Impact of Goal-Directed Therapy on Delayed Ischemia After Aneurysmal Subarachnoid Hemorrhage

Abstract

Background and Purpose: Delayed cerebral ischemia (DCI) is the most important cause for a poor clinical outcome after a subarachnoid hemorrhage. The aim of this study was to assess whether goal-directed hemodynamic therapy (GDHT), as compared to standard clinical care, reduces the rate of DCI after subarachnoid hemorrhage. Methods: We conducted a prospective randomized controlled trial. Patients >18 years of age with an aneurysmal subarachnoid hemorrhage were enrolled and randomly assigned to standard therapy or GDHT. Advanced hemodynamic monitoring and predefined GDHT algorithms were applied in the GDHT group. The primary end point was the occurrence of DCI. Functional outcome was assessed using the Glasgow Outcome Scale (GOS) 3 months after discharge. Results: In total, 108 patients were randomized to the control (n=54) or GDHT group (n=54). The primary outcome (DCI) occurred in 13% of the GDHT group and in 32% of the control group patients (odds ratio, 0.324 [95% CI, 0.11–0.86]; P =0.021). Even after adjustment for confounding parameters, GDHT was found to be superior to standard therapy (hazard ratio, 2.84 [95% CI, 1.18–6.86]; P =0.02). The GOS was assessed 3 months after discharge in 107 patients; it showed more patients with a low disability (GOS 5, minor or no deficits) than patients with higher deficits (GOS 1–4) in the GDHT group compared with the control group (GOS 5, 66% versus 44%; GOS 1–4, 34% versus 56%; P =0.025). There was no significant difference in mortality between the groups. Conclusions: GDHT reduced the rate of DCI after subarachnoid hemorrhage with a better functional outcome (GOS=5) 3 months after discharge. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT01832389.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

“…Given that optimized targets for the administration of hemodynamic augmentation methods have not been well-defined, GDHT aims to address this issue by applying advanced hemodynamic monitoring to guide volume therapy. The results from a prospective RCT investigating the risk reducing effects of a GDHT protocol for DCI were reported by Anetsberger et al [93]. This study of 108 patients randomly assigned to GDHT or standard therapy found that the GDHT group had significantly lower odds of DCI (odds ratio: 0.324; 95% CI 0.11-0.86; p = 0.021), and a significantly greater proportion of patients achieving good outcome at 3 months, as measured by a GOS score of 5.…”

Association of Troponin T levels and functional outcome 3 months after subarachnoid hemorrhage

“…Patients were enrolled between March 2013 and December 2015 9 . Both, outcome and troponin t data, were available in 106 patients.…”

“…Troponin T measurements were obtained prospectively in the frame of a randomized, controlled clinical trial exploring the association of goal-directed hemodynamic therapy and outcomes after SAH at a University Hospital in Germany (Klinikum rechts der Isar, Technical University Munich) 9 . The study was approved by the local ethics committee (Ethics Commission of the Medical faculty, Technical University of Munich, ID: 5425-12) and was first registered at 16/04/2013 at clinicaltrials.gov; Identifier: NCT01832389.…”

“…Written consent was obtained from each patient or their legal representative. Clinical management was performed according to current guidelines and was described previously in detail 9 , 10 .…”

Year in Review: Synopsis of Selected Articles in Neuroanesthesia and Neurocritical Care from 2020

“…This single-center randomized controlled prospective study was conducted to test the theory that goal-directed hemodynamic therapy (GDHT) would reduce DCI after SAH. 19 One hundred and eight patients with similar characteristics (55% coiling, 45% clipping) were randomized to two groups-GDHT group and the control group. Both the groups had similar ICU care.…”