Comparison of Initial Vasopressors Used for Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage

Abstract

Background: The main reason for morbidity after aneurysmal subarachnoid hemorrhage (aSAH) is delayed cerebral ischemia (DCI). The mainstay of medical therapy for treating DCI is induced hypertension with vasopressors to restore cerebral perfusion. Both phenylephrine (PE) and norepinephrine (NE) are commonly used for induced hypertension, but the impact of the initial choice of vasopressor on the efficacy, adverse effects, or outcome after hemodynamic therapy for DCI is unknown. Methods: Sixty-three patients with aSAH between January 2012 and October 2014, who developed DCI (defined as new focal deficit or decline in Glasgow Coma Score) and in which PE (n = 45) or NE (n = 18) treatment was initiated were evaluated in this retrospective study. Baseline characteristics, adverse effects, the need to change or add vasopressors, the response to therapy, the need for endovascular therapy, new infarct development, discharge disposition, and 3 months modified Rankin score were all compared between pressor groups. Results: Baseline characteristics (e.g., Hunt Hess and Fisher grades) were similar. There were no differences in the overall rate of complications including arrhythmia, pulmonary edema, or kidney injury. However, those initiated on PE were more likely to be changed to an alternate vasopressor (64 vs. 33%, p = 0.016), mostly for bradycardia or failure to reach therapeutic targets. Patients initially treated with PE were less likely to respond neurologically (71 vs. 94%, p = 0.01) or to be discharged to home or acute rehabilitation facilities (73 vs. 94%, p = 0.02) and were more likely to have a delayed infarct on imaging (62 vs. 33%, p = 0.04). Conclusions: Our study suggests that patients with DCI after aSAH initiated on PE are more likely to require treatment change to another vasopressor and are at greater risk for poor clinical outcomes compared to patients started on NE. Larger comparative studies are warranted.

Induced Hypertension in Preventing Cerebral Infarction in Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

“…Several observational studies exist, but none had a control or comparison group, and the largest study numbered 95 patients. [15][16][17][18][19][20][21][22][23][24][25][26][27][28] Most studies focused on clinical response to the intervention, whereas information on long-term functional outcome is scarce. Improvement of neurological deficits ranged from 50% to 100%, with most studies reporting improvement in around 80% of patients.…”

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

“…Of these, reports of studies were considered for inclusion in our review. 15,16,[19][20][21][22][23][27][28][29][30][31][32][33][34] One study was excluded as the treatment group included both those with hypervolaemic fluid supplementation and normovolaemic colloid administration and consequently effects of either of these interventions and consequent physiological changes could not be reliably attributed. 35 Two studies were excluded as the majority of patients in the treatment group had suspected vasospasm whilst those in the control did not.…”

“…[19][20][21][22]28 Four were cohort studies 27,29,30,33 ; for one of these the study protocol was published prospectively. 27 Seven reported 19,20,[27][28][29][30]33 One reported only on cerebral blood flow (CBF), as measured using CT perfusion scanning. 21,22 In six studies, the intervention was introduced as a prophylactic measure.…”

“…One cohort study by Roy, et al 33 compared outcomes between patients treated for DND with noradrenaline with those treated with phenylephrine. This demonstrated that significantly more patients in the noradrenaline group exhibited neurological improvement (94% vs. 71%; p=0.01) and were discharged to home or an acute rehabilitation facility (94% vs 73%; p=0.02) than in the phenylephrine group.…”

Commentary: Posterior Reversible Encephalopathy Syndrome as a Complication of Induced Hypertension in Subarachnoid Hemorrhage: A Case-Control Study

“…8,9 In a retrospective study, patients treated with phenylephrine for DCI after SAH were less responder to IH treatment in terms of clinical improvement and had more delayed infarct on imaging, compared to patients treated with norepinephrine. 10 In this direction, interesting results showed an increase in CBF secondary to an increase of CO in patients with DCI, independently of MAP. 11 Thus, if the choice of the vasopressor is of importance, probably more important is the choice of the most appropriate monitoring devices, in regard of the patient condition and the choice of the targets.…”