Increases in Cardiac Output can Reverse Flow Deficits from Vasospasm Independent of Blood Pressure

A Study Using Xenon Computed Tomographic Measurement of Cerebral Blood Flow

Dong H. Kim, Mathew Joseph, Saleem Ziadi, Joseph Nates, Mark Dannenbaum, Marc Malkoff, Aaron S. Dumont, Neal F. Kassell, Warren R. Selman, Howard Yonas, Daniel F. Kelly

Research output: Contribution to journalArticle

103 Citations (Scopus)

Abstract

INTRODUCTION: Vasospasm after subarachnoid hemorrhage remains a management challenge. The accepted treatment involves hypertensive, hypervolemic, hemodilution therapy. However, there is variation in the application of this treatment. Most authors increase mean arterial pressure (MAP), which can be associated with significant morbidity. Others increase cardiac output (CO). In this study, we examined the relationship between volume status, CO, and MAP and cerebral blood flow (CBF) in the setting of vasospasm. METHODS: A xenon blood flow tomography-based system was used to quantitate CBF. Sixteen patients with vasospasm after subarachnoid hemorrhage were treated with hypervolemia, phenylephrine to increase MAP, or dobutamine to increase CO. Direct CBF measurements were obtained before and after treatment. A strength of this study is that only one variable (central venous pressure, MAP, or CO) was manipulated in each patient, and the effect of this change was measured immediately. RESULTS: With phenylephrine, mean MAP increased from 102.4 to 132.1 mm Hg. In regions of diminished CBF due to vasospasm, mean CBF increased from 19.2 to 33. 7 ml/100 g/min. Similarly, dobutamine increased the cardiac index from a mean of 4.1 to 6.0 L/min/m2 and slightly decreased MAP. CBF increased from a mean of 24.8 to 35.4 ml/100 g/min. Both were statistically significant changes. With hypervolemia, the average central venous pressure increased from a mean of 5.4 to 7.3 cm H2O; no changes in mean CBF were noted. CONCLUSION: This article reports the first human study that shows with direct measurements the independent influence of CO in the setting of vasospasm. Increases in CO without changes in MAP can elevate CBF. This finding has immediate clinical application because CO manipulation is much safer than increasing MAP. Because both interventions were equally efficacious, our protocol has been changed to augment CO as a first measure. Induced hypertension is reserved for patients in whom this initial treatment fails.

Original languageEnglish (US)
Pages (from-to)1044-1052
Number of pages9
JournalNeurosurgery
Volume53
Issue number5
DOIs
StatePublished - Jan 1 2003
Externally publishedYes

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Cerebrovascular Circulation
Xenon
Cardiac Output
Arterial Pressure
Blood Pressure
Central Venous Pressure
Dobutamine
Phenylephrine
Subarachnoid Hemorrhage
Therapeutics
Hemodilution
Tomography
Hypertension
Morbidity

All Science Journal Classification (ASJC) codes

  • Surgery
  • Clinical Neurology

Cite this

Increases in Cardiac Output can Reverse Flow Deficits from Vasospasm Independent of Blood Pressure : A Study Using Xenon Computed Tomographic Measurement of Cerebral Blood Flow. / Kim, Dong H.; Joseph, Mathew; Ziadi, Saleem; Nates, Joseph; Dannenbaum, Mark; Malkoff, Marc; Dumont, Aaron S.; Kassell, Neal F.; Selman, Warren R.; Yonas, Howard; Kelly, Daniel F.

In: Neurosurgery, Vol. 53, No. 5, 01.01.2003, p. 1044-1052.

Research output: Contribution to journalArticle

Kim, Dong H. ; Joseph, Mathew ; Ziadi, Saleem ; Nates, Joseph ; Dannenbaum, Mark ; Malkoff, Marc ; Dumont, Aaron S. ; Kassell, Neal F. ; Selman, Warren R. ; Yonas, Howard ; Kelly, Daniel F. / Increases in Cardiac Output can Reverse Flow Deficits from Vasospasm Independent of Blood Pressure : A Study Using Xenon Computed Tomographic Measurement of Cerebral Blood Flow. In: Neurosurgery. 2003 ; Vol. 53, No. 5. pp. 1044-1052.
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T1 - Increases in Cardiac Output can Reverse Flow Deficits from Vasospasm Independent of Blood Pressure

T2 - A Study Using Xenon Computed Tomographic Measurement of Cerebral Blood Flow

AU - Kim, Dong H.

