Download PDF
CC BY 4.0 · J Neuroanaesth Crit Care 2024; 11(02): 100-106
DOI: 10.1055/s-0044-1787880
Original Article

Management and Outcomes of Delayed Cerebral Ischemia Associated with Vasospasm Post Nontraumatic Subarachnoid Hemorrhage: A Retrospective Cohort Study in the National Neurosurgical Center in Ireland

Patrick N. Wiseman 
1   Department of Anesthesiology and Critical Care, Beaumont Hospital, Dublin, Ireland
,
Sarah Power
2   Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
,
Stephen MacNally
3   Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
,
Deirdre Nolan
3   Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
,
Paula Corr
3   Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland
,
Gerard Curley
1   Department of Anesthesiology and Critical Care, Beaumont Hospital, Dublin, Ireland
,
Caroline M. Larkin
1   Department of Anesthesiology and Critical Care, Beaumont Hospital, Dublin, Ireland
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Abstract

Background Delayed cerebral ischemia (DCI) is the leading cause of adverse outcome in patients who survive the initial phase of subarachnoid hemorrhage (SAH). While guidelines recommend induced hypertension as a first-line treatment for DCI, there is no high-level evidence confirming outcome benefit.

Methods Patients admitted with nontraumatic SAH over 3 years period were identified. Demographics, clinical/radiological presentation, aneurysm repair method, and Glasgow outcome score (GOS) 3 months postdischarge were recorded. A subgroup of patients who suffered clinically significant vasospasm were identified, and their hypertensive therapy and outcomes were examined.

Results A total of 532 patients were admitted with SAH; 68 developed vasospasm. The vasospasm subgroup was divided based on vasopressor treatment—norepinephrine alone (n = 27) versus norepinephrine plus vasopressin (n = 35). No correlation was found between percentage of days that mean arterial pressure (MAP) targets were met and GOS outcome. Patients treated with both agents had worse GOS outcomes at than those treated with norepinephrine alone.

Conclusion In our study, 12.8% of patients SAH developed vasospasm. Twenty-seven patients were treated with norepinephrine alone and 35 were treated with norepinephrine plus vasopressin to achieve augmented MAP targets. There was no correlation between percentage of days that MAP targets were met and improved patient outcome. The 68 patients stayed a total of 783 days in ICU, with a mean length of stay of 11.5 days. Patients who required dual therapy to achieve MAP targets had significantly worse neurological outcomes.

Keywords

subarachnoid hemorrhage - delayed cerebral ischemia - cerebral vasospasm - intracranial - aneurysm - hypertensive therapy


Publication History

Article published online:
08 August 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/)

Thieme Medical and Scientific Publishers Pvt. Ltd.
A-12, 2nd Floor, Sector 2, Noida-201301 UP, India

 

