Skip to main content
SpringerLink
Log in

Hemodynamic Management of Subarachnoid Hemorrhage

  • Review
  • Published:
Neurocritical Care Aims and scope Submit manuscript

Abstract

Hemodynamic augmentation therapy is considered standard treatment to help prevent and treat vasospasm and delayed cerebral ischemia. Standard triple-H therapy combines volume expansion (hypervolemia), blood pressure augmentation (hypertension), and hemodilution. An electronic literature search was conducted of English-language papers published between 2000 and October 2010 that focused on hemodynamic augmentation therapies in patients with subarachnoid hemorrhage. Among the eligible reports identified, 11 addressed volume expansion, 10 blood pressure management, 4 inotropic therapy, and 12 hemodynamic augmentation in patients with unsecured aneurysms. While hypovolemia should be avoided, hypervolemia did not appear to confer additional benefits over normovolemic therapy, with an excess of side effects occurring in patients treated with hypervolemic targets. Overall, hypertension was associated with higher cerebral blood flow, regardless of volume status (normo- or hypervolemia), with neurological symptom reversal seen in two-thirds of treated patients. Limited data were available for evaluating inotropic agents or hemodynamic augmentation in patients with additional unsecured aneurysms. In the context of sparse data, no incremental risk of aneurysmal rupture has been reported with the induction of hemodynamic augmentation.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Nakagawa A, Su CC, Sato K, Shirane R. Evaluation of changes in circulating blood volume during acute and very acute stages of subarachnoid hemorrhage: implications for the management of hypovolemia. J Neurosurg. 2002;97:268–71.

    Article  PubMed  Google Scholar 

  2. Ract C, Vigue B. Comparison of the cerebral effects of dopamine and norepinephrine in severely head-injured patients. Intensive Care Med. 2001;27:101–6.

    Article  PubMed  CAS  Google Scholar 

  3. Steiner LA, Johnston AJ, Czosnyka M, et al. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med. 2004;32:1049–54.

    Article  PubMed  Google Scholar 

  4. Myburgh JA, Upton RN, Grant C, Martinez A. A comparison of the effects of norepinephrine, epinephrine, and dopamine on cerebral blood flow and oxygen utilisation. Acta Neurochir Suppl. 1998;71:19–21.

    PubMed  CAS  Google Scholar 

  5. Treggiari MM, Deem S. Which H is the most important in triple-H therapy for cerebral vasospasm? Curr Opin Crit Care. 2009;15:83–6.

    Article  PubMed  Google Scholar 

  6. Lennihan L, Mayer SA, Fink ME, et al. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31:383–91.

    Article  PubMed  CAS  Google Scholar 

  7. Egge A, Waterloo K, Sjoholm H, Solberg T, Ingebrigtsen T, Romner B. Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001;49:593–605.

    PubMed  CAS  Google Scholar 

  8. Mori K, Arai H, Nakajima K, Tajima A, Maeda M. Hemorheological and hemodynamic analysis of hypervolemic hemodilution therapy for cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 1995;26:1620–6.

    Article  PubMed  CAS  Google Scholar 

  9. Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35:1844–51.

    Article  PubMed  Google Scholar 

  10. Raabe A, Beck J, Keller M, Vatter H, Zimmermann M, Seifert V. Relative importance of hypertension compared with hypervolemia for increasing cerebral oxygenation in patients with cerebral vasospasm after subarachnoid hemorrhage. J Neurosurg. 2005;103:974–81.

    Article  PubMed  Google Scholar 

  11. Ekelund A, Reinstrup P, Ryding E, 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). 2002;144:703–12.

    Article  CAS  Google Scholar 

  12. Jost SC, Diringer MN, Zazulia AR, 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. 2005;103:25–30.

    Article  PubMed  Google Scholar 

  13. Yamakami I, Isobe K, Yamaura A. Effects of intravascular volume expansion on cerebral blood flow in patients with ruptured cerebral aneurysms. Neurosurgery. 1987;21:303–9.

    Article  PubMed  CAS  Google Scholar 

  14. Suarez JI, Shannon L, Zaidat OO, et al. Effect of human albumin administration on clinical outcome and hospital cost in patients with subarachnoid hemorrhage. J Neurosurg. 2004;100:585–90.

    Article  PubMed  CAS  Google Scholar 

  15. Tseng MY, Al-Rawi PG, Pickard JD, Rasulo FA, Kirkpatrick PJ. Effect of hypertonic saline on cerebral blood flow in poor-grade patients with subarachnoid hemorrhage. Stroke. 2003;34:1389–96.

    Article  PubMed  CAS  Google Scholar 

  16. Tseng MY, Al-Rawi PG, Czosnyka M, et al. Enhancement of cerebral blood flow using systemic hypertonic saline therapy improves outcome in patients with poor-grade spontaneous subarachnoid hemorrhage. J Neurosurg. 2007;107:274–82.

