Statin Use in Patients with Aneurysmal Subarachnoid Hemorrhage May not Significantly Reduce the Occurrence of Delayed Ischemic Neurological Deficit

OBJECTIVECerebral vasospasm (CV) is a delayed, sustained contraction of the cerebral arteries that tends to occur 3–14 days after aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured aneurysm. Vasospasm potentially leads to delayed cerebral ischemia, and despite medical treatment, 1 of 3 patients suffer a persistent neurological deficit. Bedside transcranial Doppler (TCD) ultrasonography is used to indirectly detect CV through recognition of an increase in cerebral blood flow velocity (CBFV). The present study aimed to use TCD ultrasonography to monitor how CBFV changes on both the ipsi- and contralateral sides of the brain in the first 24 hours after patients have received a stellate ganglion block (SGB) to treat CV that persists despite maximum standard therapy.METHODSThe data were culled from records of patients treated between 2013 and 2017. Patients were included if an SGB was administered following aSAH, whose CBFV was ≥ 120 cm/sec and who had either a focal neurological deficit or reduced consciousness despite having received medical treatment and blood pressure management. The SGB was performed on the side where the highest CBFV had been recorded with 8–10 ml ropivacaine 0.2%. The patient’s CBFV was reassessed after 2 and 24 hours.RESULTSThirty-seven patients (male/female ratio 18:19), age 17–70 years (mean age 49.9 ± 11.1), who harbored 13 clipped and 22 coiled aneurysms (1 patient received both a coil and a clip, and 3 patients had 3 untreated aneurysms) had at least one SGB. Patients received up to 4 SGBs, and thus the study comprised a total of 76 SGBs.After the first SGB, CBFV decreased in 80.5% of patients after 2 hours, from a mean of 160.3 ± 28.2 cm/sec to 127.5 ± 34.3 cm/sec (p < 0.001), and it further decreased in 63.4% after 24 hours to 137.2 ± 38.2 cm/sec (p = 0.007). A similar significant effect was found for the subsequent SGB. Adding clonidine showed no significant effect on either the onset or the duration of the SGB. Contralateral middle cerebral artery (MCA) blood flow was not reduced by the SGB.CONCLUSIONSTo the authors’ knowledge, this is the largest study on the effects of administering an SGB to aSAH patients after aneurysm rupture. The data showed a significant reduction in ipsilateral CBFV (MCA 20.5%) after SGB, lasting in about two-thirds of cases for over 24 hours with no major complications resulting from the SGB.

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STATIN USE WAS NOT ASSOCIATED WITH LESS VASOSPASM OR IMPROVED OUTCOME AFTER SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000316009.19012.e3 ◽

2008 ◽

Vol 62 (2) ◽

pp. 422-430 ◽

Cited By ~ 67

Author(s):

Andreas H. Kramer ◽

Matthew J. Gurka ◽

Bart Nathan ◽

Aaron S. Dumont ◽

Neal F. Kassell ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Vegetative State ◽

Treatment Protocol ◽

Poor Outcome ◽

Reductase Inhibitors ◽

Symptomatic Vasospasm ◽

Endovascular Coil Embolization ◽

Baseline Characteristics ◽

Statin Use

Abstract OBJECTIVE The development of delayed ischemia caused by cerebral vasospasm remains a common cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. Preliminary studies suggest that 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) may decrease the risk of vasospasm, but additional study is required. METHODS Beginning in May 2006, our treatment protocol for patients presenting with subarachnoid hemorrhage was altered to routinely include the use of 80 mg of simvastatin per day for 14 days. Before this time, only patients with other indications for statins were treated. The charts of 203 consecutive patients over a period of 27 months were retrospectively reviewed, and 150 patients were included in the analysis, of whom 71 patients received statins. These patients were compared with 79 untreated patients to determine whether or not the use of statins was associated with a reduction in the occurrence of vasospasm, delayed infarction, or poor outcome (death, vegetative state, or severe disability). RESULTS Patients who were treated with statins and those who were not had similar baseline characteristics, although more patients in the former group were managed with endovascular coil embolization. There were no statistically significant differences in the proportion of patients developing at least moderate radiographic vasospasm (41% with statins versus 42% without, P = 0.91), symptomatic vasospasm (32% with statins versus 25% without, P = 0.34), delayed infarction (23% with statins versus 28% without, P = 0.46), or poor outcome (39% with statins versus 35% without, P = 0.61). After adjustment for differences in baseline characteristics, including the method of aneurysm treatment, statins were still not significantly protective. CONCLUSION The addition of statins to standard care was not associated with any reduction in the development of vasospasm or improvement in outcomes after aneurysmal subarachnoid hemorrhage. If there is a benefit to statin use, it may be smaller than suggested by previous studies. However, further randomized controlled trials are awaited.

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Is routine transcranial Doppler ultrasound monitoring useful in the management of subarachnoid hemorrhage?