AU - Joseph, Mathew

AU - Ziadi, Saleem

AU - Nates, Joseph

AU - Dannenbaum, Mark

AU - Malkoff, Marc

AU - Dumont, Aaron S.

AU - Kassell, Neal F.

AU - Selman, Warren R.

AU - Yonas, Howard

AU - Kelly, Daniel F.

PY - 2003/1/1

Y1 - 2003/1/1

N2 - INTRODUCTION: Vasospasm after subarachnoid hemorrhage remains a management challenge. The accepted treatment involves hypertensive, hypervolemic, hemodilution therapy. However, there is variation in the application of this treatment. Most authors increase mean arterial pressure (MAP), which can be associated with significant morbidity. Others increase cardiac output (CO). In this study, we examined the relationship between volume status, CO, and MAP and cerebral blood flow (CBF) in the setting of vasospasm. METHODS: A xenon blood flow tomography-based system was used to quantitate CBF. Sixteen patients with vasospasm after subarachnoid hemorrhage were treated with hypervolemia, phenylephrine to increase MAP, or dobutamine to increase CO. Direct CBF measurements were obtained before and after treatment. A strength of this study is that only one variable (central venous pressure, MAP, or CO) was manipulated in each patient, and the effect of this change was measured immediately. RESULTS: With phenylephrine, mean MAP increased from 102.4 to 132.1 mm Hg. In regions of diminished CBF due to vasospasm, mean CBF increased from 19.2 to 33. 7 ml/100 g/min. Similarly, dobutamine increased the cardiac index from a mean of 4.1 to 6.0 L/min/m2 and slightly decreased MAP. CBF increased from a mean of 24.8 to 35.4 ml/100 g/min. Both were statistically significant changes. With hypervolemia, the average central venous pressure increased from a mean of 5.4 to 7.3 cm H2O; no changes in mean CBF were noted. CONCLUSION: This article reports the first human study that shows with direct measurements the independent influence of CO in the setting of vasospasm. Increases in CO without changes in MAP can elevate CBF. This finding has immediate clinical application because CO manipulation is much safer than increasing MAP. Because both interventions were equally efficacious, our protocol has been changed to augment CO as a first measure. Induced hypertension is reserved for patients in whom this initial treatment fails.

AB - INTRODUCTION: Vasospasm after subarachnoid hemorrhage remains a management challenge. The accepted treatment involves hypertensive, hypervolemic, hemodilution therapy. However, there is variation in the application of this treatment. Most authors increase mean arterial pressure (MAP), which can be associated with significant morbidity. Others increase cardiac output (CO). In this study, we examined the relationship between volume status, CO, and MAP and cerebral blood flow (CBF) in the setting of vasospasm. METHODS: A xenon blood flow tomography-based system was used to quantitate CBF. Sixteen patients with vasospasm after subarachnoid hemorrhage were treated with hypervolemia, phenylephrine to increase MAP, or dobutamine to increase CO. Direct CBF measurements were obtained before and after treatment. A strength of this study is that only one variable (central venous pressure, MAP, or CO) was manipulated in each patient, and the effect of this change was measured immediately. RESULTS: With phenylephrine, mean MAP increased from 102.4 to 132.1 mm Hg. In regions of diminished CBF due to vasospasm, mean CBF increased from 19.2 to 33. 7 ml/100 g/min. Similarly, dobutamine increased the cardiac index from a mean of 4.1 to 6.0 L/min/m2 and slightly decreased MAP. CBF increased from a mean of 24.8 to 35.4 ml/100 g/min. Both were statistically significant changes. With hypervolemia, the average central venous pressure increased from a mean of 5.4 to 7.3 cm H2O; no changes in mean CBF were noted. CONCLUSION: This article reports the first human study that shows with direct measurements the independent influence of CO in the setting of vasospasm. Increases in CO without changes in MAP can elevate CBF. This finding has immediate clinical application because CO manipulation is much safer than increasing MAP. Because both interventions were equally efficacious, our protocol has been changed to augment CO as a first measure. Induced hypertension is reserved for patients in whom this initial treatment fails.

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