Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm

Increased blood pressure variability predicts poor outcomes from endovascular treatment for aneurysmal subarachnoid hemorrhage

BACKGROUND

Predictors of outcomes following endovascular treatment (ET) for aneurysmal subarachnoid hemorrhage (aSAH) are not well-defined. Identifying them would be beneficial in determining which patients might benefit from ET.

OBJECTIVE

To identify the predictive factors for poor outcomes following ET for aSAH.

METHODS

120 patients with ruptured cerebral aneurysms underwent endovascular embolization between January 2017 and December 2018. Blood pressure variability was examined using the standard deviation of the 24-hour systolic blood pressure (24hSSD) and 24-hour diastolic blood pressure (24hDSD). Predictors were identified through univariate and multivariate regression analysis. All patients were followed up for three months.

RESULTS

At follow-up, 86 patients (71.7%) had good outcomes and 34 (28.3%) had poor outcomes. Patients with poor outcomes had significantly higher 24hSSD than those with good outcomes (19.3 ± 5.5 vs 14.1 ± 4.8 mmHg; P < 0.001). The 24hDSD did not differ significantly between patients with good outcomes and those with poor outcomes (9.5 ± 2.3 vs 9.9 ± 3.5 mmHg; P = 0.464). The following were significant risk factors for poor outcomes after endovascular embolization: age ≥ 65 years (odds ratio [OR] = 23.0; 95% confidence interval [CI]: 3.0-175.9; P = 0.002); Hunt-Hess grade 3-4 (OR = 6.8; 95% CI: 1.1-33.7; P = 0.039); Fisher grade 3-4 (OR = 47.1; 95% CI: 3.8-586.5; P = 0.003); postoperative complications (OR = 6.1; 95% CI: 1.1-34.8; P = 0.042); and 24hSSD ≥ 15 mmHg (OR = 14.9; 95% CI: 4.0-55.2; P < 0.001).

CONCLUSION

Elevated 24hSSD is a possibly treatable predictive factor for poor outcomes after ET for aSAH.

The Use of Standardized Management Protocols for Critically Ill Patients with Non-traumatic Subarachnoid Hemorrhage: A Systematic Review

The use of standardized management protocols (SMPs) may improve patient outcomes for some critical care diseases. Whether SMPs improve outcomes after subarachnoid hemorrhage (SAH) is currently unknown. We aimed to study the effect of SMPs on 6-month mortality and neurologic outcomes following SAH. A systematic review of randomized control trials (RCTs) and observational studies was performed by searching multiple indexing databases from their inception through January 2019. Studies were limited to adult patients (age ≥ 18) with non-traumatic SAH reporting mortality, neurologic outcomes, delayed cerebral ischemia (DCI) and other important complications. Data on patient and SMP characteristics, outcomes and methodologic quality were extracted into a pre-piloted collection form. Methodologic quality of observational studies was assessed using the Newcastle-Ottawa scale, and RCT quality was reported as per the Cochrane risk of bias tool. A total of 11,260 studies were identified, of which 37 (34 full-length articles and 3 abstracts) met the criteria for inclusion. Two studies were RCTs and 35 were observational. SMPs were divided into four broad domains: management of acute SAH, early brain injury, DCI and general neurocritical care. The most common SMP design was control of DCI, with 22 studies assessing this domain of care. Overall, studies were of low quality; most described single-center case series with small patient sizes. Definitions of key terms and outcome reporting practices varied significantly between studies. DCI and neurologic outcomes in particular were defined inconsistently, leading to significant challenges in their interpretation. Given the substantial heterogeneity in reporting practices between studies, a meta-analysis for 6-month mortality and neurologic outcomes could not be performed, and the effect of SMPs on these measures thus remains inconclusive. Our systematic review highlights the need for large, rigorous RCTs to determine whether providing standardized, best-practice management through the use of a protocol impacts outcomes in critically ill patients with SAH.Trial registration Registration number: CRD42017069173.

Intravenous magnesium infusion for the prevention of symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage

OBJECTIVE

The study examined the difference in the incidence of symptomatic cerebral vasospasm with magnesium supplementation in aneurysmal subarachnoid hemorrhage (SAH) in a Korean population.

METHODS

This retrospective analysis was performed in 157 patients diagnosed with aneurysmal SAH from January 2007 to December 2011 at a single center. Seventy patients (44.6%) received a combination treatment of nimodipine with magnesium and 87 patients (55.4%) received only nimodipine. A matched case-control study using propensity scores was conducted and 41 subjects were selected from each group. A dosage of 64 mmol/day of magnesium was administrated.

RESULTS

The infusion of magnesium did not reduce the incidence of symptomatic cerebral vasospasm (n=7, 17.1%, p=0.29) compared with simple nimodipine injection (n=11, 26.8%). The ratios of good clinical outcome (modified Rankin scale 0-2) at 6 months were similar, being 78% in the combination treatment group and 80.5% in the nimodipine only group (p=0.79). The proportions of delayed cerebral infarction was not significantly lower in patients with combination treatment (n=2, 4.9% vs. n=3, 7.3%; p=0.64). There was no difference in the serum magnesium concentrations between the patients with symptomatic vasospasm and without vasospasm who had magnesium supplementation. No major complications associated with intravenous magnesium infusion were observed.

CONCLUSION

Magnesium supplementation (64 mmol/day) may not be beneficial for the reduction of the incidence of symptomatic cerebral vasospasm in patients with aneurysmal SAH.