The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm

Abstract BACKGROUND Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. OBJECTIVE To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. METHODS A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. RESULTS A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7 ± 5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2 ± 15.5) was observed, whereas a decrease in cerebral glucose (0.9 ± 0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0 ± 2.0 mmol/L) and glycerol (104.4 ± 89.8 μmol/L) as well as a decrease of glucose (0.9 ± 0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3 ± 15.3, to lowest 30.5 ± 6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1 ± 33.1 μmol/L, to highest 141.4 ± 33.7 μmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. CONCLUSION The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.

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Relevance of intracranial hypertension for cerebral metabolism in aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2009.1.jns08587 ◽

2009 ◽

Vol 111 (1) ◽

pp. 94-101 ◽

Cited By ~ 40

Author(s):

Alexandra Nagel ◽

Daniela Graetz ◽

Tania Schink ◽

Katja Frieler ◽

Oliver Sakowitz ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Hypertension ◽

Brain Damage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Metabolism ◽

Strong Predictor ◽

Cerebral Microdialysis ◽

Secondary Brain Damage ◽

Fisher Grade ◽

Pyruvate Ratio

Object Intracranial hypertension, defined as intracranial pressure (ICP) ≥ 20 mm Hg, is a complication typically associated with head injury. Its impact on cerebral metabolism, ICP therapy, and outcome has rarely been studied in patients with aneurysmal subarachnoid hemorrhage (aSAH); such an assessment is the authors' goal in the present study. Methods Cerebral metabolism was prospectively studied in 182 patients with aSAH. The database was retrospectively analyzed with respect to ICP. Patients were classified into 2 groups based on ICP. There were 164 with low ICP (< 20 mm Hg) and 18 with high ICP (≥ 20 mm Hg, measured > 6 hours/day). Cerebral microdialysis parameters of energy metabolism, glycerol, and glutamate levels were analyzed hourly from the brain parenchyma of interest for 7 days. The 12-month outcome in these patients was evaluated. Results In the high ICP group, extended ICP therapy including decompressive craniectomy was necessary in 7 patients (39%). Cerebral glycerol levels and the lactate/pyruvate ratio were pathologically increased on Days 1–7 after aSAH (p < 0.001). The excitotoxic neurotransmitter glutamate and glycerol, a marker of membrane degradation, further increased on Days 5–7, probably reflecting the development of secondary brain damage. An ICP ≥ 20 mm Hg was shown to have a significant influence on the 12-month Glasgow Outcome Scale (GOS) score (p = 0.001) and was a strong predictor of mortality (OR = 24.6; p < 0.001). Glutamate (p = 0.012), the lactate/pyruvate ratio as a marker of anaerobic metabolism (p = 0.028), age (p < 0.001), and Fisher grade (p = 0.001) also influenced the GOS score at 12 months. Conclusions The authors confirmed the relevance of intracranial hypertension as a severe complication in patients with aSAH. Because high ICP is associated with a severely deranged cerebral metabolism and poor outcome, future studies focusing on metabolism-guided, optimized ICP therapy could help minimize secondary brain damage and improve prognosis in patients with aSAH.

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Detrimental effects of intrahospital transport on cerebral metabolism in patients suffering severe aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2020.8.jns202280 ◽

2021 ◽

pp. 1-8

Author(s):

Arthur Hosmann ◽

Carmen Angelmayr ◽

Andreas Hopf ◽

Steffen Rauscher ◽

Jonas Brugger ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Intracranial Hypertension ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Metabolism ◽

