Hunt and Hess score was 3. The proportions of patients with poor outcome (Glasgow Outcome Score ≤3) were 58.4, 54.2, and 52.1 % at 3, 6, and 12 months, respectively, after the SAH. The ICU and hospital mortality rates were both 12.7 %, and the median lengths of stay in the ICU and the hospital were 16 (IQ 7–25) and 26 (IQ 18–34) days, respectively. In multivariable analysis, older age and greater cumulative fluid balance within the first 7 days in the ICU were independently associated with a greater risk of poor outcome.

Conclusion

In this cohort of patients, older age and greater cumulative fluid balance were independently associated with a greater risk of poor outcome up to 1 year after the initial insult. Our data suggest that mild hypovolemia may be beneficial in the management of these patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13613-016-0128-6) contains supplementary material, which is available to authorized users.