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Merrill D, Craven JM, Silvey S, Gouger D, Wang C, Patel R, Yajnik V. The Impact of Fluid Balance on Acute Kidney Injury in Nontraumatic Subarachnoid Hemorrhage. J Intensive Care Med 2024; 39:693-700. [PMID: 38374621 DOI: 10.1177/08850666241226900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2024]
Abstract
Background: Nontraumatic subarachnoid hemorrhage (SAH) can lead to poor neurologic outcomes, particularly when delayed cerebral ischemia (DCI) occurs. Maintenance of euvolemia following SAH is thought to reduce the risk of DCI. However, attempts at maintaining euvolemia often err on the side of hypervolemia. In this study, we assessed the relationship between fluid balance and acute kidney injury (AKI) in SAH patients, assessing hypervolemia versus euvolemia and their impact on AKI. Methods: In a quaternary care center, neuroscience intensive care unit we conducted a retrospective longitudinal analysis in adult patients who suffered a nontraumatic SAH. Results: Out of 139 patients, 15 (10.8%) patients developed an AKI while hospitalized, with 7 stage I, 3 stage II, and 5 stage III injuries. Acute kidney injury patients had higher peak sodium (150.1 mEq/L vs 142.7 mEq/L, 95% confidence interval [CI]: [2.7-12.1 mEq/L]), higher discharge chloride (109.1 mEq/L vs 104.9 mEq/L, 95% CI: [0.7-7.6 mEq/L]), and lower hemoglobin at discharge (9.3 g/dL vs 11.3 g/dL, 95% CI: [1.0-2.9 g/dL]). At 7 days, AKI patients had a fluid balance that was 1.82 L higher (P = .04), and 3.38 L higher at 14 days (P = .02), in comparison to day 3. Acute kidney injury was associated with significant mortality increases. This increase in mortality was found at 30 days from admission with a 9.52-fold increase, and at 60 days with a 6.25-fold increase. As a secondary outcome, vasospasm (19 patients, 13.7%) showed no association with AKI. Conclusions: Acute kidney injury following SAH is correlated with clinically significant hypervolemia, elevated sodium, elevated chloride, decreased urine output, and decreased hemoglobin at discharge-risk factors for all SAH patients. This study further elucidates the harm of hypervolemia and gives greater practical evidence to physicians attempting to balance the dangers of vasospasm and AKI.
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Affiliation(s)
- Dante Merrill
- Virginia Commonwealth Medical Center, Department of Internal Medicine, Richmond VA, USA
| | - Jack M Craven
- John Hopkins Health System, Department of Anesthesiology, Baltimore, MD, USA
| | - Scott Silvey
- Virginia Commonwealth University, Department of Biostatistics, Richmond, VA, USA
| | - Daniel Gouger
- John Hopkins Health System, Department of Anesthesiology, Baltimore, MD, USA
| | - Chen Wang
- Virginia Commonwealth University, Department of Biostatistics, Richmond, VA, USA
| | - Rishi Patel
- Medical University of South Carolina, Department of Anesthesiology, Charleston, SC, USA
| | - Vishal Yajnik
- Virginia Commonwealth Medical Center, Department of Anesthesiology, Richmond VA, USA
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Park ES, Kim DW, Kang SD. Endovascular Treatment of Symptomatic Vasospasm after Aneurysmal Subarachnoid Hemorrhage: A Three-year Experience. J Cerebrovasc Endovasc Neurosurg 2017; 19:155-161. [PMID: 29159148 PMCID: PMC5680078 DOI: 10.7461/jcen.2017.19.3.155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 08/28/2017] [Accepted: 09/17/2017] [Indexed: 11/23/2022] Open
Abstract
Objective The cause of severe clinical vasospasm after aneurysmal subarachnoid hemorrhage remains unknown, despite extensive research over the past 30 years. However, the intra-arterial administration of vasodilating agents and balloon angioplasty have been successfully used in severe refractory cerebral vasospasm. Materials and Methods We retrospectively analyzed the data of 233 patients admitted to our institute with aneurysmal subarachnoid hemorrhage (SAH) over the past 3 years. Results Of these, 27 (10.6%) developed severe symptomatic vasospasm, requiring endovascular therapy. Vasospasm occurred at an average of 5.3 days after SAH. A total of 46 endovascular procedures were performed in 27 patients. Endovascular therapy was performed once in 18 (66.7%) patients, 2 times in 4 (14.8%) patients, 3 or more times in 5 (18.5%) patients. Intra-arterial vasodilating agents were used in 44 procedures (27 with nimodipine infusion, 17 with nicardipine infusion). Balloon angioplasty was performed in only 2 (7.4%) patients. The Average nimodipine infusion volume was 2.47 mg, and nicardipine was 3.78 mg. Most patients recovered after the initial emergency room visit. Two patients (7.4%) worsened, but there were no deaths. Conclusion With advances in endovascular techniques, administration of vasodilating agents and balloon angioplasty reduces the morbidity and mortality of vasospasm after aneurysmal SAH.
