Artikel
Incremental versus immediate induction of hypertension in the treatment of delayed cerebral ischemia after subarachnoid haemorrhage
Inkrementelle oder direkte Induktion von Hypertension in der Behandlung von delayed cerebral ischemia nach Subarachnoidalblutung
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Veröffentlicht: | 4. Juni 2021 |
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Objective: Delayed cerebral ischemia (DCI) is a common complication after aneurysmal subarachnoid hemorrhage (SAH) and significantly worsens outcome. In patients with neurological deterioration despite prophylactic nimodipine treatment, induced hypertension (iHTN) can be considered, though the safety and efficacy of induction is a matter of debate. It was the purpose of this study to compare an incremental and an aggressive approach to induction of HTN in patients with DCI.
Methods: In a prospective cohort of 325 consecutive SAH patients, 123 developed DCI and were treated by induced hypertension as a first tier rescue strategy. In 35 patients, blood pressure was incrementally raised in 20 mmHg steps (iHTNincr), whereas 88 patients were treated by immediate induction to systolic values above 180mmHg (iHTNimm). Both groups were compared concerning the need for additional endovascular rescue treatment, the occurrence of DCI caused infarction and clinical outcome assessed by the extended Glasgow outcome scale after 12 months.
Results: The rate of refractory DCI requiring additional rescue therapy was comparable in both groups (48.9% in iHTNincr, 40% in iHTNimm; p=0.332). However, immediate induction was associated with a significantly lower risk of DCI induced infarction (29.5% vs. 51.1%; p=0.015). This is also reflected in a higher rate of favorable outcome after 12 months in the iHTNimm group (60.5% vs. 45.2%; p=0.110), though this was not statistically significant, but also with a higher proportion of lower good recovery (22.4% vs. 11.6%; p=0.045).
Conclusion: In this observational trial, initial aggressive elevation of blood pressure was associated with a lower rate of DCI induced infarction and better outcome when compared to an incremental adjustment of blood pressure, possibly due to a more timely compensation of misery perfusion. Future studies will have to determine the additional value of more tailored approaches such as optimal cerebral perfusion pressure (CPPopt) in the treatment of delayed cerebral ischemia.