Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage
Abstract
:1. Introduction
2. Materials and Methods
2.1. Outcome Measures
2.2. Statistical Analysis
3. Results
3.1. Angiographic Vasospasm
3.2. Delayed Cerebral Ischemia (DCI)
3.3. Neurologic Outcome (mRS)
4. Discussion
4.1. Blood Pressure and SAH
4.2. End-Tidal Carbon Dioxide and SAH
4.3. Limitations of the Study
5. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Sudlow, C.L.; Warlow, C.P. Comparable studies of the incidence of stroke and its pathological types: Results from an interna-tional collaboration. International stroke incidence collaboration. Stroke 1997, 28, 491–499. [Google Scholar] [CrossRef] [PubMed]
- Lucke-Wold, B.P.; Logsdon, A.F.; Manoranjan, B.; Turner, R.C.; McConnell, E.; Vates, G.E.; Huber, J.D.; Rosen, C.L.; Simard, J.M. Aneurysmal Subarachnoid Hemorrhage and Neuroinflammation: A Comprehensive Review. Int. J. Mol. Sci. 2016, 17, 497. [Google Scholar] [CrossRef] [PubMed]
- Brathwaite, S.; Macdonald, R.L. Current Management of Delayed Cerebral Ischemia: Update from Results of Recent Clinical Trials. Transl. Stroke Res. 2013, 5, 207–226. [Google Scholar] [CrossRef] [PubMed]
- Schmieder, K.; Möller, F.; Engelhardt, M.; Scholz, M.; Schregel, W.; Christmann, A.; Harders, A. Dynamic Cerebral Autoregulation in Patients with Ruptured and Unruptured Aneurysms after Induction of General Anesthesia. Cent. Eur. Neurosurg. 2006, 67, 81–87. [Google Scholar] [CrossRef]
- Tenjin, H.; Hirakawa, K.; Mizukawa, N.; Yano, I.; Ohta, T.; Uchibori, M.; Hino, A. Dysautoregulation in patients with ruptured aneurysms: Cerebral blood flow measurements obtained during surgery by a temperature-controlled thermoelectrical method. Neurosurgery 1988, 23, 705–709. [Google Scholar] [CrossRef]
- Chang, H.S.; Hongo, K.; Nakagawa, H. Adverse effects of limited hypotensive anesthesia on the outcome of patients with sub-arachnoid hemorrhage. J. Neurosurg. 2000, 92, 971–975. [Google Scholar] [CrossRef]
- Chong, J.-Y.; Kim, D.-W.; Jwa, C.-S.; Yi, H.-J.; Ko, Y.; Kim, K.-M. Impact of Cardio-Pulmonary and Intraoperative Factors on Occurrence of Cerebral Infarction After Early Surgical Repair of the Ruptured Cerebral Aneurysms. J. Korean Neurosurg. Soc. 2008, 43, 90–96. [Google Scholar] [CrossRef] [PubMed]
- Ayling, O.G.S.; Ibrahim, G.M.; Drake, B.; Torner, J.C.; Macdonald, R.L. Operative complications and differences in outcome after clipping and coiling of ruptured intracranial aneurysms. J. Neurosurg. 2015, 123, 621–628. [Google Scholar] [CrossRef]
- Mahaney, K.B.; Todd, M.M.; Bayman, E.O.; Torner, J.C.; IHAST Investigators. Acute postoperative neurological deterioration asso-ciated with surgery for ruptured intracranial aneurysm: Incidence, predictors, and outcomes. J. Neurosurg. 2012, 116, 1267–1278. [Google Scholar] [CrossRef]
