Is Hypothermia Helpful in Severe Subarachnoid Hemorrhage? An Exploratory Study on Macro Vascular Spasm, Delayed Cerebral Infarction and Functional Outcome after Prolonged Hypothermia.
BACKGROUND
Therapeutic hypothermia (TH) is an established treatment after cardiac arrest and growing evidence supports its use as neuroprotective treatment in stroke. Only few and heterogeneous studies exist on the effect of hypothermia in subarachnoid hemorrhage (SAH). A novel approach of early and prolonged TH and its influence on key complications in poor-grade SAH, vasospasm and delayed cerebral ischemia (DCI) was evaluated.


METHODS
This observational matched controlled study included 36 poor-grade (Hunt and Hess Scale >3 and World Federation of Neurosurgical Societies Scale >3) SAH patients. Twelve patients received early TH (<48 h after ictus), mild (35°C), prolonged (7 ± 1 days) and were matched to 24 patients from the prospective SAH database. Vasospasm was diagnosed by angiography, macrovascular spasm serially evaluated by Doppler sonography and DCI was defined as new infarction on follow-up CT. Functional outcome was assessed at 6 months by modified Rankin Scale (mRS) and categorized as favorable (mRS score 0-2) versus unfavorable (mRS score 3-6) outcome.


RESULTS
Angiographic vasospasm was present in 71.0% of patients. TH neither influenced occurrence nor duration, but the degree of macrovascular spasm as well as peak spastic velocities were significantly reduced (p < 0.05). Frequency of DCI was 87.5% in non-TH vs. 50% in TH-treated patients, translating into a relative risk reduction of 43% and preventive risk ratio of 0.33 (95% CI 0.14-0.77, p = 0.036). Favorable functional outcome was twice as frequent in TH-treated patients 66.7 vs. 33.3% of non-TH (p = 0.06).


CONCLUSIONS
Early and prolonged TH was associated with a reduced degree of macrovascular spasm and significantly decreased occurrence of DCI, possibly ameliorating functional outcome. TH may represent a promising neuroprotective therapy possibly targeting multiple pathways of DCI development, notably macrovascular spasm, which strongly warrants further evaluation of its clinical impact.
Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.
Joji B
JB
Kuramatsu
Rainer
R
Kollmar
Stefan T
ST
Gerner
Dominik
D
Madžar
Andrea
A
Pisarčíková
Dimitre
D
Staykov
Stephan P
SP
Kloska
Arnd
A
Doerfler
Ilker Y
IY
Eyüpoglu
Stefan
S
Schwab
Hagen B
HB
Huttner
D000328:Adult; D001925:Brain Damage, Chronic / Q000209:etiology / Q000517:prevention & control; D016022:Case-Control Studies; D002533:Cerebral Angiography; D002544:Cerebral Infarction / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D003422:Critical Care / Q000379:methods; D016208:Databases, Factual; D057510:Endovascular Procedures; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D006849:Hydrocephalus / Q000209:etiology / Q000517:prevention & control / Q000601:surgery; D006993:Hypnotics and Sedatives / Q000627:therapeutic use; D007036:Hypothermia, Induced / Q000009:adverse effects / Q000379:methods; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D009465:Neuromuscular Agents / Q000627:therapeutic use; D055420:Perfusion Imaging; D010865:Pilot Projects; D011446:Prospective Studies; D020127:Recovery of Function; D012306:Risk; D013345:Subarachnoid Hemorrhage / Q000150:complications / Q000628:therapy*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome; D017585:Ultrasonography, Doppler, Transcranial; D020301:Vasospasm, Intracranial / Q000000981:diagnostic imaging / Q000209:etiology* / Q000517:prevention & control / Q000628:therapy; D017287:Ventriculoperitoneal Shunt
D006993:Hypnotics and Sedatives; D009465:Neuromuscular Agents