Clinical response to hypertensive hypervolemic therapy and outcome after subarachnoid hemorrhage.
OBJECTIVE
Hypertensive hypervolemic therapy is widely used to treat symptomatic vasospasm after subarachnoid hemorrhage. Few data exist to support a relationship between early clinical response and mortality or functional outcome.


METHODS
In a prospective cohort of 580 subarachnoid hemorrhage patients, we studied 95 patients with acute symptomatic vasospasm who received stepwise volume expansion with crystalloid and/or 5% albumin solution followed by intravenous pressors to maintain systolic blood pressure between 180 and 220 mm Hg. We separately assessed the effects of volume expansion and induced hypertension on the neurological examination during the first 2 hours of each intervention. We used multivariate logistic regression analysis to calculate adjusted odds ratios assessing the relationship between clinical response to hypertensive hypervolemic therapy and 3-month outcome, as measured by the modified Rankin Scale.


RESULTS
Of 95 patients with symptomatic vasospasm, volume expansion was used in 94% (n = 89), of whom 43% had a clinical response; 85% of the patients (n = 81) received pressors, of whom 68% responded. Early clinical improvement attributable to either volume expansion or pressors was not related to the development of infarction on computed tomography, but response to either modality within 2 hours was independently protective against death (adjusted odds ratio, 0.03; P < 0.05) and death-or-severe-disability (modified Rankin Scale score, 4-6; adjusted odds ratio, 0.1; P < 0.05) after adjusting for age, Hunt-Hess grade, angioplasty, and aneurysm size.


CONCLUSIONS
Subarachnoid hemorrhage patients with symptomatic vasospasm who fail to demonstrate early clinical improvement in response to volume or pressor therapy are at high risk for death or disability. Urgent endovascular intervention in this high-risk patient cohort may be justified.
Frontera
Jennifer A
JA
Departments of Neurosurgery and Neurology, Neuroscience Intensive Care Unit, Mount Sinai School of Medicine, One Gustave Levy Place, Box 1136, New York, NY 10029, USA. Jennifer.Frontera@mountsinai.org
Fernandez
Andres
A
Schmidt
J Michael
JM
Claassen
Jan
J
Wartenberg
Katja E
KE
Badjatia
Neeraj
N
Connolly
E Sander
ES
Mayer
Stephan A
SA
D000328:Adult; D000368:Aged; D000418:Albumins / Q000008:administration & dosage; D015331:Cohort Studies; D016001:Confidence Intervals; D000077324:Crystalloid Solutions; D005260:Female; D005440:Fluid Therapy; D006801:Humans; D006973:Hypertension / Q000139:chemically induced*; D007552:Isotonic Solutions / Q000008:administration & dosage; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011859:Radiography; D012189:Retrospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000000981:diagnostic imaging / Q000628:therapy*; D015898:Tomography Scanners, X-Ray Computed; D016896:Treatment Outcome; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000209:etiology / Q000628:therapy*; D055815:Young Adult
D000418:Albumins; D000077324:Crystalloid Solutions; D007552:Isotonic Solutions