Journal of Neurosurgery ◽

10.3171/jns.1998.88.2.0272 ◽

1998 ◽

Vol 88 (2) ◽

pp. 272-276 ◽

Cited By ~ 46

Author(s):

Joanna M. Wardlaw ◽

Ruth Offin ◽

Graham M. Teasdale ◽

Evelyn M. Teasdale

Keyword(s):

Subarachnoid Hemorrhage ◽

Neurological Deficit ◽

Transcranial Doppler ◽

Controlled Trial ◽

Positive Contribution ◽

Content Type ◽

Delayed Ischemic Neurological Deficit ◽

Ultrasound Monitoring ◽

The Impact ◽

Fine Print

Object. In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Methods. Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and led to altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were generally accurate when compared with those obtained on angiography. Conclusions. A routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleaned from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess both these points definitively.

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Is routine transcranial Doppler ultrasound useful in the management of subarachnoid hemorrhage?

Neurosurgical FOCUS ◽

10.3171/foc.1997.3.4.4 ◽

1997 ◽

Vol 3 (4) ◽

pp. E3 ◽

Cited By ~ 1

Author(s):

Joanna M. Wardlaw ◽

Ruth Offin ◽

Graham M. Teasdale ◽

Evelyn M. Teasdale

Keyword(s):

Subarachnoid Hemorrhage ◽

Neurological Deficit ◽

Transcranial Doppler ◽

Prospective Observational Study ◽

Controlled Trial ◽

Transcranial Doppler Ultrasound ◽

Positive Contribution ◽

Delayed Ischemic Neurological Deficit ◽

Ultrasound Monitoring ◽

The Impact

In this prospective observational study, the authors assess the impact of routine transcranial Doppler (TCD) ultrasound monitoring on the diagnosis, management, and outcome of delayed ischemic neurological deficit complicating subarachnoid hemorrhage (SAH). Over a 10-month period 186 patients admitted to a regional neurosciences center were included in the study. Three times a week, routine TCD examinations performed by neuroradiographers made an important positive contribution to the diagnosis of delayed ischemic neurological deficit in 72% of patients with this complication and altered management for the benefit of the patient in 43%. In 9% of patients with recent SAH, it was believed that the outcome might have been better if the TCD result had been acted upon appropriately. The TCD results did not adversely influence management or outcome and were accurate when compared with those obtained on angiography. The authors conclude that a routine TCD service provided by neuroradiographers is accurate and useful in diagnosing and managing elevated blood velocities and ischemic neurological deficit following SAH. In addition, it is possible that if the information gleened from TCD findings was used more often in patient management, outcome might be improved; however, a randomized controlled trial is necessary to assess this definitively.

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Observations on the perioperative management of aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.1986.65.1.0048 ◽

1986 ◽

Vol 65 (1) ◽

pp. 48-62 ◽

Cited By ~ 64

Author(s):

S. Sam Finn ◽

Sigurdur A. Stephensen ◽

Carole A. Miller ◽

Laura Drobnich ◽

William E. Hunt

Keyword(s):

Subarachnoid Hemorrhage ◽

Neurological Deficit ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Surgical Complication ◽

Neurological Deficits ◽

Arterial Line ◽

Postoperative Patient ◽

Content Type ◽

Wedge Pressure ◽

Fine Print

✓ Thirty-two patients with aneurysmal subarachnoid hemorrhage (SAH) were managed according to a protocol based on pain control and hemodynamic manipulation, monitored by an arterial line and Swan-Ganz catheter. Hemodynamic parameters were adjusted to four clinical situations. 1) For the unoperated patient with no neurological deficit, the regimen aims to maintain pulmonary wedge pressure (PWP) at 10 to 12 mm Hg, and the cardiac index (CI) and blood pressure (BP) at normal levels. 2) For the unoperated patient presenting with or developing neurological deficit, the PWP is increased until the deficit is reversed or the CI falls; the CI is high, and the BP normal. 3) For the postoperative patient with no neurological deficit, the PWP is maintained at 12 to 14 mm Hg, the CI is a high normal, and the BP is normal. 4) For the postoperative patient developing neurological deficit but showing no surgical complication on the computerized tomography scan, the PWP is increased until the deficit is reversed or the CI falls; the CI is high and the BP is increased with vasopressors if necessary. Fourteen patients developed neurological deficits either preoperatively, postoperatively, or both. Neurological deficits were repeatedly reversed by increasing the PWP, as measured hourly. In several patients an optimal wedge pressure was determined, below which deficits would reappear. In one patient whose neurological deficit was reversed on several occasions by increasing the PWP, the optimal PWP rose after each episode until it reached 22 mm Hg. Detailed event-related analysis of these patients' course illustrates these phenomena well. The optimal PWP varied from patient to patient, but ranged most frequently from 14 to 16 mm Hg. Meticulous monitoring of the patients' neurological status coupled with prompt correction of low PWP (assuming an adequate CI) has proven to be an effective way to prevent and reverse neurological deficits following aneurysmal SAH.

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