    Article  PubMed  Google Scholar 

  17. 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. 1982;11:337–43.

    Article  PubMed  CAS  Google Scholar 

  18. Brown FD, Hanlon K, Mullan S. Treatment of aneurysmal hemiplegia with dopamine and mannitol. J Neurosurg. 1978;49:525–9.

    Article  PubMed  CAS  Google Scholar 

  19. Touho H, Karasawa J, Ohnishi H, Shishido H, Yamada K, Shibamoto K. Evaluation of therapeutically induced hypertension in patients with delayed cerebral vasospasm by xenon-enhanced computed tomography. Neurol Med Chir (Tokyo). 1992;32:671–8.

    Article  CAS  Google Scholar 

  20. 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. 1994;80:857–64.

    Article  PubMed  CAS  Google Scholar 

  21. Mendelow AD, Dharker S, Patterson J, Nath F, Teasdale GM. The dopamine withdrawal test following surgery for intracranial aneurysms. J Neurol Neurosurg Psychiatry. 1986;49:35–8.

    Article  PubMed  CAS  Google Scholar 

  22. Otsubo H, Takemae T, Inoue T, Kobayashi S, Sugita K. Normovolaemic induced hypertension therapy for cerebral vasospasm after subarachnoid haemorrhage. Acta Neurochir (Wien). 1990;103:18–26.

    Article  CAS  Google Scholar 

  23. Kosnik EJ, Hunt WE. Postoperative hypertension in the management of patients with intracranial arterial aneurysms. J Neurosurg. 1976;45:148–54.

    Article  PubMed  CAS  Google Scholar 

  24. Muizelaar JP, Becker DP. Induced hypertension for the treatment of cerebral ischemia after subarachnoid hemorrhage. Direct effect on cerebral blood flow. Surg Neurol. 1986;25:317–25.

    Article  PubMed  CAS  Google Scholar 

  25. 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. 1995;26:2260–6.

    Article  PubMed  CAS  Google Scholar 

  26. Muehlschlegel S, Dunser MW, Gabrielli A, Wenzel V, Layon AJ. Arginine vasopressin as a supplementary vasopressor in refractory hypertensive, hypervolemic, hemodilutional therapy in subarachnoid hemorrhage. Neurocrit Care. 2007;6:3–10.

    Article  PubMed  CAS  Google Scholar 

  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. 1990;27:729–39. discussion 39-40.

    Article  PubMed  CAS  Google Scholar 

  28. Joseph M, Ziadi S, Nates J, Dannenbaum M, Malkoff M. Increases in cardiac output can reverse flow deficits from vasospasm independent of blood pressure: a study using xenon computed tomographic measurement of cerebral blood flow. Neurosurgery. 2003;53:1044–51.

    Article  PubMed  Google Scholar 

  29. Levy ML, Rabb CH, Zelman V, Giannotta SL. Cardiac performance enhancement from dobutamine in patients refractory to hypervolemic therapy for cerebral vasospasm. J Neurosurg. 1993;79:494–9.

    Article  PubMed  CAS  Google Scholar 

  30. Fraticelli AT, Cholley BP, Losser MR, Saint Maurice JP, Payen D. Milrinone for the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Stroke. 2008;39:893–8.

    Article  PubMed  Google Scholar 

  31. Arakawa Y, Kikuta K, Hojo M, Goto Y, Ishii A, Yamagata S. Milrinone for the treatment of cerebral vasospasm after subarachnoid hemorrhage: report of seven cases. Neurosurgery. 2001;48:723–8.

    PubMed  CAS  Google Scholar 

  32. Tranmer BI, Keller TS, Kindt GW, Archer D. Loss of cerebral regulation during cardiac output variations in focal cerebral ischemia. J Neurosurg. 1992;77:253–9.

    Article  PubMed  CAS  Google Scholar 

  33. Schmidt U, Bittner E, Pivi S, Marota JJ. Hemodynamic management and outcome of patients treated for cerebral vasospasm with intraarterial nicardipine and/or milrinone. Anesth Analg. 2010;110:895–902.

    Article  PubMed  CAS  Google Scholar 

  34. Bouma GJ, Muizelaar JP. Relationship between cardiac output and cerebral blood flow in patients with intact and with impaired autoregulation. J Neurosurg. 1990;73:368–74.

    Article  PubMed  CAS  Google Scholar 

  35. Busani S, Rinaldi L, Severino C, Cobelli M, Pasetto A, Girardis M. Levosimendan in cardiac failure after subarachnoid hemorrhage. J Trauma. 2010;68:E108–10.

    Article  PubMed  CAS  Google Scholar 

  36. Zada G, Terterov S, Russin J, Clavijo L, Giannotta S. Cerebral vasospasm and concurrent left ventricular outflow tract obstruction: requirement for modification of hyperdynamic therapy regimen. Neurocrit Care. 2010;12:265–8.

