Medical Treatment Failure for Symptomatic Vasospasm After Subarachnoid Hemorrhage Threatens Long-Term Outcome

• Published in: Stroke (1970) Vol. 50; no. 7; pp. 1696 - 1702
• Main Authors: Suwatcharangkoon, Sureerat, De Marchis, Gian Marco, Witsch, Jens, Meyers, Emma, Velazquez, Angela, Falo, Cristina, Schmidt, J. Michael, Agarwal, Sachin, Connolly, E. Sander, Claassen, Jan, Mayer, Stephan A.
• Format: Journal Article
• Language: English
• Published: United States American Heart Association, Inc 01.07.2019
• Subjects: Adult; Aged; Blood Pressure - drug effects; Female; Follow-Up Studies; Humans; Male; Middle Aged; Retrospective Studies; Subarachnoid Hemorrhage - complications; Subarachnoid Hemorrhage - drug therapy; Subarachnoid Hemorrhage - physiopathology; Treatment Failure; Vasoconstrictor Agents - administration & dosage; Vasoconstrictor Agents - adverse effects; Vasospasm, Intracranial - drug therapy; Vasospasm, Intracranial - etiology; Vasospasm, Intracranial - physiopathology; risk factors; vasospasm; treatment failure; hypertension; subarachnoid hemorrhage
• ISSN: 0039-2499; 1524-4628; 1524-4628
• DOI: 10.1161/STROKEAHA.118.022536

BACKGROUND AND PURPOSE—Symptomatic vasospasm is a common cause of morbidity and mortality after subarachnoid hemorrhage. We sought to identify predictors and the long-term impact of treatment failure with hypertensive therapy for symptomatic vasospasm. METHODS—We performed a retrospective analysis of 1520 subarachnoid hemorrhage patients prospectively enrolled in the Columbia University SAH Outcomes Project between August 1996 and August 2012. One hundred ninety-eight symptomatic vasospasm patients were treated with vasopressors to raise arterial blood pressure, with and without volume expansion. Treatment response, defined as complete or near-complete resolution of the initial neurological deficit, was adjudicated in weekly meetings of the study team based on serial clinical examination after hypertensive treatment. Outcome was evaluated at 1 year with the modified Rankin Scale. RESULTS—Twenty-one percent of the 198 patients who received hypertensive therapy did not respond to treatment. Treatment failure was associated with an increased risk of death or severe disability at 1 year (modified Rankin Scale score of 4–6; 62% versus 25%; P<0.001). Failure of medical therapy was also associated with an admission troponin I level >0.3 μg/L (64% versus 28%; P=0.001), aneurysm coiling (43% versus 20%; P=0.004), and involvement of >1 symptomatic vascular territory at onset (39% versus 22%; P=0.02). In multivariable analysis, treatment failure was independently associated only with troponin I elevation (adjusted odds ratio, 4.30; 95% CI, 1.69–11.09; P=0.002). CONCLUSIONS—Failure to respond to induced hypertension for symptomatic vasospasm threatens 1-year outcome. Subarachnoid hemorrhage patients with symptomatic vasospasm who have elevated initial troponin I levels, indicative of neurogenic cardiac injury, are at twice the risk of medical treatment failure. Expedited endovascular therapy should be considered in these patients.