Haemodynamic augmentation in the treatment of vasospasm in aneurysmal subarachnoid hemorrhage

Abstract

AIM: Hypertension, hypervolemia and hemodilution therapy is a common approach to cerebral vasospasm after subarachnoid haemorrhage. This study is designed to see the difference of moderate or aggressive hypervolemia supported with induced hypertension in symptomatic vasospasm detected with transcranial Doppler ultrasonography (TCD) measurements. MATeRIAL and MeTHods:Fifty eight patients who had aneurysm clipping and were admitted to the neurointensive care unit were treated with normovolemia and induced hypertension (n=35) or hypervolemia supported with induced hypertension (n=23) targeting a mean arterial pressure of 110-130 mm Hg and central venous pressure of 8-12 mm Hg. Daily TCD, fluid intake, fluid balance and haemodynamic values were recorded for 14 days.ResULTs: There were no differences detected in mean arterial pressure, central venous pressure, hematocrit values, fluid balance and middle cerebral artery flow velocities between the two groups through 14 days (p>0.05). Hyponatremia, pulmonary edema and cerebral ischemia were observed as complications. CoNCLUsIoN:Hypervolemia adds no benefit compared to normovolemia in the treatment of vasospasm occurred as a result of subarachnoid hemorrhage. Induced hypertension establishes the haemodynamic augmentation to prevent and treat vasospasm. BULGULAR:On dört gün boyunca takip edilen ortalama arter basıncı, santral venöz basınç, hematokrit değerleri, sıvı dengesi ve orta serebral arter akım hızlarında iki grup arasında fark yoktu. Komplikasyon olarak hiponatremi, pulmoner ödem ve serebral iskemi kaydedildi. soNUÇ: Subaraknoid kanama sonucu ortaya çıkan vasospasmın tedavisinde normovolemi ile karşılaştırıldığında hipervolemi ek bir yarar sunmamaktadır. Hipertansiyon vasospasmı önlemek ve tedavi etmek için gereken hemodinamik desteği sağlamaktadır.

Fluid management of the neurological patient: a concise review

“…The mean fluid intake was around 3–4 L/day in SAH patients who were treated with normovolemia or received fluid management based on volumetric haemodynamic monitoring versus 4–5 L/day in patients managed with hypervolemic treatment which often included CVP or pulmonary artery occlusion pressure (PAOP)-directed management. Fluid balances generally did not differ between both treatment groups and varied around neutral balance (−0.5 to +1 L) even in a study where mean daily fluid intake was >8 L [ 28 ]. Only one study [ 30 ] included weight-normalized fluid intake (ml/kg/day).…”

“…Positive fluid balances have been associated with (angiographic) vasospasm, longer hospital length of stay and poor functional outcomes [ 27 , 37 ] (see Additional file 1 ). Higher fluid intake has been associated with more cardiovascular side effects and DCI/delayed ischaemic neurologic deficit (DIND)/infarctions [ 25 , 27 , 28 , 30 , 31 , 34 , 35 ]. One may argue that the adverse prognostic value of aggressive fluid loading may reflect more intense treatments in more severely affected patients rather than causal associations because many of these studies are observational cohort studies undoubtedly prone to confounding.…”