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Affiliation(s)
- Eun-Sung Park
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
| | - Sung-Don Kang
- Department of Neurosurgery, School of Medicine, Institute of Wonkwang Medical Science, Wonkwang University, Iksan, Korea
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Barbarawi M, Smith SF, Jamous MA, Haboub H, Suhair Q, Abdullah S. Therapeutic approaches to cerebral vasospasm complicating ruptured aneurysm. Neurol Int 2009; 1:e13. [PMID: 21577350 PMCID: PMC3093235 DOI: 10.4081/ni.2009.e13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2009] [Revised: 06/20/2009] [Accepted: 09/23/2009] [Indexed: 12/02/2022] Open
Abstract
Cerebral vasospasm is a serious complication of ruptured aneurysm. In order to avoid short- and long-term effects of cerebral vasospasm, and as there is no single or optimal treatment modality employed, we have instituted a protocol for the prevention and treatment of vasospasm in patients suffering aneurysmal sub-arachnoid hemorrhage (SAH). We then reviewed the effectiveness of this protocol in reducing the mortality and morbidity rate in our institution. In this study we present a retrospective analysis of 52 cases. Between March 2004 and December 2008 52 patients were admitted to our service with aneurysmal SAH. All patients commenced nimodipine, magnesium sulphate (MgSO4) and triple H therapy. Patients with significant reduction in conscious level were intubated, ventilated and sedated. Intracranial pressure (ICP) monitoring was used for intubated patients. Sodium thiopental coma was induced for patients with refractory high ICP; angiography was performed for diagnosis and treatment. Balloon angioplasty was performed if considered necessary. Using this protocol, only 13 patients (25%) developed clinical vasospasm. Ten of them were given barbiturates to induce coma. Three patients underwent transluminal balloon angioplasty. Four out of 52 patients (7.7%) died from severe vasospasm, 3 patients (5.8%) became severely disabled, and 39 patients (75%) were discharged in a condition considered as either normal or near to their pre-hemorrhage status. Our results confirm that the aforementioned protocol for treatment of cerebral vasospasm is effective and can be used safely.
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Haque R, Kellner CP, Komotar RJ, Connolly ES, Lavine SD, Solomon RA, Meyers PM. Mechanical treatment of vasospasm. Neurol Res 2009; 31:638-43. [PMID: 19660193 DOI: 10.1179/174313209x455745] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Since cerebral vasospasm (CV) was first described nearly half a century ago, significant progress has been made in understanding its underlying pathophysiology and developing treatment modalities. The purpose of this review is to discuss the rationale behind mechanical interventions for CV as well as the efficacy and complications associated with these treatment options. METHODS The authors summarize the pertinent literature on the mechanical treatment of CV, focusing first on balloon angioplasty, second on therapy combined with intra-arterial drug infusion, and concluding by briefly discussing intra-aortic balloon counterpulsation. The epidemiology, pathophysiology, technique, outcome, timing and complications are discussed for each treatment option. RESULTS A review of the relevant medical literature reveals that in the last 20 years, endovascular techniques including transluminal balloon angioplasty, intra-arterial drug infusion and newer experimental strategies have provided an important supplement to the established medical therapy. DISCUSSION Despite these developments, however, CV remains a major contributor to poor outcome following aSAH and continued efforts are necessary to improve and refine endovascular strategies as well as develop new treatment modalities.
