Comparison of induced hypertension, fluid bolus, and blood transfusion to augment cerebral oxygen delivery after subarachnoid hemorrhage

Clinical article

View More View Less
  • 1 Departments of Neurology
  • | 2 Neurological Surgery, and
  • | 3 Radiology, Washington University School of Medicine, St. Louis, Missouri
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
Print or Print + Online

Object

Critical reductions in oxygen delivery (DO2) underlie the development of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH). If DO2 is not promptly restored, then irreversible injury (that is, cerebral infarction) may result. Hemodynamic therapies for DCI (that is, induced hypertension [IH] and hypervolemia) aim to improve DO2 by raising cerebral blood flow (CBF). Red blood cell (RBC) transfusion may be an alternate strategy that augments DO2 by improving arterial O2 content. The authors compared the relative ability of these 3 interventions to improve cerebral DO2, specifically their ability to restore DO2 to regions where it is impaired.

Methods

The authors compared 3 prospective physiological studies in which PET imaging was used to measure global and regional CBF and DO2 before and after the following treatments: 1) fluid bolus of 15 ml/kg normal saline (9 patients); 2) raising mean arterial pressure 25% (12 patients); and 3) transfusing 1 U of RBCs (17 patients) in 38 individuals with aneurysmal SAH at risk for DCI. Response between groups in regions with low DO2 (< 4.5 ml/100 g/min) was compared using repeated-measures ANOVA.

Results

Groups were similar except that the fluid bolus cohort had more patients with symptoms of DCI and lower baseline CBF. Global CBF or DO2 did not rise significantly after any of the interventions, except after transfusion in patients with hemoglobin levels < 9 g/dl. All 3 treatments improved CBF and DO2 to regions with impaired baseline DO2, with a greater improvement after transfusion (23%) than hypertension (14%) or volume loading (10%); p < 0.001. Transfusion also resulted in a nonsignificantly greater (47%) reduction in the number of brain regions with low DO2 when compared with fluid bolus (7%) and hypertension (12%) (p = 0.33).

Conclusions

The IH, fluid bolus, and blood transfusion interventions all improve DO2 to vulnerable brain regions at risk for ischemia after SAH. Transfusion appeared to provide a physiological benefit at least comparable to IH, especially among patients with anemia, but transfusion is associated with risks. The clinical significance of these findings remains to be established in controlled clinical trials.

Abbreviations used in this paper:

CaO2 = arterial oxygen content; CBF = cerebral blood flow; CMRO2 = cerebral metabolic rate for O2; CVP = central venous pressure; DCI = delayed cerebral ischemia; DO2 = O2 delivery; IH = induced hypertension; MAP = mean arterial pressure; NNICU = Neurology/Neurosurgery ICU; OEF = O2 extraction fraction; RBC = red blood cell; SAH = subarachnoid hemorrhage; triple-H therapy = hypervolemia, hypertension and hemodilution.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $515.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $612.00
  • 1

    Awad IA, , Carter LP, , Spetzler RF, , Medina M, & Williams FC Jr: Clinical vasospasm after subarachnoid hemorrhage: response to hypervolemic hemodilution and arterial hypertension. Stroke 18:365372, 1987

    • Search Google Scholar
    • Export Citation
  • 2

    Brix G, , Zaers J, , Adam LE, , Bellemann ME, , Ostertag H, & Trojan H, et al.: Performance evaluation of a whole-body PET scanner using the NEMA protocol. J Nucl Med 38:16141623, 1997

    • Search Google Scholar
    • Export Citation
  • 3

    Carpenter DA, , Grubb RL Jr, , Tempel LW, & Powers WJ: Cerebral oxygen metabolism after aneurysmal subarachnoid hemorrhage. J Cereb Blood Flow Metab 11:837844, 1991

    • Search Google Scholar
    • Export Citation
  • 4

    Claassen J, , Bernardini GL, , Kreiter K, , Bates J, , Du YE, & Copeland D, et al.: Effect of cisternal and ventricular blood on risk of delayed cerebral ischemia after subarachnoid hemorrhage: the Fisher scale revisited. Stroke 32:20122020, 2001

    • Search Google Scholar
    • Export Citation
  • 5

    Dankbaar JW, , Slooter AJ, , Rinkel GJ, & Schaaf IC: Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review. Crit Care 14:R23, 2010