  • References

  • 1 Cossu G, Messerer M, Oddo M, Daniel RT. To look beyond vasospasm in aneurysmal subarachnoid haemorrhage. BioMed Res Int 2014; 2014: 628597
    CrossrefPubMedSearch in Google Scholar
  • 2 Lee Y, Zuckerman SL, Mocco J. Current controversies in the prediction, diagnosis, and management of cerebral vasospasm: where do we stand?. Neurol Res Int 2013; 2013: 373458
    PubMedSearch in Google Scholar
  • 3 Hoh BL, Ko NU, Amin-Hanjani S. et al. 2023 guideline for the management of patients with aneurysmal subarachnoid hemorrhage: a guideline from the American Heart Association/American Stroke Association. Stroke 2023; 54 (07) e314-e370
    CrossrefPubMedSearch in Google Scholar
  • 4 Roy B, McCullough LD, Dhar R, Grady J, Wang YB, Brown RJ. Comparison of initial vasopressors used for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Cerebrovasc Dis 2017; 43 (5-6): 266-271
    CrossrefPubMedSearch in Google Scholar
  • 5 Maher M, Schweizer TA, Macdonald RL. Treatment of spontaneous subarachnoid hemorrhage: guidelines and gaps. Stroke 2020; 51 (04) 1326-1332
    CrossrefPubMedSearch in Google Scholar
  • 6 Ironside N, Buell TJ, Chen CJ. et al. High-grade aneurysmal subarachnoid hemorrhage: predictors of functional outcome. World Neurosurg 2019; 125: e723-e728
    CrossrefPubMedSearch in Google Scholar
  • 7 Mielke D, Bleuel K, Stadelmann C, Rohde V, Malinova V. The ESAS-score: a histological severity grading system of subarachnoid hemorrhage using the modified double hemorrhage model in rats. PLoS One 2020; 15 (02) e0227349
    CrossrefPubMedSearch in Google Scholar
  • 8 Kosnik EJ, Hunt WE. Postoperative hypertension in the management of patients with intracranial arterial aneurysms. J Neurosurg 1976; 45 (02) 148-154
    CrossrefPubMedSearch in Google Scholar
  • 9 Otsubo H, Takemae T, Inoue T, Kobayashi S, Sugita K. Normovolaemic induced hypertension therapy for cerebral vasospasm after subarachnoid haemorrhage. Acta Neurochir (Wien) 1990; 103 (1-2): 18-26
    CrossrefPubMedSearch in Google Scholar
  • 10 Gathier CS, van den Bergh WM, van der Jagt M. et al; HIMALAIA Study Group. Induced hypertension for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a randomized clinical trial. Stroke 2018; 49 (01) 76-83
    CrossrefPubMedSearch in Google Scholar
  • 11 Perales AJ, Torregrosa G, Salom JB, Barberá MD, Jover T, Alborch E. Effects of magnesium sulphate on the noradrenaline-induced cerebral vasoconstrictor and pressor responses in the goat. Br J Obstet Gynaecol 1997; 104 (08) 898-903
    CrossrefPubMedSearch in Google Scholar
  • 12 Van Riper DA, Bevan JA. Evidence that neuropeptide Y and norepinephrine mediate electrical field-stimulated vasoconstriction of rabbit middle cerebral artery. Circ Res 1991; 68 (02) 568-577
    CrossrefPubMedSearch in Google Scholar
  • 13 Kimmerly DS, Tutungi E, Wilson TD. et al. Circulating norepinephrine and cerebrovascular control in conscious humans. Clin Physiol Funct Imaging 2003; 23 (06) 314-319
    CrossrefPubMedSearch in Google Scholar
  • 14 Brassard P, Seifert T, Secher NH. Is cerebral oxygenation negatively affected by infusion of norepinephrine in healthy subjects?. Br J Anaesth 2009; 102 (06) 800-805
    CrossrefPubMedSearch in Google Scholar
  • 15 Yousef KM, Crago E, Chang Y. et al. Vasopressor infusion after subarachnoid hemorrhage does not increase regional cerebral tissue oxygenation. J Neurosci Nurs 2018; 50 (04) 225-230
    CrossrefPubMedSearch in Google Scholar
  • 16 Zeiler FA, Silvaggio J, Kaufmann AM, Gillman LM, West M. Norepinephrine as a potential aggravator of symptomatic cerebral vasospasm: two cases and argument for milrinone therapy. Case Rep Crit Care 2014; 2014: 630970
    PubMedSearch in Google Scholar
  • 17 Sharman A, Low J. Vasopressin and its role in critical care. Contin Educ Anaesth Crit Care Pain 2008; 8 (04) 134-137
    CrossrefPubMedSearch in Google Scholar
  • 18 Trandafir CC, Nishihashi T, Wang A, Murakami S, Ji X, Kurahashi K. Participation of vasopressin in the development of cerebral vasospasm in a rat model of subarachnoid haemorrhage. Clin Exp Pharmacol Physiol 2004; 31 (04) 261-266
    CrossrefPubMedSearch in Google Scholar
  • 19 Delgado TJ, Arbab MA, Warberg J, Svendgaard NA. The role of vasopressin in acute cerebral vasospasm. Effect on spasm of a vasopressin antagonist or vasopressin antiserum. J Neurosurg 1988; 68 (02) 266-273
    CrossrefPubMedSearch in Google Scholar
  • 20 Vakili A, Kataoka H, Plesnila N. Role of arginine vasopressin V1 and V2 receptors for brain damage after transient focal cerebral ischemia. J Cereb Blood Flow Metab 2005; 25 (08) 1012-1019
    CrossrefPubMedSearch in Google Scholar
  • 21 Hockel K, Schöller K, Trabold R, Nussberger J, Plesnila N. Vasopressin V(1a) receptors mediate posthemorrhagic systemic hypertension thereby determining rebleeding rate and outcome after experimental subarachnoid hemorrhage. Stroke 2012; 43 (01) 227-232
    CrossrefPubMedSearch in Google Scholar
  • 22 Bernier TD, Schontz MJ, Izzy S. et al. Treatment of subarachnoid hemorrhage-associated delayed cerebral ischemia with milrinone: a review and proposal. J Neurosurg Anesthesiol 2021; 33 (03) 195-202
    CrossrefPubMedSearch in Google Scholar