Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

Seule, Martin; Muroi, Carl; Sikorski, Christopher; Hugelshofer, Michael; Winkler, Kerstin; Keller, Emanuela

doi:10.1007/s12028-013-9927-x

Cited by 26 publications

(17 citation statements)

References 50 publications

(65 reference statements)

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“…As previously suggested, TH mediates its neuroprotective effects by modulations of molecular, metabolic and inflammatory processes, possibly supporting associations with cerebral blood flow velocities [6,12,[28][29][30] . Such a mechanistic association of TH seems likely, yet its influence on actual peak spasm and its clinical significance warrant further investigations [31] . Available clinical studies have investigated TH rather as acute treatment strategy for increased ICP than for its effects on vasospasm and DCI [12-14, 29, 31] .…”

Section: Discussionmentioning

confidence: 96%

“…Reported macrovascular spasm rate may be exaggerated as low Doppler thresholds were applied and hypothermia itself may reduce cerebral blood flow limiting the interpretation of Doppler-based results but reinforce the positive associations of TH for DCI and functional outcome [23,31] . Within this study, DCI rate was very high as DCI detection was based exclusively on CT findings rather than on apparent neurologic deficits or multimodal imaging since assessment and executability in critically ill, mechanically ventilated SAH patients are limited.…”

Section: Discussionmentioning

confidence: 99%

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Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia

Kuramatsu

Kollmar²,

Gerner³

et al. 2015

Cerebrovasc Dis

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Background: Therapeutic hypothermia (TH) is an established treatment after cardiac arrest and growing evidence supports its use as neuroprotective treatment in stroke. Only few and heterogeneous studies exist on the effect of hypothermia in subarachnoid hemorrhage (SAH). A novel approach of early and prolonged TH and its influence on key complications in poor-grade SAH, vasospasm and delayed cerebral ischemia (DCI) was evaluated. Methods: This observational matched controlled study included 36 poor-grade (Hunt and Hess Scale >3 and World Federation of Neurosurgical Societies Scale >3) SAH patients. Twelve patients received early TH (<48 h after ictus), mild (35°C), prolonged (7 ± 1 days) and were matched to 24 patients from the prospective SAH database. Vasospasm was diagnosed by angiography, macrovascular spasm serially evaluated by Doppler sonography and DCI was defined as new infarction on follow-up CT. Functional outcome was assessed at 6 months by modified Rankin Scale (mRS) and categorized as favorable (mRS score 0-2) versus unfavorable (mRS score 3-6) outcome. Results: Angiographic vasospasm was present in 71.0% of patients. TH neither influenced occurrence nor duration, but the degree of macrovascular spasm as well as peak spastic velocities were significantly reduced (p < 0.05). Frequency of DCI was 87.5% in non-TH vs. 50% in TH-treated patients, translating into a relative risk reduction of 43% and preventive risk ratio of 0.33 (95% CI 0.14-0.77, p = 0.036). Favorable functional outcome was twice as frequent in TH-treated patients 66.7 vs. 33.3% of non-TH (p = 0.06). Conclusion: Early and prolonged TH was associated with a reduced degree of macrovascular spasm and significantly decreased occurrence of DCI, possibly ameliorating functional outcome. TH may represent a promising neuroprotective therapy possibly targeting multiple pathways of DCI development, notably macrovascular spasm, which strongly warrants further evaluation of its clinical impact.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia

Kuramatsu

Kollmar²,

Gerner³

et al. 2015

Cerebrovasc Dis

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“…Despite evidence from animal studies that therapeutic hypothermia may reduce secondary brain injury and the risk of cerebral vasospasm, hypothermia during aneurysm surgery has failed to demonstrate a clinical benefit [25]. One recent study examined Doppler middle cerebral artery (MCA) blood flow after induction of therapeutic hypothermia (33°, on average 5 days after SAH) in patients with increased intracranial pressure or DCI [25]. The authors demonstrated that therapeutic hypothermia resulted in decreased MCA blood flow, suggesting that therapeutic hypothermia may be useful for select patients.…”

Section: Improving Neurological Outcomes After Subarachnoid Hemorrhagementioning

confidence: 99%

Postoperative ICU management of patients after subarachnoid hemorrhage

Gruenbaum

Bilotta²

2014

Current Opinion in Anaesthesiology

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Purpose of review This article reviews recent advances in the postoperative ICU management of patients after subarachnoid hemorrhage (SAH), especially with regards to hemodynamic management, methods of improving neurological outcomes, and management of cardiac and pulmonary complications. Recent findings Several hemodynamic monitors and parameters may be useful for guiding volume therapy, including cardiac output, stroke volume variation monitoring, and global end-diastolic volume index. Early goal-directed hemodynamic therapy after SAH has recently been shown to improve clinical outcomes in patients with a poor clinical grade or coexisting cardiopulmonary complications. Recent laboratory and imaging modalities are being developed to identify patients at risk for developing vasospasm after SAH. Evidence for the use of various prophylactic adjuvant therapies to prevent vasospasm, including magnesium, phosphodiesterase 3 inhibitors, and therapeutic hypothermia, is emerging. Intrathecal administration of vasodilators or fibrinolytics may have offered advantages over systemic drug administration in the treatment of vasospasm. Pulmonary and cardiac complications are common after SAH, and are associated with an increased risk of mortality. Summary The postoperative ICU period after SAH is associated with a significant morbidity and mortality risk, and recent studies have greatly contributed to our understanding of how to optimally manage these patients.

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“…A few very interesting randomized trials are currently investigating neurocritical care measures beyond neurosurgery in or including SAH: EARLYDRAIN on early lumbar drainage combined with EVD [9], SETPOINT2 on early tracheostomy [10], NEWTON on slow-release nimodipine via EVD [11], ULTRA on early tranexamic acid [12], and HIMALAIA on induced hypertension [13]. However, there are so many other NCCU aspects to be addressed prospectively: level of sedation, modes of ventilation [14,15], cardiopulmonary stability [16,17], monitoring-based circulatory strategies [18], temperature control [19][20][21], delirium management, the nursing factor and mobilization, policies of do-not-resuscitate orders and withdrawal of care [22,23], and many other day-to-day care decisions that may substantially impact outcome. Particularly, the poor-grade SAH patient, prone to so many cerebral and systemic complications, may benefit from aggressive surveillance, superb nursing care, and close clinical monitoring.…”

mentioning

confidence: 99%

What Do We Mean by Poor-Grade Aneurysmal Subarachnoid Hemorrhage and What Can We Do?

Bösel

2016

Neurocrit Care

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Therapeutic Hypothermia Reduces Middle Cerebral Artery Flow Velocity in Patients with Severe Aneurysmal Subarachnoid Hemorrhage

Cited by 26 publications

References 50 publications

Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia

Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia

Postoperative ICU management of patients after subarachnoid hemorrhage

What Do We Mean by Poor-Grade Aneurysmal Subarachnoid Hemorrhage and What Can We Do?

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