Hemodynamic Management of Subarachnoid Hemorrhage

Abstract

Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.

Multicenter Prospective Cohort Study on Volume Management After Subarachnoid Hemorrhage

“…8,11,12,31,32 This lack of clarity may have arisen because the hemodynamics of each patient have been unclear in previous studies. Recently, goal-directed fluid management using a transpulmonary thermodilution system has given good results in treatment of SAH.…”

Early prediction of delayed cerebral ischemia in subarachnoid hemorrhage based on quantitative EEG: A prospective study in adults

“…In the case of relevant vasospasm or DCI/DIND, triple-H therapy (hypervolemia, hypertension, and hemodilution) (Treggiari, 2011) was initiated. If neurological deficits persisted, patients underwent interventional angiography and they were treated by chemical vasospasmolysis or balloon angioplasty (Sayama et al, 2006;Aburto-Murrieta et al, 2012).…”

Blood Pressure Control in Neurological ICU Patients: What is Too High and What is Too Low?

“…The goal is to prevent infarction by increasing MAP, and thus CBF, until neurological changes are reversed. A possible target range for SBP is 160-180mmHg, but this goal should be individualized based on age, severity, and cardiovascular comorbidities [29][30][31]. Therapeutic hypertension should be avoided in the setting of an unsecured aneurysm because of the risk of rebleeding [29][30][31].…”