Cerebral Microdialysis ◽

Ct Scans ◽

Intrahospital Transport ◽

Imaging Results ◽

Neurosurgical Patients ◽

The Impact

OBJECTIVE Intrahospital transport for CT scans is routinely performed for neurosurgical patients. Particularly in the sedated and mechanically ventilated patient, intracranial hypertension and blood pressure fluctuations that might impair cerebral perfusion are frequently observed during these interventions. This study quantifies the impact of intrahospital patient transport on multimodality monitoring measurements, with a particular focus on cerebral metabolism. METHODS Forty intrahospital transports in 20 consecutive patients suffering severe aneurysmal subarachnoid hemorrhage (SAH) under continuous intracranial pressure (ICP), brain tissue oxygen tension (pbtO2), and cerebral microdialysis monitoring were prospectively included. Changes in multimodality neuromonitoring data during intrahospital transport to the CT scanner and the subsequent 10 hours were evaluated using linear mixed models. Furthermore, the impact of risk factors at transportation, such as cerebral vasospasm, cerebral hypoxia (pbtO2 < 15 mm Hg), metabolic crisis (lactate-pyruvate ratio [LPR] > 40), and transport duration on cerebral metabolism, was analyzed. RESULTS During the transport, the mean ICP significantly increased from 7.1 ± 3.9 mm Hg to 13.5 ± 6.0 mm Hg (p < 0.001). The ICP exceeded 20 mm Hg in 92.5% of patients; pbtO2 showed a parallel rise from 23.1 ± 13.3 mm Hg to 28.5 ± 23.6 mm Hg (p = 0.02) due to an increase in the fraction of inspired oxygen during the transport. Both ICP and pbtO2 returned to baseline values thereafter. Cerebral glycerol significantly increased from 71.0 ± 54.9 µmol/L to 75.3 ± 56.0 µmol/L during the transport (p = 0.01) and remained elevated for the following 9 hours. In contrast, cerebral pyruvate and lactate levels were stable during the transport but showed a significant secondary increase 1–8 hours and 2–9 hours, respectively, thereafter (p < 0.05). However, the LPR remained stable over the entire observation period. Patients with extended transport duration (more than 25 minutes) were found to have significantly higher levels of cerebral pyruvate and lactate as well as lower glutamate concentrations in the posttransport period. CONCLUSIONS Intrahospital transport and horizontal positioning during CT scans induce immediate intracranial hypertension and an increase in cerebral glycerol, suggesting neuronal injury. Afterward, sustained impairment of neuronal metabolism for several hours could be observed, which might increase the risk of secondary ischemic events. Therefore, intrahospital transport for neuroradiological imaging should be strongly reconsidered and only indicated if the expected benefit of imaging results outweighs the risks of transportation.

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Abstract TP425: The Impact of Social Determinants of Health on 1-Month Outcomes Post Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.51.suppl_1.tp425 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Drew Prescott ◽

Xueyuan Cao ◽

Brandon Baughman ◽

Ansley Stanfill

Keyword(s):

Subarachnoid Hemorrhage ◽

Drug Abuse ◽

Marital Status ◽

Social Determinants ◽

Household Income ◽

Physical Disability ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Stroke Severity ◽

Depression And Anxiety ◽

The Impact

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) carries high disability rates. Depression and anxiety are also common for survivors, but little work has been done to investigate the role of social determinants of health (SDOH) on such outcomes. The purpose of this abstract is to examine the impact of SDOH on physical disability, depression, and anxiety at 1-month post-aSAH, in order to better identify factors that are amenable to intervention to improve quality of life for these patients. Methods: A retrospective chart review was conducted of aSAH patients (selected by ICD-9/10 code) seen at a high-volume neurology and neurosurgery clinic from 2002-2018. Standard patient demographic and clinical characteristics were collected. The outcomes of physical disability, depression, and anxiety were also collected at 1-month post-aSAH. The studied SDOH characteristics were: race, gender, marital status, employment, smoking, drug/alcohol use, and household income level category (defined as low or middle income per US Census Bureau standards). Results: These patients (N=970) were 52.9 (±14.5) years old, 59.5% Caucasian, and 67.4% female. In addition to stroke severity measures (i.e., Hunt/Hess Grade, Fisher, GCS at time of admission), physical disability at 1-month was also associated with female gender, drug abuse, and low household income ( p ≤0.05). Depression at 1-month was not associated with stroke severity measures but was associated with these same SDOH factors and also with unemployment prior to aSAH ( p <0.0001). Anxiety was not associated with drug abuse or income in this group. Race, marital status, and smoking history were not found to be associated with these 1-month outcomes. Conclusions: This work demonstrates that measures of SDOH should be included in addition to clinical variables in a comprehensive predictive model of outcomes post-aSAH.

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Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard

Journal of Neurosurgery ◽

10.3171/2018.9.jns182105 ◽

2020 ◽

Vol 132 (1) ◽

pp. 79-86 ◽

Cited By ~ 3

Author(s):

Marvin Darkwah Oppong ◽

Kathrin Buffen ◽

Daniela Pierscianek ◽

Annika Herten ◽

Yahya Ahmadipour ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Antiplatelet Therapy ◽

Clinical Data ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Final Analysis ◽

Minor Bleeding ◽

Thrombolytic Agents ◽

Poor Outcome ◽

Hemorrhagic Complications ◽

The Impact

OBJECTIVEClinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.METHODSAll consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients’ charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.RESULTSSixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.CONCLUSIONSSHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.

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THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311351.32904.8b ◽

2008 ◽

Vol 62 (3) ◽

pp. 610-617 ◽

Cited By ~ 47

Author(s):

Leonie Jestaedt ◽

Mirko Pham ◽

Andreas J. Bartsch ◽

Ekkehard Kunze ◽

Klaus Roosen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Fisher Exact Test ◽

Computed Tomographic ◽

Fisher Grade ◽

The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (>70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P < 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

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Cigarette smoking and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide analysis

Journal of Neurosurgery ◽

10.3171/2016.10.jns16748 ◽

2017 ◽

Vol 129 (2) ◽

pp. 446-457 ◽

Cited By ~ 10

Author(s):

Hormuzdiyar H. Dasenbrock ◽

Robert F. Rudy ◽

Pui Man Rosalind Lai ◽

Timothy R. Smith ◽

Kai U. Frerichs ◽

...

