Systolic Blood Pressure Variability is a Novel Risk Factor for Rebleeding in Acute Subarachnoid Hemorrhage

Abstract

Rebleeding of an aneurysm is a major cause of morbidity and mortality after subarachnoid hemorrhage (SAH). Whereas numerous studies have demonstrated predictors of rebleeding and effect of systolic blood pressure variability (SBPV) on stroke, few data on the association between SBPV and rebleeding.Here, we sought to identify the effect of SBPV on rebleeding in acute aneurysmal SAH.Case–control study.From January 2010 to June 2015, 612 patients with aneurysmal SAH were enrolled in our tertiary care medical center.Main outcome measures: Consecutive patients with acute (<3 days from ictus) aneurismal rebleeding or repair or death were retrospectively included. Antihypertensive therapy based on a predefined standardized protocol was prescribed to lower and maintain SBP between 120 and 160 mm Hg. SBP was measured hourly until a censoring event occurred. SBPV was determined as standard deviation (SD) and successive variation (SV). Binary logistic regression was used to assess the association between SBPV and rebleeding.Rebleeding occurred in 61 (10.0%) of the 612 patients. We identified 47 acute rebleeding as cases and 382 early repair or early death as controls. On binary logistic regression analysis, rebleeding was associated with the SD of SBP (odds ratio [OR], 1.254; 95% confidence interval [CI], 1.131–1.391; P < 0.001) and the SV of SBP (OR, 1.131; 95% CI, 1.039–1.231; P = 0.004). No significant difference was seen between rebleeding and mean systolic blood pressure (MSBP).SBPV is associated with increased rates of acute aneurysmal rebleeding. Further prospective research is warranted to confirm that SBP stability prevents acute aneurysm rebleeding.

Outcome of In-Hospital Rebleeding and Early Aneurysm Rupture at the Referral Center

“…Despite several reports on the dismal prognosis of inhospital rebleeding [8,19,20], we found 68.2% favorable outcome (mRS=0, 1 and 2) in our series. We believe that the lobectomy with a large Frazier suction tip (Fr 12) in this technique provides the ideal surgical corridor for access to the aneurysm and its main feeders without causing significant neurologic damages (Figure 1; A, B and C).…”

“…With the provided technique, we have achieved favorable outcomes in as much as 68% (15 of 22) of patients. functional outcome [8,19,20]. Data regarding the efficacy of antifibrinolytics in prevention of rebleeding are equivocal [21] and early surgery still remains the only hope they have for survival.…”

“…Risk factors for rebleeding are low Glasgow Coma Scale (GCS) score [3,4,6], poor Hunt and Hess (H&H) clinical grades 3 or 4, high systolic blood pressure [4,7], systolic blood pressure variability [8], intraventricular or intracerebral hematoma [4,9], number of aneurysms [10], and undergoing angiographic evaluation within 6 hours of SAH [4]. Genotyping assays performed on blood samples of patients with aSAH have detected common endothelin Single Nucleotide Polymorphism (SNP) on blood samples of patients with aSAH and identified TT genotype of EDN1 G/T SNP as an independent risk factor [11].…”

Blood pressure management in stroke patients

“…European guidelines recommend a MAP above 90 mmHg to maintain proper CPP [22]. Recent studies have reported that BP variability is also associated with rebleeding or other negative outcomes in patients with acute SAH [23,24]. In the case of symptomatic cerebral vasospasm and delayed cerebral ischemia after SAH, induced hypertension is recommended by some guidelines [20,21].…”

Blutdruckmanagement beim akuten Schlaganfall (Ischämie, Blutung, SAB)

“…Ebenso zeigte eine größere retrospektive Observations-studie (n = 612), dass spezifische Blutdruckparameter, wie z. B. die systolische Blutdruckvariabilität, mit einer erhöhten Nachblutungsrate assoziiert sind [75]. Im Umkehrschluss identifizierte eine weitere retrospektive Arbeit (n = 309), dass ein systolischer Blutdruck von um die 120 mmHg (100-140 mmHg) mit selteneren Nachblutungen vergesellschaftet sei [76].…”