The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms

Matthew R. Reynolds, Robert T. Buckley, Santoshi S. Indrakanti, Ali H. Turkmani, Gerald Oh, Emanuela Crobeddu, Kyle M. Fargen, Tarek Y. El Ahmadieh, Andrew M. Naidech, Sepideh Amin-Hanjani, Giuseppe Lanzino, Brian L. Hoh, Bernard Bendok, Gregory J. Zipfel

Research output: Contribution to journalArticle

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Abstract

OBJECT: Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.

METHODS: This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.

RESULTS: For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p <0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p <0.01).

CONCLUSIONS: For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

Original languageEnglish (US)
Pages (from-to)862-871
Number of pages10
JournalJournal of Neurosurgery
Volume123
Issue number4
DOIs
StatePublished - Oct 1 2015

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Intracranial Aneurysm
Subarachnoid Hemorrhage
Hypertension
Safety
Aneurysm
Therapeutics
Ruptured Aneurysm
Blood Pressure
Water-Electrolyte Balance

Keywords

  • ACA = anterior cerebral artery
  • DCI = delayed cerebral ischemia
  • delayed cerebral ischemia
  • DVT/PE = deep vein thrombosis/pulmonary embolism
  • ICA = internal carotid artery
  • induced hypertension
  • intracranial aneurysm
  • MAP = mean arterial pressure
  • MCA = middle cerebral artery
  • SAH = subarachnoid hemorrhage
  • SBP = systolic blood pressure
  • SEM = standard error of the mean
  • subarachnoid hemorrhage
  • triple-H therapy
  • unprotected
  • unruptured
  • vascular disorders
  • vasospasm
  • VIH = vasopressor-induced hypertension
  • WFNS = World Federation of Neurosurgical Societies

ASJC Scopus subject areas

  • Medicine(all)

Cite this

The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms. / Reynolds, Matthew R.; Buckley, Robert T.; Indrakanti, Santoshi S.; Turkmani, Ali H.; Oh, Gerald; Crobeddu, Emanuela; Fargen, Kyle M.; El Ahmadieh, Tarek Y.; Naidech, Andrew M.; Amin-Hanjani, Sepideh; Lanzino, Giuseppe; Hoh, Brian L.; Bendok, Bernard; Zipfel, Gregory J.

In: Journal of Neurosurgery, Vol. 123, No. 4, 01.10.2015, p. 862-871.

Research output: Contribution to journalArticle

Reynolds, MR, Buckley, RT, Indrakanti, SS, Turkmani, AH, Oh, G, Crobeddu, E, Fargen, KM, El Ahmadieh, TY, Naidech, AM, Amin-Hanjani, S, Lanzino, G, Hoh, BL, Bendok, B & Zipfel, GJ 2015, 'The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms', Journal of Neurosurgery, vol. 123, no. 4, pp. 862-871. https://doi.org/10.3171/2014.12.JNS141201
Reynolds, Matthew R. ; Buckley, Robert T. ; Indrakanti, Santoshi S. ; Turkmani, Ali H. ; Oh, Gerald ; Crobeddu, Emanuela ; Fargen, Kyle M. ; El Ahmadieh, Tarek Y. ; Naidech, Andrew M. ; Amin-Hanjani, Sepideh ; Lanzino, Giuseppe ; Hoh, Brian L. ; Bendok, Bernard ; Zipfel, Gregory J. / The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms. In: Journal of Neurosurgery. 2015 ; Vol. 123, No. 4. pp. 862-871.
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title = "The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms",
abstract = "OBJECT: Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.METHODS: This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.RESULTS: For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1{\%} ± 1.0{\%} vs 98.2{\%} ± 1.2{\%}, respectively; p <0.01) and systolic blood pressure (125.6{\%} ± 1.1{\%} vs. 104.1{\%} ± 5.2{\%}, respectively; p <0.01).CONCLUSIONS: For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.",
keywords = "ACA = anterior cerebral artery, DCI = delayed cerebral ischemia, delayed cerebral ischemia, DVT/PE = deep vein thrombosis/pulmonary embolism, ICA = internal carotid artery, induced hypertension, intracranial aneurysm, MAP = mean arterial pressure, MCA = middle cerebral artery, SAH = subarachnoid hemorrhage, SBP = systolic blood pressure, SEM = standard error of the mean, subarachnoid hemorrhage, triple-H therapy, unprotected, unruptured, vascular disorders, vasospasm, VIH = vasopressor-induced hypertension, WFNS = World Federation of Neurosurgical Societies",
author = "Reynolds, {Matthew R.} and Buckley, {Robert T.} and Indrakanti, {Santoshi S.} and Turkmani, {Ali H.} and Gerald Oh and Emanuela Crobeddu and Fargen, {Kyle M.} and {El Ahmadieh}, {Tarek Y.} and Naidech, {Andrew M.} and Sepideh Amin-Hanjani and Giuseppe Lanzino and Hoh, {Brian L.} and Bernard Bendok and Zipfel, {Gregory J.}",
year = "2015",
month = "10",
day = "1",
doi = "10.3171/2014.12.JNS141201",
language = "English (US)",
volume = "123",
pages = "862--871",
journal = "Journal of Neurosurgery",
issn = "0022-3085",
publisher = "American Association of Neurological Surgeons",
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TY - JOUR

T1 - The safety of vasopressor-induced hypertension in subarachnoid hemorrhage patients with coexisting unruptured, unprotected intracranial aneurysms

AU - Reynolds, Matthew R.

AU - Buckley, Robert T.

AU - Indrakanti, Santoshi S.

AU - Turkmani, Ali H.

AU - Oh, Gerald

AU - Crobeddu, Emanuela

AU - Fargen, Kyle M.

AU - El Ahmadieh, Tarek Y.

AU - Naidech, Andrew M.

AU - Amin-Hanjani, Sepideh

AU - Lanzino, Giuseppe

AU - Hoh, Brian L.

AU - Bendok, Bernard

AU - Zipfel, Gregory J.

PY - 2015/10/1

Y1 - 2015/10/1

N2 - OBJECT: Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.METHODS: This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.RESULTS: For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p <0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p <0.01).CONCLUSIONS: For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

AB - OBJECT: Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain.METHODS: This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy.RESULTS: For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p <0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p <0.01).CONCLUSIONS: For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

KW - ACA = anterior cerebral artery

KW - DCI = delayed cerebral ischemia

KW - delayed cerebral ischemia

KW - DVT/PE = deep vein thrombosis/pulmonary embolism

KW - ICA = internal carotid artery

KW - induced hypertension

KW - intracranial aneurysm

KW - MAP = mean arterial pressure

KW - MCA = middle cerebral artery

KW - SAH = subarachnoid hemorrhage

KW - SBP = systolic blood pressure

KW - SEM = standard error of the mean

KW - subarachnoid hemorrhage

KW - triple-H therapy

KW - unprotected

KW - unruptured

KW - vascular disorders

KW - vasospasm

KW - VIH = vasopressor-induced hypertension

KW - WFNS = World Federation of Neurosurgical Societies

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