title: The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms.
abstract: OBJECTIVE
  Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.
  
  
  METHODS
  This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.
  
  
  RESULTS
  For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01).
  
  
  CONCLUSIONS
  For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, St. Louis, Missouri;
authors.forename: Matthew R
authors.initials: MR
authors.lastname: Reynolds
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, St. Louis, Missouri;
authors.forename: Robert T
authors.initials: RT
authors.lastname: Buckley
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, St. Louis, Missouri;
authors.forename: Santoshi S
authors.initials: SS
authors.lastname: Indrakanti
authors.affiliation: Department of Neurological Surgery, University of Illinois at Chicago, Illinois;
authors.forename: Ali H
authors.initials: AH
authors.lastname: Turkmani
authors.affiliation: Department of Neurological Surgery, University of Illinois at Chicago, Illinois;
authors.forename: Gerald
authors.initials: G
authors.lastname: Oh
authors.affiliation: Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota;
authors.forename: Emanuela
authors.initials: E
authors.lastname: Crobeddu
authors.affiliation: Department of Neurological Surgery, University of Florida, Gainesville, Florida; and.
authors.forename: Kyle M
authors.initials: KM
authors.lastname: Fargen
authors.affiliation: Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Tarek Y
authors.initials: TY
authors.lastname: El Ahmadieh
authors.affiliation: Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Naidech
authors.affiliation: Department of Neurological Surgery, University of Illinois at Chicago, Illinois;
authors.forename: Sepideh
authors.initials: S
authors.lastname: Amin-Hanjani
authors.affiliation: Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota;
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Lanzino
authors.affiliation: Department of Neurological Surgery, University of Florida, Gainesville, Florida; and.
authors.forename: Brian L
authors.initials: BL
authors.lastname: Hoh
authors.affiliation: Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bendok
authors.affiliation: Department of Neurological Surgery, Washington University Medical School, St. Louis, Missouri;
authors.forename: Gregory J
authors.initials: GJ
authors.lastname: Zipfel
mesh_terms: D005260:Female; D006801:Humans; D006973:Hypertension / Q000139:chemically induced; D002532:Intracranial Aneurysm / Q000150:complications*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000188:drug therapy*; D014662:Vasoconstrictor Agents / Q000009:adverse effects / Q000627:therapeutic use*
chemical_list: D014662:Vasoconstrictor Agents
keywords: ACA = anterior cerebral artery; DCI = delayed cerebral ischemia; DVT/PE = deep vein thrombosis/pulmonary embolism; ICA = internal carotid artery; MAP = mean arterial pressure; MCA = middle cerebral artery; SAH = subarachnoid hemorrhage; SBP = systolic blood pressure; SEM = standard error of the mean; VIH = vasopressor-induced hypertension; WFNS = World Federation of Neurosurgical Societies; delayed cerebral ischemia; induced hypertension; intracranial aneurysm; subarachnoid hemorrhage; triple-H therapy; unprotected; unruptured; vascular disorders; vasospasm