Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

Rabinstein, Alejandro A.; Busl, Katharina M.; Caylor, Meghan M.; Citerio, Giuseppe; Deem, Steven; Diringer, Michael N.; Fox, Elizabeth D.; Livesay, Sarah; Sheth, Kevin N; Suárez, José I.; Tjoumakaris, Stavropoula

doi:10.1007/s12028-023-01713-5

Cited by 75 publications

(24 citation statements)

References 153 publications

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“…International guidelines were applied (6). Nimodipine (Nimotop, Bayer Healthcare, Loos, France) was administered for 21 days (enteral route if possible: 60 mg every 4 hr; otherwise IV: 2 mg/hr) and was not discontinued during vasospasm treatment.…”

Section: Methodsmentioning

confidence: 99%

Cerebral Vasospasm After Subarachnoid Hemorrhage: Respective Short-Term Effects of Induced Arterial Hypertension and its Combination With IV Milrinone: A Proof-of-Concept Study Using Transcranial Doppler Ultrasound

Lakhal,

Fresco,

Hivert

et al. 2023

Critical Care Explorations

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OBJECTIVES: It is unclear whether IV milrinone relaxes spasmed cerebral arteries and therefore reduces cerebral blood mean velocity (Vmean). In patients treated for cerebral vasospasm, we aimed to assess and delineate the respective impacts of induced hypertension and its combination with IV milrinone on cerebral hemodynamics as assessed with transcranial Doppler. DESIGN: Observational proof-of-concept prospective study. SETTING: ICU in a French tertiary care center. PATIENTS: Patients with aneurysmal subarachnoid hemorrhage who received induced hypertension (mean arterial blood pressure [MBP] of 100–120 mm Hg) and IV milrinone (0.5 µg/kg/min) for moderate-to-severe cerebral vasospasm. We excluded patients who underwent invasive angioplasty or milrinone discontinuation within 12 hours after the diagnosis of vasospasm. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Vmean was measured at vasospasm diagnosis (TDIAGNOSIS), after the induction of hypertension (THTN), and 1 (THTN+MILRINONE_H1) and 12 hours after the adjunction of IV milrinone (THTN+MILRINONE_H12). Thirteen patients were included. Median Vmean was significantly lower (p < 0.01) at THTN+MILRINONE_H1 (99 [interquartile range (IQR) 89; 134] cm.s−1) and THTN+MILRINONE_H12 (85 [IQR 73–127] cm/s) than at TDIAGNOSIS (136 [IQR 115–164] cm/s) and THTN (148 [IQR 115–183] cm/s), whereas TDIAGNOSIS and THTN did not significantly differ. In all patients but one, Vmean at THTN+MILRINONE_H1 was lower than its value at TDIAGNOSIS (p = 0.0005). Vmean-to-MBP and Vmean-to-cardiac output (CO) ratios (an assessment of Vmean regardless of the level of MBP [n = 13] or CO [n = 7], respectively) were, respectively, similar at TDIAGNOSIS and THTN but were significantly lower after the adjunction of milrinone (p < 0.01). CONCLUSIONS: The induction of arterial hypertension was not associated with a significant decrease in Vmean, whereas the adjunction of IV milrinone was, regardless of the level of MBP or CO. This suggests that IV milrinone may succeed in relaxing spasmed arteries.

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Section: Methodsmentioning

confidence: 99%

Cerebral Vasospasm After Subarachnoid Hemorrhage: Respective Short-Term Effects of Induced Arterial Hypertension and its Combination With IV Milrinone: A Proof-of-Concept Study Using Transcranial Doppler Ultrasound

Lakhal,

Fresco,

Hivert

et al. 2023

Critical Care Explorations

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“…Recognizing the paucity of high-quality data, the 2023 Neurocritical Care Society Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage acknowledged that there is, at present, insufficient evidence to recommend for using an Hb transfusion threshold >7 g/dL. 93 The Aneurysmal SubArachnoid Hemorrhage—Red Blood Cells Transfusion and Outcome (SAHaRA) trial is an ongoing international, multicenter, open-label, assessor-blinded RCT comparing a liberal transfusion trigger (Hb < 100 g/dL) and a restrictive transfusion trigger (Hb < 80 g/dL) in aSAH patients whose Hb < 100 g/dL within the first 10 days of hospital admission (NCT03309579). With an anticipated recruitment of 740 subjects and an estimated completion date in 2024, the SAHaRA study aims to inform better evidence-based transfusion practice in aSAH patients.…”

Section: Methodsmentioning

confidence: 99%

Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature

Ma,

Bebawy

2023

Anesthesia &Amp; Analgesia

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Anemia is a highly prevalent condition that may compromise oxygen delivery to vital organs, especially among the critically ill. Although current evidence supports the adoption of a restrictive transfusion strategy and threshold among the nonbleeding critically ill patient, it remains unclear whether this practice should apply to the brain-injured patient, given the predisposition to cerebral ischemia in this patient population, in which even nonprofound anemia may exert a detrimental effect on clinical outcomes. The purpose of this review is to provide an overview of the pathophysiological changes related to impaired cerebral oxygenation in the brain-injured patient and to present the available evidence on the effect of anemia and varying transfusion thresholds on the clinical outcomes of patients with acute brain injury.

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“…1,5 This recommendation is in line with the Neurocritical Care Society's guidelines on the management of aneurysmal patients with SAH. 6…”

Section: Hyponatremiamentioning

confidence: 99%

Importance of Medical Management in Patients With Aneurysmal Subarachnoid Hemorrhage

Choi

2024

Stroke

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Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage

Cited by 75 publications

References 153 publications

Cerebral Vasospasm After Subarachnoid Hemorrhage: Respective Short-Term Effects of Induced Arterial Hypertension and its Combination With IV Milrinone: A Proof-of-Concept Study Using Transcranial Doppler Ultrasound

Cerebral Vasospasm After Subarachnoid Hemorrhage: Respective Short-Term Effects of Induced Arterial Hypertension and its Combination With IV Milrinone: A Proof-of-Concept Study Using Transcranial Doppler Ultrasound

Anemia and Optimal Transfusion Thresholds in Brain-Injured Patients: A Narrative Review of the Literature

Importance of Medical Management in Patients With Aneurysmal Subarachnoid Hemorrhage

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