Peer-Review ReportBalloon-Pump Counterpulsation for Management of Severe Cardiac Dysfunction After Aneurysmal Subarachnoid Hemorrhage
Introduction
Cerebral vasospasm and delayed cerebral ischemia are among the leading causes of poor outcome after aneurysmal subarachnoid hemorrhage (SAH) (8). Traditional management of symptomatic cerebral vasospasm involves the institution of hypertension and hypervolemia as first-line treatment (24). This therapy seeks to maximize both cerebral blood flow and cerebral perfusion pressure by increasing vascular tone, intravascular volume, and myocardial contractility. However, such hyperdynamic therapy has been associated with significant morbidity from pulmonary edema and myocardial ischemia, particularly in patients with underlying cardiac dysfunction (23).
Cardiac injury leading to echocardiographic changes accompanied by left ventricular (LV) wall motion abnormalities also occurs commonly in the acute period after SAH (13). These abnormalities include the phenomenon of neurogenic stunned myocardium, which often develops in patients with normal coronary arteries (17). Although multiple patterns of wall motion abnormalities have been described after SAH, all are associated with profound LV dysfunction and severe pulmonary edema (11). In patients with cerebral vasospasm, this cardiac dysfunction may prevent the application of traditional hyperdynamic therapy. Intraaortic balloon pump (IABP) counterpulsation may provide an effective strategy to support cardiac function and to assist with the management of vasospasm in patients with SAH who present with cardiogenic shock. We evaluated the demographic characteristics and clinical outcomes of the largest reported series of patients undergoing IABP placement after aneurysmal SAH.
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Methods
This study was approved by the institutional review board at St. Joseph’s Hospital and Medical Center (Phoenix, Arizona, USA).
Results
On admission, all patients underwent placement of an external ventricular drain for the management of hydrocephalus. Three patients (37.5%) underwent microsurgical aneurysm clipping, and five patients (62.5%) underwent endovascular coiling. One of the patients who underwent clipping also had a decompressive craniectomy with concurrent evacuation of a large temporal/sylvian fissure hemorrhage from a ruptured middle cerebral artery aneurysm. Another patient with a ruptured posterior communicating
Discussion
Cardiac injury, which occurs in >20% of patients with aneurysmal SAH, typically begins within 72 hours of ictus 10, 11. This injury, termed neurogenic stunned myocardium, predominates in postmenopausal women with severe hemorrhages (27). This syndrome is characterized by a severely reduced ejection fraction, mild elevations in troponin, and electrocardiographic abnormalities, including Q–Tc prolongation and T wave and ST segment changes (12). Although the underlying mechanism of injury is
Conclusions
The present series shows the use of IABP counterpulsation in a population of primarily poor-grade, female patients with aneurysmal SAH and severe cardiac dysfunction. The relatively positive clinical outcomes observed and the low incidence of complications suggest that balloon-pump counterpulsation may represent an important adjunctive technique to ameliorate cardiogenic shock and assist with the management of cerebral vasospasm in select patients. Nevertheless, further work is needed to define
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Conflict of interest: The authors declare that the article content was composed in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.