Keyword(s):

Sensitivity Analysis ◽

Subarachnoid Hemorrhage ◽

Cigarette Smoking ◽

Cerebral Aneurysm ◽

Scale Score ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Institutional Care ◽

Care Facility ◽

Severity Scale ◽

The Impact

OBJECTIVEAlthough cigarette smoking is one of the strongest risk factors for cerebral aneurysm development and rupture, there are limited data evaluating the impact of smoking on outcomes after aneurysmal subarachnoid hemorrhage (SAH). Additionally, two recent studies suggested that nicotine replacement therapy was associated with improved neurological outcomes among smokers who had sustained an SAH compared with smokers who did not receive nicotine.METHODSPatients who underwent endovascular or microsurgical repair of a ruptured cerebral aneurysm were extracted from the Nationwide Inpatient Sample (NIS, 2009–2011) and stratified by cigarette smoking. Multivariable logistic regression analyzed in-hospital mortality, complications, tracheostomy or gastrostomy placement, and discharge to institutional care (a nursing or an extended care facility). Additionally, the composite NIS-SAH outcome measure (based on mortality, tracheostomy or gastrostomy, and discharge disposition) was evaluated, which has been shown to have excellent agreement with a modified Rankin Scale score greater than 3. Covariates included in regression constructs were patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities (including hypertension, drug and alcohol abuse), the NIS-SAH severity scale (previously validated against the Hunt and Hess grade), treatment modality used for aneurysm repair, and hospital characteristics. A sensitivity analysis was performed matching smokers to nonsmokers on age, sex, number of comorbidities, and NIS-SAH severity scale score.RESULTSAmong the 5784 admissions evaluated, 37.1% (n = 2148) had a diagnosis of tobacco use, of which 31.1% (n = 1800) were current and 6.0% (n = 348) prior tobacco users. Smokers were significantly younger (mean age 51.4 vs 56.2 years) and had more comorbidities compared with nonsmokers (p < 0.001). There were no significant differences in mortality, total complications, or neurological complications by smoking status. However, compared with nonsmokers, smokers had significantly decreased adjusted odds of tracheostomy or gastrostomy placement (11.9% vs 22.7%, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51–0.78, p < 0.001), discharge to institutional care (OR 0.71, 95% CI 0.57–0.89, p = 0.002), and a poor outcome (OR 0.65, 95% CI 0.55–0.77, p < 0.001). Similar statistical associations were noted in the matched-pairs sensitivity analysis and in a subgroup of poor-grade patients (the upper quartile of the NIS-SAH severity scale).CONCLUSIONSIn this nationwide study, smokers experienced SAH at a younger age and had a greater number of comorbidities compared with nonsmokers, highlighting the negative ramifications of cigarette smoking among patients with cerebral aneurysms. However, smoking was also associated with paradoxical superior outcomes on some measures, and future research to confirm and further understand the basis of this relationship is needed.

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Proximity to the Treating Centre and Outcomes Following Subarachnoid Hemorrhage

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100011069 ◽

2011 ◽

Vol 38 (1) ◽

pp. 36-40 ◽

Cited By ~ 3

Author(s):

Cian J. O'Kelly ◽

Julian Spears ◽

David Urbach ◽

M. Christopher Wallace

Keyword(s):

Subarachnoid Hemorrhage ◽

Critically Ill ◽

Critically Ill Patients ◽

Survival Benefit ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mortality Rates ◽

Limited Resources ◽

Early Complications ◽

The Impact ◽

The Relationship

Abstract:Background:In the management of subarachnoid hemorrhage (SAH), the potential for early complications and the centralization of limited resources often challenge the delivery of timely neurosurgical care. We sought to determine the impact of proximity to the accepting neurosurgical centre on outcomes following aneurysmal SAH.Methods:Using administrative data, we analyzed patients undergoing treatment for aneurysmal subarachnoid hemorrhage at neurosurgical centres in Ontario between 1995 and 2004. We compared mortality for patients receiving treatment at a centre in their county (in-county) versus those treated from outside counties (out-of-county). We also examined the impact of distance from the patient's residence to the treating centre.Results:The mortality rates were significantly lower for in-county versus out-of-county patients (23.5% vs. 27.6%, p=0.009). This advantage remained significant after adjusting for potential confounders (HR=0.84, p=0.01). The relationship between distance from the treating centre and mortality was biphasic. Under 300km, mortality increased with increasing distance. Over 300km, a survival benefit was observed.Conclusions:Proximity to the treating neurosurgical centre impacts survival after aneurysmal SAH. These results have significant implications for the triage of these critically ill patients.

