Incremental Versus Immediate Induction of Hypertension in the Treatment of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Intra-arterial nimodipine for the treatment of refractory delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) is one of the main contributors to poor clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). Endovascular spasmolysis with intra-arterial nimodipine (IAN) may resolve angiographic vasospasm, but its effect on infarct prevention and clinical outcome is still unclear. We report the effect of IAN on infarction rates and functional outcome in a consecutive series of SAH patients.

METHODS

To assess the effectiveness of IAN, we collected functional outcome data of all SAH patients referred to a single tertiary center since its availability (2011-2020). IAN was primarily reserved as a last tier option for DCI refractory to induced hypertension (iHTN). Functional outcome was assessed after 12 months according to the Glasgow Outcome Scale (GOS, favorable outcome = GOS4-5).

RESULTS

Out of 376 consecutive SAH patients, 186 (49.5%) developed DCI. Thereof, a total of 96 (25.5%) patients remained unresponsive to iHTN and received IAN. DCI-related infarction was observed in 44 (45.8%) of IAN-treated patients with a median infarct volume of 111.6 mL (Q1: 51.6 to Q3: 245.7). Clinical outcome was available for 84 IAN-treated patients. Of those, a total of 40 (47.6%) patients reached a favorable outcome after 1 year. Interventional complications were observed in 9 (9.4%) of the IAN-treated patients.

CONCLUSION

Intra-arterial spasmolysis using nimodipine infusion was associated with low treatment specific complications. Despite presenting a subgroup of severely affected SAH patients, almost half of IAN-treated patients were able to lead an independent life after 1 year of follow-up.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register DRKS00030505.

Treatment challenges of ruptured intracranial aneurysms during pregnancy: A case record and review of the literature

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) during pregnancy is a rare but serious complication associated with significant maternal and fetal morbidity and mortality. Due to a limited number of published cases, development of guidelines for the management of aSAH in pregnant women has proven difficult. In the present article, we present a case and review the available literature on patients with aSAH during pregnancy.

Research question

What is the optimal management of aSAH during pregnancy?

Material and methods

We describe the case of a pregnant woman with aSAH. In addition, a search of the PUBMED database was conducted to collect all pertinent case reports of aSAH in pregnant women published since 1990.

Results

A 36 years old Caucasian primigravid woman in the 37th GW presented to our department with aSAH, due to rupture of a saccular basilar tip aneurysm. After multidisciplinary discussion, a Caesarian section (CS) and subsequent aneurysm treatment by endovascular coiling were performed without complications. On day four after ictus endovascular spasmolysis were initiated as the patient developed angiographic cerebral vasospasm and delayed cerebral ischemia (DCI). Two days later, brain tissue hypoperfusion was further aggravated by cardiopulmonary failure under induced hypertension, so that the patient died on day seven from severe cerebral infarction.

Discussion and conclusion

While there are still no formal studies that could guide the optimal management of aSAH during pregnancy, primary CS prior to definitive management of ruptured aneurysms during the third trimester seems to be the safest treatment approach for both mother and child.