Mild controlled hypothermia – a neuroprotective method for late ischaemic complications in resuscitation care for patients with severe spontaneous subarachnoid hemorrhage caused by aneurism rupture


Authors: E. Neuman 1;  M. Smrčka 1;  R. Gál 2;  R. Jura 3
Authors‘ workplace: Neurochirurgická klinika LF MU a FN Brno 1;  Klinika anestezie, resuscitace a intenzivní medicíny LF MU a FN Brno 2;  Neurologická klinika LF MU a FN Brno 3
Published in: Cesk Slov Neurol N 2008; 71/104(2): 180-187
Category: Original Paper

Overview

Introduction:
The article deals with the potential for the use and the benefit of mild controlled hypothermia in resuscitation care for patients with spontaneous subarachnoid hemorrhage (SAH) of grade IV and V according to Hunt and Hess scale (H-H), with the objective to increase the tolerance of ischemia developing in the cerebral tissue as a result of vasospasms (delayed cerebral ischemia, DCI).

Patient set:
3 groups of patients with SAH H-H IV and V. Group 1 included patients treated in 2003, a total of 12 patients aged 56 on average, with mean Fisher score 3.25. Group 2 included patients treated from the beginning of 2004 to mid 2005, a total of 13 patients aged 51 years on average, with mean Fisher score 3.23. Group 3 of patients (with retrospectively acquired data) were those treated in 2002, a total of 12 patients aged 50 years on average, with mean Fisher score 3.50. Only the patients with proven aneurysm treated with coiling were enrolled in the study.

Methodology:
Mild controlled hypothermia at 34° C was applied, induced by means of surface cooling for the period of 72 hours (a Hypo 01 apparatus made by the Czech Space Research Centre, s.r.o). In the first group of patients, hypothermia was induced immediately after admission. In the second group of patients, hypothermia was applied after the evidence of vasospasms (by means of transcranial Doppler imaging (TCD), or detected by CT in case of ischaemia). The third group of patients (with retrospectively acquired data) was the control group. 

Results:
The use of hypothermia applied immediately after admission (the first above-mentioned group) did not improve the results of treatment (evaluated using the Glasgow Outcome Score, GOS). The use of hypothermia only upon detection of vasospasms (the second group of patients) did improve the results of treatment, but the improvement did not achieve the level of statistical significance (p=0.11).

Conclusions:
Mild controlled hypothermia at 34˚ C lasting for 72 hours applied to patients with detected vasospasms was observed to improve the results of treatment of patients with SAH H-H IV and I at risk of ischaemia. However, improvement of treatment results did not achieve the level of statistical significance.

Key words:
spontaneous subarachnoid hemorrhage – vasospasm – cerebral ischaemia  - mild controlled hypothermia


Sources

1. Heros RC, Zervas NT, Varsos V. Cerebral vasospasm after subarachnoid hemorrhage: an update. Ann Neurol 1983; 14: 599–608.

2. van Gijn J, Rinkel GJ. Subarachnoid haemorrhage: diagnosis, causes and management. Brain 2001; 124: 249–278.

3. Kassell NF, Sasaki T, Colohan AR, Nazar G. Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke 1985; 16: 562–572.

4. Ohlstein EH, Storer BL. Oxyhemoglobin stimulation of endothelin production in cultured endothelial cells. J Neurosurg 1992; 77: 274–278.

5. Fuwa I, Mayberg M, Gadjusek C, Harada T, Luo Z. Enhanced secretion of endothelin by endothelial cells in response to hemoglobin. Neurol Med Chir (Tokyo) 1993; 33: 739–743.

6. Thomas JE, Nemirovsky A, Zelman V, Giannotta SL. Rapid reversal of endothelin-1-induced cerebral vasoconstriction by intrathecal administration of nitric oxide donors. Neurosurgery 1997; 40: 1245–1249.

7. Giller CA, Giller AM, Landreneau F. Detection of emboli after surgery for intracerebral aneurysms. Neurosurgery 1998; 42: 490–493.

8. Charpentier C, Audibert G, Guillemin F, Civit T, Ducrocq X, Bracard S et al. Multivariate analysis of predictors of cerebral vasospasm occurrence after aneurysmal subarachnoid hemorrhage. Stroke 1999; 30: 1402–1408.

9. Inagawa T. Cerebral vasospasm in elderly patients treated by early operation for ruptured intracranial aneurysms. Acta Neurochir (Wien) 1992; 115: 79–85.

10. Rabb CH, Tang G, Chin LS, Giannotta SL. A statistical analysis of factors related to symptomatic cerebral vasospasm. Acta Neurochir (Wien) 1994; 127: 27–31.

11. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computed tomographic scanning. Neurosurgery 1980; 6: 1–9.

12. Hirai S, Ono J, Yamaura A. Clinical grading and outcome after early surgery in aneurysmal subarachnoid hemorrhage. Neurosurgery 1996; 39: 441–447.

13. Lanzino G, Kassell NF, Germanson TP, Kongable GL, Truskowski LL, Torner JC et al. Age and outcome after aneurysmal subarachnoid hemorrhage: why do older patients fare worse? J Neurosurg 1996; 85: 410–418.

14. Chang HS, Hongo K, Nakagawa H. Adverse effects of limited hypotensive anesthesia on the outcome of patients with subarachnoid hemorrhage. J Neurosurg 2000; 92: 971–975.

15. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R. Serial changes of hemostasis in aneurysmal subarachnoid hemorrhage with special reference to delayed ischemic neurological deficits. J Neurosurg 1997; 86: 594–602.

16. Hop JW, Rinkel GJ, Algra A, van Gijn J. Initial loss of consciousness and risk of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Stroke 1999; 30: 2268–2271.

17. Weyer GW, Nolan CP, Macdonald RL. Evidence-based cerebral vasospasm management. Neurosurg Focus 2006; 21: E8.

18. Raabe A, Zimmermann M, Setzer M, Vatter H, Berkefeld J, Seifert V. Effect of intraventricular sodium nitroprusside on cerebral hemodynamics and oxygenation in poor-grade aneurysm patients with severe, medically refractory vasospasm. Neurosurgery 2002; 50: 1006–1014.

19. Song JK, Elliott JP, Eskridge JM. Neuroradiologic diagnosis and treatment of vasospasm. Neuroimaging Clin N Am 1997; 7: 819–835.

20. Eskridge JM, Newell DW, Winn HR. Endovascular treatment of vasospasm. Neurosurg Clin N Am 1994; 5: 437–447.

21. Bejjani GK, Bank WO, Olan WJ, Sekhar LN. The efficacy and safety of angioplasty for cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 1998; 42: 979–987.

22. Rosenwasser RH, Armonda RA, Thomas JE, Benitez RP, Gannon PM, Harrop J. Therapeutic modalities for the management of cerebral vasospasm: timing of endovascular options. Neurosurgery 1999; 44: 975–980.

23. Hossmann KA. Viability thresholds and the penumbra of focal ischemia. Ann Neurol 1994; 36: 557–565.

24. Ginsberg MD, Pulsinelli WA. The ischemic penumbra, injury thresholds, and the therapeutic window for acute stroke. Ann Neurol 1994; 36: 553–554.

25. Hammer MD, Krieger DW. Acute ischemic stroke: is there a role for hypothermia? Cleve Clin J Med 2002; 69: 770–777.

26. Bernard SA, Jones BM, Horne MK. Clinical trial of induced hypothermia in comatose survivors of out-of-hospital cardiac arrest. Ann Emerg Med 1997; 30: 146–153.

27. Yanagawa Y, Ishihara S, Norio H, Takino M, Kawakami M, Takasu A et al. Preliminary clinical outcome study of mild resuscitative hypothermia after out-of-hospital cardiopulmonary arrest. Resuscitation 1998; 39: 61–66.

28. Zeiner A, Holzer M, Sterz F, Behringer W, Schörkhuber W, Müllner M et al. Mild resuscitative hypothermia to improve neurological outcome after cardiac arrest. A clinical feasibility trial. Hypothermia After Cardiac Arrest (HACA) Study Group. Stroke 2000; 31: 86–94.

29. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557–563.

30. Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: 549–556.

31. Schwab S, Schwarz S, Spranger M, Keller E, Bertram M, Hacke W. Moderate hypothermia in the treatment of patients with severe middle cerebral artery infarction. Stroke 1998; 29: 2461–2466.

32. Krieger DW, De Georgia MA, Abou-Chebl A, Andrefsky JC, Sila CA, Katzan IL et al. Cooling for acute ischemic brain damage (cool aid): an open pilot study of induced hypothermia in acute ischemic stroke. Stroke 2001; 32: 1847–1854.

33. De Georgia MA, Krieger DW, Abou-Chebl A, Devlin TG, Jauss M, Davis SM et al. Cooling for Acute Ischemic Brain Damage (COOL AID): a feasibility trial of endovascular cooling. Neurology 2004; 63: 312–317.

34. Thomé C, Schubert G, Piepgras A, Elste V, Schilling L, Schmiedek P. Hypothermia reduces acute vasospasm following SAH in rats. Acta Neurochir 2001; 77(Suppl): 255–258.