- Tang, C.; Zhang, T.-S.; Zhou, L.-F. Risk Factors for Rebleeding of Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. PLoS ONE 2014, 9, e99536. [Google Scholar] [CrossRef]
- Solaiman, O.; Singh, J.M. Hypocapnia in aneurysmal subarachnoid hemorrhage: Incidence and association with poor clinical outcomes. J. Neurosurg. Anesthesiol. 2013, 25, 254–261. [Google Scholar] [CrossRef] [PubMed]
- Li, K.C.; Tam, C.W.Y.; Shum, H.-P.; Yan, W.W. Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study. Crit. Care Res. Pract. 2019, 2019, 7584573. [Google Scholar] [CrossRef]
- Williamson, C.A.; Sheehan, K.M.; Tipirneni, R.; Roark, C.D.; Pandey, A.S.; Thompson, B.G.; Rajajee, V. The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hem-orrhage. Neurocritical Care 2015, 23, 330–338. [Google Scholar] [CrossRef] [PubMed]
- Westermaier, T.; Stetter, C.; Kunze, E.; Willner, N.; Holzmeier, J.; Kilgenstein, C.; Lee, J.Y.; Ernestus, R.I.; Roewer, N.; Muellenbach, R.M. Controlled transient hypercapnia: A novel approach for the treatment of delayed cerebral ischemia after subarachnoid hem-orrhage? J. Neurosurg. 2014, 121, 1056–1062. [Google Scholar] [CrossRef]
- Westermaier, T.; Stetter, C.; Kunze, E.; Willner, N.; Holzmeier, J.; Weiland, J.; Koehler, S.; Lotz, C.; Kilgenstein, C.; Ernestus, R.-I.; et al. Controlled Hypercapnia Enhances Cerebral Blood Flow and Brain Tissue Oxygenation After Aneurysmal Subarachnoid Hemorrhage: Results of a Phase 1 Study. Neurocritical Care 2016, 25, 205–214. [Google Scholar] [CrossRef]
- Hoff, R.G.; VANDijk, G.W.; Mettes, S.; Verweij, B.H.; Algra, A.; Rinkel, G.J.; Kalkman, C.J. Hypotension in anaesthetized patients during aneurysm clipping: Not as bad as expected? Acta Anaesthesiol. Scand. 2008, 52, 1006–1011. [Google Scholar] [CrossRef]
- Akkermans, A.; van Waes, J.A.; Peelen, L.M.; Rinkel, G.J.; van Klei, W.A. Blood Pressure and End-tidal Carbon Dioxide Ranges during Aneurysm Occlusion and Neurologic Outcome after an Aneurysmal Subarachnoid Hemorrhage. Anesthesiology 2019, 130, 92–105. [Google Scholar] [CrossRef] [PubMed]
- Dernbach, P.D.; Little, J.R.; Jones, S.C.; Ebrahim, Z.Y. Altered cerebral autoregulation and CO2 reactivity after aneurysmal sub-arachnoid hemorrhage. Neurosurgery 1988, 22, 822–826. [Google Scholar] [CrossRef]
- Connolly, E.S., Jr.; Rabinstein, A.A.; Carhuapoma, J.R.; Derdeyn, C.P.; Dion, J.; Higashida, R.T.; Hoh, B.L.; Kirkness, C.J.; Naideh, A.M.; Ogilvy, C.S.; et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012, 43, 1711–1737. [Google Scholar] [CrossRef]
- García, R.P.L.; Pupo, R.L.R.; García, R.D. Diagnosis of delayed cerebral ischaemia and cerebral vasospasm in subarachnoid haem-orrhage. Neurologia 2010, 25, 322–330. [Google Scholar] [CrossRef]
