Risk of hemorrhage from unsecured, unruptured aneurysms during and after hypertensive hypervolemic therapy.
OBJECTIVE
Hypertensive hypervolemic therapy for vasospasm is widely practiced. It is not clear, however, whether the use of hypertension and hypervolemia as a treatment for vasospasm risks hemorrhage from an unsecured, unruptured aneurysm.


METHODS
From 1991 to 2000, the neurovascular unit at the Massachusetts General Hospital treated 1908 aneurysms, of which 966 were ruptured. Forty patients with ruptured aneurysms had unsecured, unruptured aneurysms and underwent hypertensive hypervolemic therapy for vasospasm. Hypertension was induced by intravenously administered phenylephrine, norepinephrine, and/or dopamine, and hypervolemia was achieved by intravenously administered crystalloid and colloid solutions. The 24-hour mean arterial systolic blood pressure (SBP) and the 24-hour mean central venous pressure were calculated on the basis of hourly measurements during hypertensive hypervolemic treatment.


RESULTS
The 40 study patients harbored 124 aneurysms, of which 51 aneurysms were treated (clipping, 37; coiling, 14) by the time hypertensive hypervolemic therapy began, leaving 73 unsecured aneurysms at risk. The mean size of the unsecured aneurysms was 4.45 mm. Nineteen patients were treated with mild hypertension (SBP, 140-180 mmHg), 12 patients were treated with moderate hypertension (SBP, 180-200 mmHg), and 9 patients were treated with severe hypertension (SBP, >200 mmHg). The 24-hour mean SBP readings were 166.81 +/- 8.19, 187.57 +/- 5.79, and 204.01 +/- 3.75 mmHg for the mild, moderate, and severe hypertension groups, respectively. The mean central venous pressure was 10.43 +/- 3.89 mmHg. The mean course of hypertensive hypervolemic therapy was 7.25 days, and therapy began on mean post-subarachnoid hemorrhage Day 6.73. Twenty-eight aneurysms were eventually treated in later procedures (clipping, 25; coiling, 3). The mean interval to treatment was 6.93 months. In a treatment and follow-up period of 121.75 aneurysm-years of risk, there was no instance of hemorrhage.


CONCLUSIONS
Hypertension and hypervolemia do not seem to increase the risk of hemorrhage from unsecured, unruptured aneurysms in the acute setting or in their short-term natural history.
Hoh
Brian L
BL
Neurosurgical Service, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA.
Carter
Bob S
BS
Ogilvy
Christopher S
CS
D017542:Aneurysm, Ruptured / Q000150:complications; D001794:Blood Pressure / Q000187:drug effects; D001810:Blood Volume / Q000187:drug effects; D002316:Cardiotonic Agents / Q000009:adverse effects / Q000627:therapeutic use; D003102:Colloids / Q000009:adverse effects / Q000627:therapeutic use; D000077324:Crystalloid Solutions; D004298:Dopamine / Q000009:adverse effects / Q000627:therapeutic use; D004359:Drug Therapy, Combination; D006801:Humans; D002532:Intracranial Aneurysm / Q000150:complications*; D007552:Isotonic Solutions; D009638:Norepinephrine / Q000009:adverse effects / Q000627:therapeutic use; D010656:Phenylephrine / Q000009:adverse effects / Q000627:therapeutic use; D010952:Plasma Substitutes / Q000009:adverse effects / Q000627:therapeutic use; D012307:Risk Factors; D012996:Solutions; D013345:Subarachnoid Hemorrhage / Q000209:etiology*; D014662:Vasoconstrictor Agents / Q000009:adverse effects / Q000627:therapeutic use; D020301:Vasospasm, Intracranial / Q000209:etiology* / Q000503:physiopathology / Q000628:therapy*
D002316:Cardiotonic Agents; D003102:Colloids; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D010952:Plasma Substitutes; D012996:Solutions; D014662:Vasoconstrictor Agents; D010656:Phenylephrine; D004298:Dopamine; D009638:Norepinephrine