Treatment of Ischemic Deficits from Vasospasm with Intravascular Volume Expansion and Induced Arterial Hypertension

Abstract

In 58 patients with progressive neurological deterioration from angiographically confirmed cerebral vasospasm after spontaneous subarachnoid hemorrhage, arterial hypertension was induced in an attempt to improve their deficits. The most effective regimen consisted of intravascular volume expansion, blockade of the vagal depressor response, and the administration of antidiuretics and vasopressor agents. With this protocol, arterial blood pressure could be sustained at high levels for prolonged periods. Neurological deterioration was reversed in 47 patients, transiently in 4; permanent improvement occurred in 43. Complications experienced during therapy included pulmonary edema, dilutional hyponatremia, aneurysmal rebleeding, coagulopathy, hemothorax, and myocardial infarction. Elevating systemic arterial pressure in states of cerebrovascular insufficiency resulting from vasospasm is safe if meticulous attention is paid to physiological, biochemical, and hematological parameters, with the exception that it may be hazardous in the presence of an untreated ruptured or intact aneurysm. Intravascular volume expansion and induced hypertension are effective in reversing ischemic deficits from vasospasm provided that treatment commences before cerebral infarction and that adequate pressures are maintained for a sufficient period. The production of a hypervolemic state by the use of colloid and crystalloid infusion accompanied by atropine blockade of the vagal depressor response and blunting of the diuresis with vasopressin enables arterial pressure to be elevated for longer than 1 week.

Intraventricular Nicardipine for Refractory Cerebral Vasospasm after Subarachnoid Hemorrhage

“…Blood pressure augmentation is achieved using vasopressors or inotropes in patients who remain symptomatic. The resolution of neurologic deficits from cerebral vasospasm with triple H therapy has been reported in several uncontrolled studies; however, triple H therapy may carry significant morbidity [5][6][7][8][9][10]. Published studies show conflicting results with relation to the effect of triple H on cerebral blood flow and on the development of infarcts.…”

Comparison of Initial Vasopressors Used for Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage

“…This is mainly supported by noncontrolled case series, which have demonstrated success with the use of dopamine, NE, and PE [6,8,17,18]. However, no randomized trials have compared the efficacy of these agents.…”

Quantitative Regional Cerebral Blood Flow Measurement Techniques Improve Noninvasive Detection of Cerebrovascular Vasospasm after Aneurysmal Subarachnoid Hemorrhage

“…These findings were finally confirmed by PA and thus underline the impact of rCBF measurements in this indication as it allows the initiation of specific treatment modalities without any further invasive diagnostic investigations. The definite diagnosis of this condition is of considerable value since the general therapeutic measures used for the treatment of VS, such as hypervolemic-hyperdynamic hemodilution, carry some serious medical risks, especially when applied to hyperemic patients [16, 33]. …”