Results of a preventive rebleeding protocol in patients with ruptured cerebral aneurysm: A retrospective cohort study

Abstract

Objective: In 2015, a protocol to prevent rebleeding was implemented to improve the outcome of patients with ruptured intracranial aneurysm. We performed a single-center retrospective analysis to compare the outcomes of pre/post using protocol. Methodology: Over a 3-year period, 208 patients with ruptured cerebral aneurysm were treated at our institution. The protocol for preventing rebleeding was initiated in 2015. We compared the two cohorts between the group of patients before initiating the protocol ( n = 104) and after initiating the protocol ( n = 104). We analyzed the protocol for preventing rebleeding which consisted of absolute bed rest, adequate pain control, avoiding stimuli (R), keeping euvolemia (E), preoperative systolic blood pressure <160 mmHg and within 140–180 mmHg after definite treatment (S), a short course (<72 h) of intravenous transaminic acid, and aneurysm treatment as early as possible (T). Outcomes are presented as in-hospital rebleeding, delayed cerebral ischemia (DCI), and proportion of unfavorable outcomes (score of 4–6 on a modified Rankin scale at 6 and 12 months). Results: Postprotocol, there was a reduction in the incidence of in-hospital rebleeding from 6.7% to 2.8% ( P = 0.20, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.10–1.63) and in the proportion of patients who presented with good WFNS grades (1–3) with unfavorable clinical outcomes at 12 months from 27.0% to 12.8% ( P = 0.03, OR = 0.40, 95% CI = 0.17–0.95). The DCI experienced a significant reduction from 44.2% to 7.7% ( P < 0.001, OR = 0.10, 95% CI = 0.04–0.23), and their 180-day mortality rate in good WFNS grades patients decreased from 16.3% to 8.8% (hazard ratio 0.80, 95% CI = 0.28–2.28). Conclusion: Ruptured cerebral aneurysm patients benefit from this protocol due to its ability to reduce the incidence of DCI and reduce unfavorable outcome on good WFNS grade patients.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

“…362 With euvolemia as part of goal-directed therapy, DCI was observed in 13% of the patients in the goal-directed therapy group and in 32% of the patients in the control group (odds ratio, 0.324 [95% CI, 0.11–0.86]; P =0.021) in 1 study. 245 Duangthongphon and colleagues 320 found that initiation of the euvolemic protocol reduced DCI from 44.2% to 7.7% (odds ratio, 0.10 [95% CI, 0.04–0.23]; P <0.001). Furthermore, mortality rates in patients with a good WFNS grade decreased from 16.3% to 8.8% (hazard ratio, 0.80 [95% CI, 0.28–2.28]).…”

“…In patients with aSAH, maintaining euvolemia can be beneficial in preventing DCI and improving functional outcomes. 320,321 2b B-NR 3. In patients with aSAH and symptomatic vasospasm, elevating systolic BP values may be reasonable to reduce the progression and severity of DCI.…”

CT perfusion-guided administration of IV milrinone is associated with a reduction in delayed cerebral infarction after subarachnoid hemorrhage

“…Even though those diagnostic tools are widely accepted, consensual treatments are very few 18 , 19 , and first consist in non-pharmacological approaches aiming at optimizing systemic and ergo cerebral hemodynamics, mainly through euvolemia 20 , 21 and elevated blood pressure 22 , 23 . The principal drug used in prophylaxis is nimodipine, which systemic administration has been shown to improve patients outcome 24 , 25 .…”

Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage

“…A retrospective, single-center cohort study found a low incidence (3.1%) of rebleeding after the implementation of a strategy of intensive reduction of systolic blood pressure (target 120 ± 20 mm Hg) but did not include a control group [ 26 ]. Another retrospective, single-center study investigated the incidence of rebleeding before and after implementation of a blood pressure management protocol (systolic blood pressure target 160 mm Hg) [ 27 ]. After implementation of the protocol, a trend was observed toward a lower incidence of in-hospital rebleeding and a lower incidence of DCI compared with the time period prior to implementation of the protocol.…”