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Delayed neurological deficits detected by an ischemic pattern in the extracellular cerebral metabolites in patients with aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2004.100.1.0008 ◽

2004 ◽

Vol 100 (1) ◽

pp. 8-15 ◽

Cited By ~ 101

Author(s):

Jane Skjøth-Rasmussen ◽

Mette Schulz ◽

Soren Risom Kristensen ◽

Per Bjerre

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Metabolism ◽

Brain Infarction ◽

Neurological Deficits ◽

Parent Artery ◽

Glycerol Concentration ◽

Microdialysis Probe ◽

Content Type ◽

Fine Print

Object. In the treatment of patients with aneurysmal subarachnoid hemorrhage (SAH), early occlusion of the aneurysm is necessary as well as monitoring and treatment of complications following the primary bleeding episode. Monitoring with microdialysis has been studied for its ability to indicate and predict the occurrence of delayed ischemic neurological deficits (DINDs) in patients with SAH. Methods. In 42 patients with aneurysmal SAH microdialysis monitoring of metabolites was performed using a 0.3-µl/minute perfusion flow over several days, and the results were correlated to clinical events and to brain infarction observed on computerized tomography scans. The microdialysis probe was inserted into the territory of the parent artery of the aneurysm. The authors defined an ischemic pattern as increases in the lactate/glucose (L/G) and lactate/pyruvate (L/P) ratios that were greater than 20% followed by a 20% increase in glycerol concentration. This ischemic pattern was found in 17 of 18 patients who experienced a DIND and in three of 24 patients who did not experience a delayed clinical deterioration. The ischemic pattern preceded the occurrence of a DIND by a mean interval of 11 hours. Maximum L/G and L/P ratios did not correlate with the presence of DIND or outcome, and there was no association between the glycerol level and subsequent brain infarction. Conclusions. Microdialysis monitoring of the cerebral metabolism in patients with SAH may predict with high sensitivity and specificity the occurrence of a DIND. Whether an earlier diagnosis results in better treatment of DINDs and, therefore, in overall better outcomes remains to be proven, as it is linked to an efficacious treatment of cerebral vasospasm.

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Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

Critical Care Research and Practice ◽

10.1155/2019/7584573 ◽

2019 ◽

Vol 2019 ◽

pp. 1-8

Author(s):

Kin Chio Li ◽

Catherine Wing Yan Tam ◽

Hoi-Ping Shum ◽

Wing Wa Yan

Keyword(s):

Subarachnoid Hemorrhage ◽

Critically Ill ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Classification Tree ◽

Tertiary Hospital ◽

Classification Tree Analysis ◽

Radiological Findings ◽

Neurological Outcomes ◽

Poor Outcomes ◽

The Impact

In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients’ demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131–12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.

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Cerebral circulation and metabolism in the acute stage of subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2000.93.6.1014 ◽

2000 ◽

Vol 93 (6) ◽

pp. 1014-1018 ◽

Cited By ~ 47

Author(s):

Toshiaki Hayashi ◽

Akifumi Suzuki ◽

Jun Hatazawa ◽

Iwao Kanno ◽

Reizo Shirane ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Circulation ◽

Cerebral Blood Volume ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cerebral Metabolism ◽

Aneurysm Rupture ◽

Acute Stage ◽

Content Type ◽

Positron Emission ◽

Fine Print

Object. The mechanism of reduction of cerebral circulation and metabolism in patients in the acute stage of aneurysmal subarachnoid hemorrhage (SAH) has not yet been fully clarified. The goal of this study was to elucidate this mechanism further.Methods. The authors estimated cerebral blood flow (CBF), cerebral metabolic rate of oxygen (CMRO2), O2 extraction fraction (OEF), and cerebral blood volume (CBV) preoperatively in eight patients with aneurysmal SAH (one man and seven women, mean age 63.5 years) within 40 hours of onset by using positron emission tomography (PET). The patients' CBF, CMRO2, and CBF/CBV were significantly lower than those in normal control volunteers. However, OEF and CBV did not differ significantly from those in control volunteers. The significant decrease in CBF/CBV, which indicates reduced cerebral perfusion pressure, was believed to be caused by impaired cerebral circulation due to elevated intracranial pressure (ICP) after rupture of the aneurysm. In two of the eight patients, uncoupling between CBF and CMRO2 was shown, strongly suggesting the presence of cerebral ischemia.Conclusions. The initial reduction in CBF due to elevated ICP, followed by reduction in CMRO2 at the time of aneurysm rupture may play a role in the disturbance of CBF and cerebral metabolism in the acute stage of aneurysmal SAH.

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