- Sun, J.; Yuan, J.; Li, B. SBP Is Superior to MAP to Reflect Tissue Perfusion and Hemodynamic Abnormality Perioperatively. Front. Physiol. 2021, 12, 705558. [Google Scholar] [CrossRef]
- Brown, R.J.; Kumar, A.; McCullough, L.D.; Butler, K. A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage. Int. J. Neurosci. 2017, 127, 51–58. [Google Scholar] [CrossRef]
- Steiner, T.; Juvela, S.; Unterberg, A.; Jung, C.; Forsting, M.; Rinkel, G. European Stroke Organization Guidelines for the Management of Intracranial Aneurysms and Subarachnoid Haemorrhage. Cerebrovasc. Dis. 2013, 35, 93–112. [Google Scholar] [CrossRef] [PubMed]
- Hoh, B.L.; Ko, N.U.; Amin-Hanjani, S.; Chou, S.H.-Y.; Cruz-Flores, S.; Dangayach, N.S.; Derdeyn, C.P.; Du, R.; Hänggi, D.; Hetts, S.W.; et al. 2023 Guideline for the Management of Patients with Aneurysmal Subarachnoid Hemorrhage: A Guideline from the American Heart Association/American Stroke Association. Stroke 2023, 54, e314. [Google Scholar] [CrossRef] [PubMed]
- Yosefy, C.; Hay, E.; Nasri, Y.; Magen, E.; Reisin, L. End tidal carbon dioxide as a predictor of the arterial PCO2 in the emergency department setting. Emerg. Med. J. 2004, 21, 557–559. [Google Scholar] [CrossRef]
- Husaini, J.; Choy, Y.C. End-tidal to arterial carbon dioxide partial pressure difference during craniotomy in anaesthetised patients. Med. J. Malays. 2008, 63, 384–387. [Google Scholar]
Characteristic | Angiographic Vasospasm (No) (n = 258) | Angiographic Vasospasm (Yes) (n = 132) | p Value | DCI (No) (n = 276) | DCI (Yes) (n = 114) | p Value | mRS Good Outcome (n = 169) | mRS Poor Outcome (n = 201) | p Value |
---|---|---|---|---|---|---|---|---|---|
Age (Median/IQR) | 56 (48, 68) | 52 (46, 61) | 0.014 | 55 (47, 67) | 54 (48, 64) | 0.653 | 50 (44, 59) | 60 (50, 71) | <0.0001 |
Male Gender n (%) | 79 (31%) | 36 (27%) | 0.478 | 79 (29%) | 36 (32%) | 0.575 | 43 (25%) | 63 (31%) | 0.211 |
Family History n (%) | 20 (8%) | 9 (7%) | 0.731 | 22 (8%) | 7 (6%) | 0.51 | 18 (11%) | 11 (6%) | 0.055 |
Anterior Circulation n (%) | 214 (83%) | 112 (85%) | 0.631 | 229 (83%) | 97 (85%) | 0.608 | 139 (82%) | 170 (85%) | 0.623 |
Clipping n (%) | 99 (39%) | 52 (39%) | 0.867 | 98 (36%) | 53 (46%) | 0.046 | 70 (41%) | 72 (36%) | 0.270 |
H and H Grading (Median/IQR) | 3 (2, 3) | 3 (2, 4) | 0.001 | 3 (2, 3) | 3/2 (2, 4) | <0.0001 | 2 (2, 3) | 3 (2, 4) | <0.0001 |
Modified Fisher (Median/IQR) | 3 (1, 4) | 3 (3, 4) | <0.0001 | 3 (1, 4) | 3/1 (3, 4) | <0.0001 | 2 (1, 3) | 3 (2, 4) | <0.0001 |
Size of Ruptured Aneurysm (Median/IQR) | 6 (4, 8) | 5 (4, 8) | 0.629 | 5 (4, 8) | 6 (4, 8) | 0.981 | 5 (4, 7) | 6 (4, 8) | 0.322 |
AUC SBP < 100 (mm Hg mins) (Median/IQR) | 175 (16, 436) | 138 (12, 424) | 0.579 | 146 (14, 429) | 166 (19, 451) | 0.468 | 224 (24, 445) | 97 (12, 419) | 0.035 |
