Beneficial effects of adrenergic blockade in patients with subarachnoid haemorrhage.

Abstract

A total of 148 patients presenting within 48 hours of subarachnoid haemorrhage were assigned at random to receive standard management only or standard management and treatment with the adrenergic-blocking agents propranolol and phentolamine (or propranolol alone) for three weeks. One hundred and thirty-four patients completed the study. Assessment at four weeks showed a strong trend for less neurological deficit in the treated group, almost statistically significant (p=0053) in the women. During the first month the treated group suffered fewer episodes of clinical deterioration consistent with cerebral arterial spasm: thus more treated patients underwent operation and those who did had a better outcome (p=0 030).At one year fewer were dead or disabled (unable to work) in the treated group; a significant difference for women (p = 0-030). Possible mechanisms for these actions may include a reduction in pulmonary oedema, prevention of myocardial infarcts, a reduction in plasma renin activity, and a reduction in cerebral oxygen requirements.It is concluded that early adrenergic blockade benefits patients (particularly women) with subarachnoid haemorrhage for up to one year in terms of lesser neurological deficit. Beta-blockade rather than alpha-blockade

Pulmonary and cardiac sequelae of subarachnoid haemorrhage: time for active management?

“…There was no difference in the mortality (perhaps because of small numbers) but, at autopsy, focal necrosis of the myocardium was only present in the placebo group, implying a protective cardiac effect. Another report by the same group showed benefit in terms of survival and neurological state in SAH patients given prophylactic phentolamine and propranolol [96]. They surmised this was due to a reduction in complications such as NPO and cardiac lesions.…”

“…In patients with reduced left ventricular work, dobutamine has proved effective [37,41,56,96]. A recent series of SAH patients with pulmonary oedema, increased PAOP and variable cardiac index (but all with low ejection fractions on echocardiography) were treated successfully with dobutamine and a combination of epinephrine and/or norepinephrine (although one patient did also received intra-aortic balloon pump assistance) [41].…”

Relationship between leukocytosis and ischemic complications following aneurysmal subarachnoid hemorrhage

“…The increase in the total WBC counts observed at the time of neurological deterioration might indicate initial structural damage of the brain tissue and/or an increased sympathetic and adrenocortical activity [11], which might contribute to the production of cerebral vasospasm after SAH "per se" [1,11,23]. Whatever the case may be, the present data do not prove (but do not exclude) that neutrophils may have a direct causal role in the pathogenesis of ICs of SAH, perhaps mediated through leukotrienes C4 and D4, which are known to increase vascular permeability [2].…”

The Pragmatic Approach to Stroke Trial Design: Stroke Register, Pilot Trial, Assessment of Neurological then Functional Outcome

“…The reasons for assessing the effects of pblockade in acute stroke will be discussed more fully elsewhere, but there is already evidence of benefit from propranolol in pa tients with subarachnoid haemorrhage [6], Our aim was to investigate whether these benefits might be extended to patients with ischaemic stroke and at the same time to dis tinguish cardiovascular effects from possible effects on cerebral metabolism. To this end we used a lipophilic drug (propranolol) which penetrates into brain tissue, as well as the hydrophilic atenolol which does not [7],…”