35. Piepgras A, Elste V, Frietsch T, Schmiedek P, Reith W, Schilling L. Effect of moderate hypothermia on experimental severe subarachnoid hemorrhage, as evaluated by apparent diffusion coefficient changes. Neurosurgery 2001; 48: 1128–1134.

36. Nagao S, Irie K, Kawai N, Kunishio K, Ogawa T, Nakamura T et al. Protective effect of mild hypothermia on symptomatic vasospasm: a preliminary report. Acta Neurochir 2000; 76(Suppl): 547–550.

37. Todd MM, Hindman BJ, Clarke WR, Torner JC; Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) Investigators. Mild intraoperative hypothermia during surgery for intracranial aneurysm. N Engl J Med 2005; 352: 135–145.

38. Gál R, Smrčka M. Neuroprotektivní použití mírné hypotermie během intrakraniální chirurgie mozkových aneuryzmat. Cesk Slov Neurol N 2006; 69/102: 371–375.

39. Erecinska M, Thoresen M, Silver IA. Effects of hypothermia on energy metabolism in Mammalian central nervous system. J Cereb Blood Flow Metab 2003; 23: 513–530.

40. Baker AJ, Zornow MH, Grafe MR, Scheller MS, Skilling SR, Smullin DH et al. Hypothermia prevents ischemia-induced increases in hippocampal glycine concentration in rabbits. Stroke 1991; 22: 666–673.

41. Nicholls DG, Ward MW. Mitochondrial membrane potential and neuronal glutamate excitotoxicity: mortality and millivolts. Trends Neurosci 2000; 23: 166–174.

42. Yamashita K, Eguchi Y, Kajiwara K et al. Mild hypothermia ameliorates ubiquitin synthesis and prevents delayed neuronal death in the gerbil hippocampus. Stroke 1991; 22: 1574–1581.

43. Hayashi N. Enhanced neuronal damage in severely brain–injured patients by hypothalamus, pituitary, and ardenal axis neurohormonal changes. In: Hayashi N (ed). Brain Hypothermia. Tokyo: Springer-Verlag 2000: 3–25.

44. Dietrich WD. Therapeutic hypothermia in experimental models of traumatic brain injury. In: Hayashi N (ed). Brain Hypothermia. Tokyo: Springer-Verlag 2000: 39–46.

45. Mantovani A, Sozzani S, Introna M. Endothelial activation by cytokines. Ann N Y Acad Sci 1997; 832: 93–116.

46. Carlos TM, Harlan JM. Leukocyte-endothelial adhesion molecules. Blood 1994; 84: 2068–2101.

47. Chatzipanteli K, Alonso OF, Kraydieh S, Dietrich WD. Importance of posttraumatic hypothermia and hyperthermia on the inflammatory response after fluid percussion brain injury: biochemical and immunocytochemical studies. J Cereb Blood Flow Metab 2000; 20: 531–542.

48. Whalen MJ, Carlos TM, Clark RS, Marion DW, DeKosky MS, Heineman S et al. The relationship between brain temperature and neutrophil accumulation after traumatic brain injury in rats. Acta Neurochir1997; 70(Suppl): 260–261.

49. Gundersen Y, Vaagenes P, Pharo A, Valo ET, Opstad PK. Moderate hypothermia blunts the inflammatory response and reduces organ injury after acute haemorrhage. Acta Anaesthesiol Scand 2001; 45: 994–1001.

50. Tisherman SA. To control temperature, all you need is a "cool" line. Crit Care Med 2002; 30: 2598–2600.

51. Sloan MA, Haley EC jr, Kassell NF, Henry ML, Stewart SR, Beskin RR et al. Sensitivity and specificity of transcranial Doppler ultrasonography in the diagnosis of vasospasm following subarachnoid hemorrhage. Neurology 1989; 39: 1514–1518.

52. Sloan MA, Burch CM, Wozniak MA, Rothman MI, Rigamonti D, Permutt T et al. Transcranial Doppler detection of vertebrobasilar vasospasm following subarachnoid hemorrhage. Stroke 1994; 25: 2187–2197.

53. Okada Y, Shima T, Nishida M, Yamane K, Hatayama T, Yamanaka C et al. Comparison of transcranial Doppler investigation of aneurysmal vasospasm with digital subtraction angiographic and clinical findings. Neurosurgery 1999; 45: 443–449.

54. Vora YY, Suarez-Almazor M, Steinke DE, Martin ML, Findlay JM. Role of transcranial Doppler monitoring in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 1999; 44: 1237–1247.

Labels
Paediatric neurology Neurosurgery Neurology
Login
Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account