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Affiliation(s)
- Raqeeb Haque
- Department of Neurological Surgery, Columbia University, College of Physicians and Surgeons, Neurological Institute of New York, New York 10032, USA
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Eddleman CS, Hurley MC, Naidech AM, Batjer HH, Bendok BR. Endovascular options in the treatment of delayed ischemic neurological deficits due to cerebral vasospasm. Neurosurg Focus 2009; 26:E6. [PMID: 19249962 DOI: 10.3171/2008.11.focus08278] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The second leading cause of death and disability in patients with aneurysmal subarachnoid hemorrhage (SAH) is delayed cerebral ischemia due to vasospasm. Although up to 70% of patients have been shown to have angiographic evidence of vasospasm, only 20-30% will present with clinical changes, including mental status changes and neurological deficits that necessitate acute management. Endovascular capabilities have progressed to become viable options in the treatment of cerebral vasospasm. The rationale for intraarterial therapy includes the fact that morbidity and mortality rates have not changed in recent years despite optimized noninvasive medical care. In this report, the authors discuss the most common endovascular options-namely intraarterial vasodilators and transluminal balloon angioplasty-from the standpoint of mechanism, efficacy, limitations, and complications as well as the treatment algorithms for cerebral vasospasm used at our institution.
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Affiliation(s)
- Christopher S Eddleman
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Lerch C, Yonekawa Y, Muroi C, Bjeljac M, Keller E. Specialized neurocritical care, severity grade, and outcome of patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 2007; 5:85-92. [PMID: 17099253 DOI: 10.1385/ncc:5:2:85] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/1999] [Revised: 11/30/1999] [Accepted: 11/30/1999] [Indexed: 11/11/2022]
Abstract
INTRODUCTION To evaluate the impact of specialized neurocritical care on the population admitted to a neurovascular center and on the outcome of patients with severe aneurysmal subarachnoid hemorrhage (aSAH). METHODS After exclusion of patients treated with endovascular techniques, between 1999 and 2003, 198 patients with aSAH treated with early aneurysm clipping were analysed. In 1999, a new standardized protocol for intensive care treatment was established in the Department of Neurosurgery, University Hospital Zurich. The results were compared to the earlier time period (1993-1994) immediately after introduction of early aneurysm clipping. RESULTS Out of 198 patients with aSAH, 90 patients (45.5%) suffered from mild aSAH World Federation of Neurosurgical Societies (WFNS) grade 1 and 2, 41 (27.3%) from aSAH WFNS grade 3, 36 (18.2%) from grade 4, and 57 (28.8%) from grade 5. From 1999 to 2003, significantly more patients with severe aSAH WFNS grade 4 and 5 underwent (further) treatment (93 out of 198 patients; 47.0%) compared to the former time-period after introduction of early surgery (23 out of 150 patients; 15.3%) (p < 0.0001). In the early series, 10 out of 23 patients (43.5%) with WFNS 4 recovered with good outcome Glasgow Outcome Score 4 and 5, whereas in the later series 23 out of 36 (63.9%) with WFNS grade 4 survived in a good functional state. Before 1999, all patients with WFNS grade 5 died or survived in a vegetative state. From 1999 to 2003, 20 out of 57 patients (35.1%) with aSAH WFNS grade 5 survived with good outcome. CONCLUSIONS The availability of extended specialized neurocritical care seems to induce a change within the patient population towards a higher severity grade. Patients with highgrade aSAH might benefit most from highly specialized neurocritical care treatment.
