Effect of Hypervolemic Therapy on Cerebral Blood Flow After Subarachnoid Hemorrhage

Abstract

Background and Purpose-Cerebral blood flow (CBF) is reduced after subarachnoid hemorrhage (SAH), and symptomatic vasospasm is a major cause of morbidity and mortality. Volume expansion has been reported to increase CBF after SAH, but CBF values in hypervolemic (HV) and normovolemic (NV) subjects have never been directly compared. Methods-On the day after aneurysm clipping, we randomly assigned 82 patients to receive HV or NV fluid management until SAH day 14. In addition to 80 mL/h of isotonic crystalloid, 250 mL of 5% albumin solution was given every 2 hours to maintain normal (NV group, nϭ41) or elevated (HV group, nϭ41) cardiac filling pressures. CBF ( 133 xenon clearance) was measured before randomization and approximately every 3 days thereafter (mean, 4.5 studies per patient). Results-HV patients received significantly more fluid and had higher pulmonary artery diastolic and central venous pressures than NV patients, but there was no effect on net fluid balance or on blood volume measured on the third postoperative day. There was no difference in mean global CBF during the treatment period between HV and NV patients (Pϭ0.55, random-effects model). Symptomatic vasospasm occurred in 20% of patients in each group and was associated with reduced minimum regional CBF values (Pϭ0.04). However, there was also no difference in minimum regional CBF between the 2 treatment groups. Conclusions-HV therapy resulted in increased cardiac filling pressures and fluid intake but did not increase CBF or blood volume compared with NV therapy. Although careful fluid management to avoid hypovolemia may reduce the risk of delayed cerebral ischemia after SAH, prophylactic HV therapy is unlikely to confer an additional benefit. (Stroke. 2000;31:383-391.)

Milrinone Reduces Cerebral Vasospasm After Subarachnoid Hemorrhage of WFNS Grade IV or V

“…5,15) Vasospasm is known to occur more often and with greater severity if the initial grade of injury is high. SAH invariably induces cerebral vasospasm within 3 weeks of the initial ictus.…”

A multicenter prospective cohort study of volume management after subarachnoid hemorrhage: circulatory characteristics of pulmonary edema after subarachnoid hemorrhage

“…2,17 In contrast, triple-H therapy has been shown to not be superior to normovolemic fluid therapy in the prevention of DCI. 5 Moreover, Lennihan et al 19 have reported that triple-H therapy does not increase cerebral blood flow. Therefore, it is necessary to validate the benefits of triple-H therapy and clarify the characteristics of systemic circulation after SAH.…”

“…Some studies have suggested that triple-H therapy increases the incidence of heart failure and pulmonary edema in patients with SAH. 5,19,38 Pulmonary edema is common after SAH; neurogenic pulmonary edema may occur in the acute phase of SAH. Moreover, pulmonary edema associated with SAH has a variety of causes.…”

The Critical Care Management of Aneurysmal Subarachnoid Hemorrhage

“…Induced hypervolemia has been investigated in two prospective randomized trials -no benefit was found in vasospasm or clinical outcome [33,34]. Therefore, our clinical practice is to target euvolemia.…”