Introduction: Delayed cerebral ischemia, is one of the most severe complications after aneurysmal subarachnoid hemorrhage. Previous, triple H therapy was recommended to prevent delayed cerebral ischemia. However, we noticed several cases had refractory low central venous pressure (CVP) after triple H therapy. In addition, the cases with low CVP level seemed to have lower risk of developing delayed cerebral ischemia. We performed this retrospective study to clarify the relationship between the body fluid level change under triple H therapy and the risk of developing delayed cerebral ischemia.
Methods: We evaluated patients who underwent surgery and received triple H therapy postoperatively from 2001 to 2011. Delayed cerebral ischemia was defined as (1) the development of new focal neurological signs and (2) CT scan showed new hypodensity lesion.
Results: Totally 54 patients were included in our study. Delayed cerebral ischemia occurred in 14 patients (25.93%). Patients who initially presented with poor GCS (GCS <=13) had higher risk of developing delayed cerebral ischemia (p=0.004). During postoperative period, all patient received triple H therapy had similar CVP and MAP. However, patients who developed delayed cerebral ischemia had significant positive net fluid balance especially in the 2nd (904.5cc v.s. 93.33cc, p=0.01) and 3rd day (785.21cc v.s.-148.56cc, p=0.009). In addition, patients who developed delayed cerebral ischemia had anti-diuretic phase in the first 5 days and the following diuretic phase. However, patients who did not have ischemia had stable net fluid balance in the 10-day period.
Conclusions: Under prophylactic triple H therapy, patients who developed delayed cerebral ischemia could have anti-diuretic phase and diuretic phase after SAH. Therefore, the extra fluid accumulated in the beginning would be expelled in the following day. This could be the possible reason to explain why triple H therapy is unlikely to prevent delayed cerebral ischemia.
Patient Care: according to the postoperative net fluid balance change, we could identify the patient who is at the risk of developing delayed cerebral ischemia.
Learning Objectives: By the conclusion of this session, we demonstrated the totally different natural courses in patients with aneurysmal SAH. Besides, net fluid balance change could help us to identify the patient who is at the risk of developing delayed cerebral ischemia.