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Affiliation(s)
- Corinne Lerch
- Neurocritical Care Unit, Department of Neurosurgery, University Hospital, Zurich, Switzerland
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Sayama CM, Liu JK, Couldwell WT. Update on endovascular therapies for cerebral vasospasm induced by aneurysmal subarachnoid hemorrhage. Neurosurg Focus 2006; 21:E12. [PMID: 17029336 DOI: 10.3171/foc.2006.21.3.12] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral vasospasm remains a major source of morbidity and death in patients with aneurysmal subarachnoid hemorrhage (SAH). When vasospasm becomes refractory to maximal medical management consisting of induced hypertension and hypervolemia and administration of calcium channel antagonists, endovascular therapies should be considered. The primary goal of endovascular treatment is to increase cerebral blood flow to prevent cerebral infarction. Two of the more frequently studied endovascular treatments are transluminal balloon angioplasty and intraarterial papaverine infusion. These two have been used either alone or in combination for the treatment of vasospasm. Other pharmacological vasodilating agents currently being investigated are intraarterial nimodipine, nicardipine, verapamil, and milrinone. Newer intraarterial agents, such as fasudil and colforsin daropate, have also been investigated. In this article the authors review the current options in terms of endovascular therapies for treatment of cerebral vasospasm. The mechanism of action, technique of administration, clinical effect and outcomes, and complications of each modality are discussed.
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Affiliation(s)
- Christina M Sayama
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah 84132, USA
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Mindea SA, Yang BP, Bendok BR, Miller JW, Batjer HH. Endovascular treatment strategies for cerebral vasospasm. Neurosurg Focus 2006; 21:E13. [PMID: 17029337 DOI: 10.3171/foc.2006.21.3.13] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Cerebral vasospasm is a significant cause of morbidity and mortality in patients who have sustained a subarachnoid hemorrhage from aneurysm rupture. Symptomatic cerebral vasospasm is also a strong predictor of poor clinical outcome and has thus drawn a great deal of interest from cerebrovascular surgeons. Although medical management is the cornerstone of treatment for this condition, endovascular intervention may be warranted for those in whom this treatment fails and in whom symptomatic vasospasm subsequently develops. The rapid advancements in endovascular techniques and pharmacological agents used to combat this pathological state continue to offer promise in broadening the available treatment armamentarium. In this article the authors discuss the rationale and basis for using the various endovascular options for the treatment of cerebral vasospasm, and they also discuss the limitations, complications, and efficacy of these treatment strategies in regard to neurological condition and outcome.
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Affiliation(s)
- Stefan A Mindea
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Terry A, Zipfel G, Milner E, Cross DT, Moran CJ, Diringer MN, Dacey RG, Derdeyn CP. Safety and technical efficacy of over-the-wire balloons for the treatment of subarachnoid hemorrhage–induced cerebral vasospasm. Neurosurg Focus 2006; 21:E14. [PMID: 17029338 DOI: 10.3171/foc.2006.21.3.14] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Over the past decade, low-pressure, flow-directed balloons have been replaced by over-the-wire balloons in the treatment of vasospasm induced by subarachnoid hemorrhage (SAH). The authors assess the procedural safety and technical efficacy of these newer devices.
Methods
Seventy-five patients who underwent 85 balloon angioplasty procedures for the treatment of SAH-induced vasospasm were identified from a prospective quality-assurance database. Medical records and angiographic reports were reviewed for evidence of procedural complications and technical efficacy.
No vessel rupture or perforation occurred, but thromboembolic complications were noted in four (4.7%) of the 85 procedures. Balloon angioplasty was frequently attempted and successfully accomplished in the distal internal carotid (100%), proximal middle cerebral (94%), vertebral (73%), and basilar (88%) arteries. Severe narrowing was present in 89 proximal anterior cerebral arteries. Angioplasty was attempted in 41 of these vessels and was successful in only 14 (34%). In 19 of the 27 unsuccessful attempts, the balloon could not be advanced over the wire due to severe vasospasm or unfavorable vessel angle. Follow-up angiography in a subset of patients demonstrated that severe recurrent vasospasm occurred in 15 (13%) of 116 vessels studied after angioplasty.
Conclusions
Over-the-wire balloons involve a low risk for vessel rupture. The anterior cerebral artery remains difficult to access and successfully treat with current devices. Further improvements in balloon design, such as smaller inflated diameters and better tracking, are necessary. Finally, thromboembolic complications remain an important concern, and severe vasospasm may recur after balloon angioplasty.
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Affiliation(s)
- Anna Terry
- Department of Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Affiliation(s)
- Valery L Feigin
- Department of Medicine, School of Population Health, University of Auckland, New Zealand.
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