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Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

  • Practice Guidance for the Neurocritical Care Management of SAH
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Abstract

Delayed cerebral ischemia (DCI) is one of the most important complications of subarachnoid hemorrhage. Despite lack of prospective evidence, medical rescue interventions for DCI include hemodynamic augmentation using vasopressors or inotropes, with limited guidance on specific blood pressure and hemodynamic parameters. For DCI refractory to medical interventions, endovascular rescue therapies (ERTs), including intraarterial (IA) vasodilators and percutaneous transluminal balloon angioplasty, are the cornerstone of management. Although there are no randomized controlled trials assessing the efficacy of ERTs for DCI and their impact on subarachnoid hemorrhage outcomes, survey studies suggest that they are widely used in clinical practice with significant variability worldwide. IA vasodilators are first line ERTs, with better safety profiles and access to distal vasculature. The most commonly used IA vasodilators include calcium channel blockers, with milrinone gaining popularity in more recent publications. Balloon angioplasty achieves better vasodilation compared with IA vasodilators but is associated with higher risk of life-threatening vascular complications and is reserved for proximal severe refractory vasospasm. The existing literature on DCI rescue therapies is limited by small sample sizes, significant variability in patient populations, lack of standardized methodology, variable definitions of DCI, poorly reported outcomes, lack of long-term functional, cognitive, and patient-centered outcomes, and lack of control groups. Therefore, our current ability to interpret clinical results and make reliable recommendations regarding the use of rescue therapies is limited. This review summarizes existing literature on rescue therapies for DCI, provides practical guidance, and identifies future research needs.

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Authors and Affiliations

  1. Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Zayed 3014A, Baltimore, MD, USA

    Vishank A. Shah & Jose I. Suarez

  2. Division of Cerebrovascular and Endovascular Neurosurgery, Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA

    L. Fernando Gonzalez

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  1. Vishank A. Shah
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  2. L. Fernando Gonzalez
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  3. Jose I. Suarez
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Contributions

VAS conceptualized the manuscript structure, conducted the literature search, wrote the first draft of the manuscript, and prepared figures and tables. LFG reviewed and edited the manuscript, wrote the sections on techniques of intraarterial pharmacotherapy and percutaneous transluminal balloon angioplasty, and prepared Fig. 2. JIS conceptualized the manuscript, supervised the literature search, and performed critical review and editing of the entire manuscript. The final manuscript was approved by all authors.

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Correspondence to Vishank A. Shah.

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VAS does not report any conflict of interest for this publication; disclosures include being a member of the Editorial Board of the journal Neurohospitalist. LFG does not report any conflicts of interest for this publication. JIS reports no conflicts of interests for this publication; disclosures include being a member of the clinical events committee for the REACT Study, which is funded by Idorsia; member of the Editorial Board of the journal Stroke; ex-officio member of the Board of Directors of the Neurocritical Care Society.

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Shah, V.A., Gonzalez, L.F. & Suarez, J.I. Therapies for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 39, 36–50 (2023). https://doi.org/10.1007/s12028-023-01747-9

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