Enhancement of cerebral blood flow using systemic hypertonic saline therapy improves outcome in patients with poor-grade spontaneous subarachnoid hemorrhage

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Object

Systemic administration of 23.5% hypertonic saline enhances cerebral blood flow (CBF) in patients with poor-grade spontaneous subarachnoid hemorrhage (SAH). Whether the increment of change in CBF correlates with changes in autoregulation of CBF or outcome at discharge remains unknown.

Methods

Thirty-five patients with poor-grade spontaneous SAH received 2 ml/kg 23.5% hypertonic saline intravenously, and they underwent bedside transcranial Doppler (TCD) ultrasonography and intracranial pressure (ICP) monitoring. Seventeen of them underwent Xe-enhanced computed tomography (CT) scanning for measuring CBF. Outcome was assessed using the modified Rankin Scale (mRS) at discharge from the hospital. The data were analyzed using repeated-measurement analysis of variance and Dunnett correction. A comparison was made between patients with favorable and unfavorable outcomes using multivariate logistic regression.

Results

The authors observed a maximum increase in blood pressure by 10.3% (p <0.05) and cerebral perfusion pressure (CPP) by 21.2% (p <0.01) at 30 minutes, followed by a maximum decrease in ICP by 93.1% (p <0.01) at 60 minutes. Changes in ICP and CPP persisted for longer than 180 and 90 minutes, respectively. The results of TCD ultrasonography showed that the baseline autoregulation was impaired on the ipsilateral side of ruptured aneurysm, and increments in flow velocities were higher and lasted longer on the contralateral side (48.75% compared with 31.96% [p = 0.045] and 180 minutes compared with 90 minutes [p <0.05], respectively). The autoregulation was briefly impaired on the contralateral side during the infusion. A dose-dependent effect of CBF increments on favorable outcome was seen on Xe-CT scans (mRS Score 1–3, odds ratio 1.27 per 1 ml/100 g tissue × min, p = 0.045).

Conclusions

Bolus systemic hypertonic saline therapy may be used for reversal of cerebral ischemia to normal perfusion in patients with poor-grade SAH.

Abbreviations used in this paper:ABP = arterial blood pressure; ANOVA = analysis of variance; BBB = blood–brain barrier; CBF = cerebral blood flow; CI = confidence interval; CPP = cerebral perfusion pressure; CT = computed tomography; CVP = central venous pressure; ICP = intracranial pressure; MCA = middle cerebral artery; mRS = modified Rankin Scale; Mx = mean index of cerebral autoregulation; PRx = pressure reactivity index; rCBF = regional CBF; ROI = region of interest; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler.
Article Information

Contributor Notes

Address reprint requests to: Peter J. Kirkpatrick, F.R.C.S.(SN), Department of Neurosurgery, Box 167, Addenbrooke's Hospital, Cambridge CB2 2QQ, United Kingdom. email: pjk21@medschl.cam.ac.uk.
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