Elsevier

World Neurosurgery

Volume 80, Issue 6, December 2013, Pages e347-e352
World Neurosurgery

Peer-Review Report
Balloon-Pump Counterpulsation for Management of Severe Cardiac Dysfunction After Aneurysmal Subarachnoid Hemorrhage

https://doi.org/10.1016/j.wneu.2012.05.029Get rights and content

Objective

To evaluate the use of intraaortic balloon pump (IABP) placement to counter severe cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH).

Methods

From August 2006 to October 2011, eight patients (seven women, mean age 47 years ± 5) with aneurysmal SAH underwent IABP placement. The modified Rankin scale (mRS) was used to assess outcome at discharge and long-term follow-up.

Results

Most patients presented in poor Hunt & Hess grade (grade III, 25%; grade IV, 62.5%; grade V, 12.5%). Three patients underwent surgical clipping, and five patients underwent endovascular treatment. All patients had severe cardiogenic shock, with a mean ejection fraction of 21%. One patient (12.5%) experienced transient left leg ischemia attributable to the IABP. No patient deaths occurred. At discharge, one patient was moderately disabled (mRS = 3), two patients were moderately to severely disabled (mRS, 4), and five patients were severely disabled (mRS = 5). The seven patients available for long-term follow-up (mean, 11.25 months) showed substantial functional improvements. Two patients exhibited no significant disability (mRS = 1), two patients exhibited only slight disability (mRS = 2), and 3 patients exhibited moderate to severe disability (mRS = 4).

Conclusions

In select patients, particularly young women with poor-grade SAH, balloon-pump counterpulsation may serve as a useful adjunct in the management of severe cardiac dysfunction after SAH. Further investigation is necessary to define the optimal patient population for this technique.

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.

Section snippets

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.

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