CBF changes and cerebral energy metabolism during hypervolemia, hemodilution, and hypertension therapy in patients with poor-grade subarachnoid hemorrhage

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OBJECTIVE

Despite the multifactorial pathogenesis of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH), augmentation of cerebral blood flow (CBF) is still considered essential in the clinical management of DCI. The aim of this prospective observational study was to investigate cerebral metabolic changes in relation to CBF during therapeutic hypervolemia, hemodilution, and hypertension (HHH) therapy in poor-grade SAH patients with DCI.

METHODS

CBF was assessed by bedside xenon-enhanced CT at days 0–3, 4–7, and 8–12, and the cerebral metabolic state by cerebral microdialysis (CMD), analyzing glucose, lactate, pyruvate, and glutamate hourly. At clinical suspicion of DCI, HHH therapy was instituted for 5 days. CBF measurements and CMD data at baseline and during HHH therapy were required for study inclusion. Non-DCI patients with measurements in corresponding time windows were included as a reference group.

RESULTS

In DCI patients receiving HHH therapy (n = 12), global cortical CBF increased from 30.4 ml/100 g/min (IQR 25.1–33.8 ml/100 g/min) to 38.4 ml/100 g/min (IQR 34.2–46.1 ml/100 g/min; p = 0.006). The energy metabolic CMD parameters stayed statistically unchanged with a lactate/pyruvate (L/P) ratio of 26.9 (IQR 22.9–48.5) at baseline and 31.6 (IQR 22.4–35.7) during HHH. Categorized by energy metabolic patterns during HHH, no patient had severe ischemia, 8 showed derangement corresponding to mitochondrial dysfunction, and 4 were normal. The reference group of non-DCI patients (n = 11) had higher CBF and lower L/P ratios at baseline with no change over time, and the metabolic pattern was normal in all these patients.

CONCLUSIONS

Global and regional CBF improved and the cerebral energy metabolic CMD parameters stayed statistically unchanged during HHH therapy in DCI patients. None of the patients developed metabolic signs of severe ischemia, but a disturbed energy metabolic pattern was a common occurrence, possibly explained by mitochondrial dysfunction despite improved microcirculation.

ABBREVIATIONS ACA = anterior cerebral artery; CBF = cerebral blood flow; CMD = cerebral microdialysis; CPP = cerebral perfusion pressure; DCI = delayed cerebral ischemia; GCS = Glasgow Coma Scale; HHH = hypervolemia, hemodilution, and hypertension; ICP = intracranial pressure; L/P = lactate/pyruvate; MAP = mean arterial pressure; MCA = middle cerebral artery; NIC = neurosurgical intensive care; PCA = posterior cerebral artery; rCBF = regional CBF; ROI = region of interest; SAH = subarachnoid hemorrhage; SBP = systolic blood pressure; TBI = traumatic brain injury; XeCT = xenon-enhanced CT.
Article Information

Contributor Notes

Correspondence Henrik Engquist: Uppsala University Hospital, Uppsala, Sweden. henrik.engquist@akademiska.se.INCLUDE WHEN CITING Published online January 10, 2020; DOI: 10.3171/2019.11.JNS192759.Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.
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