    Article  PubMed  Google Scholar 

  37. Apostolides PJ, Greene KA, Zabramski JM, Fitzgerald JW, Spetzler RF. Intra-aortic balloon pump counterpulsation in the management of concomitant cerebral vasospasm and cardiac failure after subarachnoid hemorrhage: technical case report. Neurosurgery. 1996;38:1056–9.

    Article  PubMed  CAS  Google Scholar 

  38. Lazaridis C, Pradilla G, Nyquist PA, Tamargo RJ. Intra-aortic balloon pump counterpulsation in the setting of subarachnoid hemorrhage, cerebral vasospasm, and neurogenic stress cardiomyopathy. Case report and review of the literature. Neurocrit Care. 2010;13:101–8.

    Article  PubMed  Google Scholar 

  39. Hoh BL, Carter BS, Ogilvy CS. Risk of hemorrhage from unsecured, unruptured aneurysms during and after hypertensive hypervolemic therapy. Neurosurgery. 2002;50:1207–11.

    PubMed  Google Scholar 

  40. Bernardini GL, Mayer SA, Kossoff SB, Hacein-Bey L, Solomon RA, Pile-Spellman J. Anticoagulation and induced hypertension after endovascular treatment for ruptured intracranial aneurysms. Crit Care Med. 2001;29:641–4.

    Article  PubMed  CAS  Google Scholar 

  41. Hashimoto M, Johkura K, Ichikawa T, Kojima A, Nishimura S, Shinonaga M. Conservative treatment of ruptured vertebrobasilar dissecting aneurysm. Neurol Sci. 2008;29:241–4.

    Article  PubMed  Google Scholar 

  42. Juvela S. Prehemorrhage risk factors for fatal intracranial aneurysm rupture. Stroke. 2003;34:1852–7.

    Article  PubMed  Google Scholar 

  43. Kim HC, Nam CM, Jee SH, Suh I. Comparison of blood pressure-associated risk of intracerebral hemorrhage and subarachnoid hemorrhage: Korea Medical Insurance Corporation study. Hypertension. 2005;46:393–7.

    Article  PubMed  Google Scholar 

  44. Ohkuma H, Tsurutani H, Suzuki S. Incidence and significance of early aneurysmal rebleeding before neurosurgical or neurological management. Stroke. 2001;32:1176–80.

    Article  PubMed  CAS  Google Scholar 

  45. Lall RR, Eddleman CS, Bendok BR, Batjer HH. Unruptured intracranial aneurysms and the assessment of rupture risk based on anatomical and morphological factors: sifting through the sands of data. Neurosurg Focus. 2009;26:E2.

    Article  PubMed  Google Scholar 

  46. Nader-Sepahi A, Casimiro M, Sen J, Kitchen ND. Is aspect ratio a reliable predictor of intracranial aneurysm rupture? Neurosurgery. 2004;54:1343–7.

    Article  PubMed  Google Scholar 

  47. Sforza DM, Putman CM, Scrivano E, Lylyk P, Cebral JR. Blood-flow characteristics in a terminal basilar tip aneurysm prior to its fatal rupture. Am J Neuroradiol. 2010;31:1127–31.

    Article  PubMed  CAS  Google Scholar 

  48. van der Kolk NM, Algra A, Rinkel GJ. Risk of aneurysm rupture at intracranial arterial bifurcations. Cerebrovasc Dis. 2010;30:29–35.

    Article  PubMed  Google Scholar 

  49. Meyer R, Deem S, David Yanez N, Souter M, Lam A, Treggiari MM. Current practices of triple-H prophylaxis and therapy in patients with subarachnoid hemorrhage. Neurocrit Care. 2011;14:24–36.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Pain Medicine, University of Washington, Box 359724, Seattle, WA, USA

    Miriam M. Treggiari

Authors
  1. Miriam M. Treggiari
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage

Corresponding author

Correspondence to Miriam M. Treggiari.

Additional information

Participants in the International Multi-disciplinary Consensus Conference: Michael N. Diringer, Thomas P. Bleck, Nicolas Bruder, E. Sander Connolly, Jr., Giuseppe Citerio, Daryl Gress, Daniel Hanggi, J. Claude Hemphill, III, MAS, Brian Hoh, Giuseppe Lanzino, Peter Le Roux, David Menon, Alejandro Rabinstein, Erich Schmutzhard, Lori Shutter, Nino Stocchetti, Jose Suarez, Miriam Treggiari, MY Tseng, Mervyn Vergouwen, Paul Vespa, Stephan Wolf, and Gregory J. Zipfel.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Treggiari, M.M., Participants in the International Multi-disciplinary Consensus Conference on the Critical Care Management of Subarachnoid Hemorrhage. Hemodynamic Management of Subarachnoid Hemorrhage. Neurocrit Care 15, 329–335 (2011). https://doi.org/10.1007/s12028-011-9589-5

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-011-9589-5

Keywords

Search

Navigation