    • Search Google Scholar
    • Export Citation
  • 6

    Darby JM, , Yonas H, , Marks EC, , Durham S, , Snyder RW, & Nemoto EM: Acute cerebral blood flow response to dopamine-induced hypertension after subarachnoid hemorrhage. J Neurosurg 80:857864, 1994

    • Search Google Scholar
    • Export Citation
  • 7

    Dhar R, , Zazulia A, , Videen T, , Zipfel G, & Diringer M: Transfusion may be more effective at improving cerebral oxygen delivery after subarachnoid hemorrhage at lower hemoglobin levels. Neurocrit Care 13:S12, 2010. (Abstract)

    • Search Google Scholar
    • Export Citation
  • 8

    Dhar R, , Zazulia AR, , Videen TO, , Zipfel GJ, , Derdeyn CP, & Diringer MN: Red blood cell transfusion increases cerebral oxygen delivery in anemic patients with subarachnoid hemorrhage. Stroke 40:30393044, 2009

    • Search Google Scholar
    • Export Citation
  • 9

    Diringer MN, , Aiyagari V, , Zazulia AR, , Videen TO, & Powers WJ: Effect of hyperoxia on cerebral metabolic rate for oxygen measured using positron emission tomography in patients with acute severe head injury. J Neurosurg 106:526529, 2007

    • Search Google Scholar
    • Export Citation
  • 10

    Egge A, , Waterloo K, , Sjøholm H, , Solberg T, , Ingebrigtsen T, & Romner B: Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery 49:593606, 2001

    • Search Google Scholar
    • Export Citation
  • 11

    Ekelund A, , Reinstrup P, , Ryding E, , Andersson AM, , Molund T, & Kristiansson KA, et al.: Effects of iso- and hypervolemic hemodilution on regional cerebral blood flow and oxygen delivery for patients with vasospasm after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 144:703713, 2002

    • Search Google Scholar
    • Export Citation
  • 12

    Frykholm P, , Andersson JL, , Långström B, , Persson L, & Enblad P: Haemodynamic and metabolic disturbances in the acute stage of subarachnoid haemorrhage demonstrated by PET. Acta Neurol Scand 109:2532, 2004

    • Search Google Scholar
    • Export Citation
  • 13

    Grubb RL Jr, , Raichle ME, , Eichling JO, & Gado MH: Effects of subarachnoid hemorrhage on cerebral blood volume, blood flow, and oxygen utilization in humans. J Neurosurg 46:446453, 1977

    • Search Google Scholar
    • Export Citation
  • 14

    Hatazawa J, , Fujita H, , Kanno I, , Satoh T, , Iida H, & Miura S, et al.: Regional cerebral blood flow, blood volume, oxygen extraction fraction, and oxygen utilization rate in normal volunteers measured by the autoradiographic technique and the single breath inhalation method. Ann Nucl Med 9:1521, 1995

    • Search Google Scholar
    • Export Citation
  • 15

    Hudak ML, , Koehler RC, , Rosenberg AA, , Traystman RJ, & Jones MD Jr: Effect of hematocrit on cerebral blood flow. Am J Physiol 251:H63H70, 1986

    • Search Google Scholar
    • Export Citation
  • 16

    Ito H, , Kanno I, & Fukuda H: Human cerebral circulation: positron emission tomography studies. Ann Nucl Med 19:6574, 2005

  • 17

    Jost SC, , Diringer MN, , Zazulia AR, , Videen TO, , Aiyagari V, & Grubb RL, et al.: Effect of normal saline bolus on cerebral blood flow in regions with low baseline flow in patients with vasospasm following subarachnoid hemorrhage. J Neurosurg 103:2530, 2005

    • Search Google Scholar
    • Export Citation
  • 18

    Kassell NF, , Peerless SJ, , Durward QJ, , Beck DW, , Drake CG, & Adams HP: Treatment of ischemic deficits from vasospasm with intravascular volume expansion and induced arterial hypertension. Neurosurgery 11:337343, 1982

    • Search Google Scholar
    • Export Citation
  • 19

    Kramer AH, , Diringer MN, , Suarez JI, , Naidech AM, , Macdonald LR, & Le Roux PD: Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey. Crit Care 15:R30, 2011

    • Search Google Scholar
    • Export Citation
  • 20

    Kramer AH, , Zygun DA, , Bleck TP, , Dumont AS, , Kassell NF, & Nathan B: Relationship between hemoglobin concentrations and outcomes across subgroups of patients with aneurysmal subarachnoid hemorrhage. Neurocrit Care 10:157165, 2009

