Intra-aortic Balloon Pump Counterpulsation in the Management of Concomitant Cerebral Vasospasm and Cardiac Failure after Subarachnoid Hemorrhage: Technical Case Report

Abstract

We report two patients who had symptomatic cerebral vasospasm and cardiac failure after aneurysmal subarachnoid hemorrhage and who were treated successfully with intra-aortic balloon pump counterpulsation therapy. Both patients developed congestive heart failure and pulmonary edema while receiving postoperative hypertensive, hypervolemic, hemodilutional (Triple-H) therapy for symptomatic cerebral vasospasm. Both cases of cardiac failure were refractory to maximum pressor and inotropic infusions. Intra-aortic balloon pump counterpulsation was used to optimize cardiac performance to allow continuation of Triple-H therapy and to maintain adequate cerebral perfusion in an attempt to decrease the risk of cerebral ischemic complications. Both patients have had good long-term outcomes. These two cases illustrate the potential usefulness of the intra-aortic balloon pump as an adjunct to Triple-H therapy in patients with symptomatic cerebral vasospasm and cardiac failure. To our knowledge, this report documents the first clinical application of this adjunctive therapy for vasospasm after aneurysmal subarachnoid hemorrhage.

Cardiogenic Shock with Stunned Myocardium during Triple-H Therapy Treated with Intra-aortic Balloon Pump Counterpulsation

“…To our knowledge, IABP has been used before in only six patients with SAH to increase cerebral perfusion pressure in the setting of vasospasm [25,[38][39][40] ( Table 2). The ability of IABP counterpulsation to improve cerebral perfusion pressure in human subjects was reported by Nussbaum et al [38] in a patient suffering from SAH and myocardial infarction secondary to triple-H therapy for vasospasm.…”

Intra‐aortic counterpulsation during carotid stenting

“…PTA and stenting of the carotid artery is perceived to be a good alternative to vascular surgery in the presence of multiple comorbid conditions especially when performed by a well experienced operator [4]. Nevertheless, the complications and risks of the procedure should be noted.…”

“…Furthermore, Apostolides et al [4] reported successful treatment using IABP therapy in two patients with concomitant cerebral vasospasm and cardiac failure after subarachnoid hemorrhage, illustrating the potential usefulness of IABP as an adjunctive treatment in patients with cerebrovascular insufficiency.…”

Current Options for the Management of Aneurysmal Subarachnoid Hemorrhage-Induced Cerebral Vasospasm: A Comprehensive Review of the Literature

“…The intra-aortic balloon pump has been successfully used to treat patients with symptomatic vasospasm who cannot tolerate or are refractory to ‘triple-H' therapy [129,130,131,132]. In 1 patient, CBF improvement ranging from 33 to 161% (average: 69.3%) above the baseline could be documented by serial measurements on xenon-enhanced CT [130].…”