AUC SBP > 160 (mm Hg mins) (Median/IQR) | 48 (0, 219) | 42 (0, 200) | 0.655 | 41 (0, 195) | 54 (0, 275) | 0.25 | 43 (0, 198) | 49 (0, 229) | 0.587 |
AUC MAP < 65 (mm Hg mins) (Median/IQR) | 38 (0, 159) | 36 (0, 114) | 0.935 | 31 (0, 127) | 50 (2, 176) | 0.227 | 33 (2, 167) | 33 (0, 124) | 0.392 |
AUC MAP > 100 (mm Hg mins) (Median/IQR) | 118 (14, 368) | 128 (16, 474) | 0.639 | 111 (10, 370) | 145 (19, 488) | 0.262 | 137 (34, 427) | 117 (5, 408) | 0.185 |
AUC ETCO2 < 30 (mm Hg mins) (Median/IQR) | 133 (16, 620) | 110 (19, 731) | 0.954 | 118 (16, 533) | 216 (21, 901) | 0.068 | 92 (16, 757) | 130 (20, 578) | 0.689 |
AUC ETCO2 > 45 (mm Hg mins) (Median/IQR) | 0 (0, 1) | 0 (0, 1) | 0.674 | 0 (0, 1) | 0 (0, 2) | 0.454 | 0 (0, 3) | 0 (0, 0) | 0.269 |
Intraoperative Average SBP (Median/IQR) | 120 (112, 129) | 120 (112, 127) | 0.669 | 120 (111, 129) | 119 (114, 127) | 0.81 | 119 (109, 128) | 121 (113, 130) | 0.051 |
Intraoperative Average DBP (Median/IQR) | 64 (57, 70) | 64 (59, 70) | 0.387 | 64 (57, 71) | 63 (58, 68) | 0.772 | 64 (59, 71) | 63 (57, 70) | 0.128 |
Intraoperative Average MBP (Median/IQR) | 81 (75, 87) | 81 (76, 88) | 0.554 | 81 (75, 88) | 82 (77, 85) | 0.537 | 82 (76, 87) | 80 (76, 87) | 0.86 |
Intraoperative Average ETCO2 (Median/IQR) | 31 (28, 33) | 31 (29, 33) | 0.819 | 31 (29, 33) | 31 (28, 33) | 0.09 | 31 (28, 33) | 31 (29, 33) | 0.933 |
COPD n (%) | 24 (9%) | 8 (6%) | 0.270 | 26 (9%) | 6 (5%) | 0.174 | 11 (7%) | 20 (10%) | 0.240 |
HTN n (%) | 161 (62%) | 64 (49%) | 0.008 | 167 (61%) | 58 (51%) | 0.08 | 85 (50%) | 130 (65%) | 0.006 |
Diabetes n (%) | 35 (14%) | 12 (9%) | 0.199 | 36 (13%) | 11 (10%) | 0.349 | 15 (9%) | 29 (14%) | 0.104 |
CAD n (%) | 24 (9%) | 5 (4%) | 0.05 | 22 (8%) | 7 (6%) | 0.531 | 13 (8%) | 14 (7%) | 0.779 |
Liver Failure n (%) | 2 (1%) | 1 (1%) | 1.000 | 3 (1%) | 0 (0%) | 0.353 | 0 (0%) | 3 (1%) | 0.112 |
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Athiraman, U.; Norris, A.J.; Jayaraman, K.; Lele, A.V.; Kentner, R.; Singh, P.M.; Higo, O.M.; Zipfel, G.J.; Dhar, R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. J. Clin. Med. 2023, 12, 5488. https://doi.org/10.3390/jcm12175488
Athiraman U, Norris AJ, Jayaraman K, Lele AV, Kentner R, Singh PM, Higo OM, Zipfel GJ, Dhar R. Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage. Journal of Clinical Medicine. 2023; 12(17):5488. https://doi.org/10.3390/jcm12175488
Chicago/Turabian StyleAthiraman, Umeshkumar, Aaron J. Norris, Keshav Jayaraman, Abhijit V. Lele, Rainer Kentner, Preet Mohinder Singh, Omokhaye M. Higo, Gregory J. Zipfel, and Rajat Dhar. 2023. "Intraoperative Blood Pressure and Carbon Dioxide Values during Aneurysmal Repair and the Outcomes after Aneurysmal Subarachnoid Hemorrhage" Journal of Clinical Medicine 12, no. 17: 5488. https://doi.org/10.3390/jcm12175488