    • Search Google Scholar
    • Export Citation
  • 21

    Lennihan L, , Mayer SA, , Fink ME, , Beckford A, , Paik MC, & Zhang H, et al.: Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke 31:383391, 2000

    • Search Google Scholar
    • Export Citation
  • 22

    Marik PE, & Corwin HL: Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 36:26672674, 2008

    • Search Google Scholar
    • Export Citation
  • 23

    Miller JA, , Dacey RG Jr, & Diringer MN: Safety of hypertensive hypervolemic therapy with phenylephrine in the treatment of delayed ischemic deficits after subarachnoid hemorrhage. Stroke 26:22602266, 1995

    • Search Google Scholar
    • Export Citation
  • 24

    Muench E, , Horn P, , Bauhuf C, , Roth H, , Philipps M, & Hermann P, et al.: Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med 35:18441852, 2007

    • Search Google Scholar
    • Export Citation
  • 25

    Naidech AM, , Drescher J, , Ault ML, , Shaibani A, , Batjer HH, & Alberts MJ: Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage. Neurosurgery 59:775780, 2006

    • Search Google Scholar
    • Export Citation
  • 26

    Naidech AM, , Jovanovic B, , Wartenberg KE, , Parra A, , Ostapkovich N, & Connolly ES, et al.: Higher hemoglobin is associated with improved outcome after subarachnoid hemorrhage. Crit Care Med 35:23832389, 2007

    • Search Google Scholar
    • Export Citation
  • 27

    Origitano TC, , Wascher TM, , Reichman OH, & Anderson DE: Sustained increased cerebral blood flow with prophylactic hypertensive hypervolemic hemodilution (“triple-H” therapy) after subarachnoid hemorrhage. Neurosurgery 27:729740, 1990

    • Search Google Scholar
    • Export Citation
  • 28

    Powers WJ, , Grubb RL Jr, , Baker RP, , Mintun MA, & Raichle ME: Regional cerebral blood flow and metabolism in reversible ischemia due to vasospasm. Determination by positron emission tomography. J Neurosurg 62:539546, 1985

    • Search Google Scholar
    • Export Citation
  • 29

    Powers WJ, , Grubb RL Jr, , Darriet D, & Raichle ME: Cerebral blood flow and cerebral metabolic rate of oxygen requirements for cerebral function and viability in humans. J Cereb Blood Flow Metab 5:600608, 1985

    • Search Google Scholar
    • Export Citation
  • 30

    Raichle ME, , Martin WR, , Herscovitch P, , Mintun MA, & Markham J: Brain blood flow measured with intravenous H2(15)O. II. Implementation and validation. J Nucl Med 24:790798, 1983

    • Search Google Scholar
    • Export Citation
  • 31

    Siesjö BK: Pathophysiology and treatment of focal cerebral ischemia. Part I: pathophysiology. J Neurosurg 77:169184, 1992

  • 32

    Smith MJ, , Stiefel MF, , Magge S, , Frangos S, , Bloom S, & Gracias V, et al.: Packed red blood cell transfusion increases local cerebral oxygenation. Crit Care Med 33:11041108, 2005

    • Search Google Scholar
    • Export Citation
  • 33

    Teasdale GM, , Drake CG, , Hunt W, , Kassell N, , Sano K, & Pertuiset B, et al.: A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. J Neurol Neurosurg Psychiatry 51:1457, 1988

    • Search Google Scholar
    • Export Citation
  • 34

    Wienhard K, , Dahlbom M, , Eriksson L, , Michel C, , Bruckbauer T, & Pietrzyk U, et al.: The ECAT EXACT HR: performance of a new high resolution positron scanner. J Comput Assist Tomogr 18:110118, 1994

    • Search Google Scholar
    • Export Citation
  • 35

    Woods RP, , Cherry SR, & Mazziotta JC: Rapid automated algorithm for aligning and reslicing PET images. J Comput Assist Tomogr 16:620633, 1992

    • Search Google Scholar
    • Export Citation
  • 36

    Yundt KD, , Grubb RL Jr, , Diringer MN, & Powers WJ: Autoregulatory vasodilation of parenchymal vessels is impaired during cerebral vasospasm. J Cereb Blood Flow Metab 18:419424, 1998

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 765 151 10
Full Text Views 241 19 1
PDF Downloads 160 19 2
EPUB Downloads 0 0 0