Abstract
Introduction
Pharmacologic blood pressure elevation is often utilized to prevent or treat ischemia in patients with acute neurologic injury, and routinely requires administration of vasopressor agents. Depending on the indication, vasopressor agents may be administered to treat hypotension or to induce hypertension.
Methods
Although numerous guideline statements exist regarding the management of blood pressure in these patients, most recommendations are based largely on Class III evidence. Further, there are few randomized controlled trials comparing vasopressor agents in these patients and selection is often guided by expert consensus.
Results
We discuss the clinical evidence regarding vasopressor administration for blood pressure management in patients with acute neurologic injury. The effect of various vasopressors on cerebral hemodynamics is also discussed.
Conclusion
Although high-quality clinical data are scarce, the available evidence suggests that norepinephrine should be considered as the vasopressor of choice when blood pressure elevation is indicated in patients with acute neurologic injury.
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References
Adams HP Jr, del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Circulation. 2007;115:478–534. doi:10.1161/CIRCULATIONAHA.107.181486.
Shin HK, Nishimura M, Jones PB, et al. Mild induced hypertension improves blood flow and oxygen metabolism in transient focal cerebral ischemia. Stroke. 2008;39:1548–55. doi:10.1161/STROKEAHA.107.499483.
Wityk RJ. Blood pressure augmentation in acute ischemic stroke. J Neurol Sci. 2007;261:63–73. doi:10.1016/j.jns.2007.04.033.
Stead LG, Bellolio MF, Gilmore RM, Porter AB, Rabinstein AA. Pharmacologic elevation of blood pressure for acute brain ischemia. Neurocrit Care. 2008;8:259–61. doi:10.1007/s12028-007-9010-6.
Bogoslovsky T, Häppölä O, Salonen O, Lindsberg PJ. Induced hypertension for the treatment of acute MCA occlusion beyond the thrombolysis window: case report. BMC Neurol. 2006;6:46. doi:10.1186/1471-2377-6-46.
Rordorf G, Cramer SC, Efird JT, Schwamm LH, Buonanno F, Koroshetz WJ. Pharmacological elevation of blood pressure in acute stroke: clinical effects and safety. Stroke. 1997;28:2133–8.
Rordorf G, Koroshetz WJ, Ezzeddine MA, Segal AZ, Buonanno FS. A pilot study of drug-induced hypertension for treatment of acute stroke. Neurology. 2001;56:1210–3.
Hillis AE, Kane A, Tuffiash E, et al. Reperfusion of specific brain regions by raising blood pressure restores selective language functions in subacute stroke. Brain Lang. 2001;79:495–510. doi:10.1006/brln.2001.2563.
Hillis AE, Barker PB, Beauchamp NJ, Winters BD, Mirski M, Wityk RJ. Restoring blood pressure reperfused Wernicke’s area and improved language. Neurology. 2001;56:670–2.
Hillis AE, Ulatowski JA, Barker PB, et al. A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke. Cerebrovasc Dis. 2003;16:236–46. doi:10.1159/000071122.
Hillis AE, Wityk RJ, Beauchamp NJ, Ulatowski JA, Jacobs MA, Barker PB. Perfusion-weighted MRI as a marker of response to treatment in acute and subacute stroke. Neuroradiology. 2004;46:31–9. doi:10.1007/s00234-002-0918-4.
Muench E, Horn P, Bauhuf C, et al. Effects of hypervolemia and hypertension on regional cerebral blood flow, intracranial pressure, and brain tissue oxygenation after subarachnoid hemorrhage. Crit Care Med. 2007;35:1844–51. doi:10.1097/01.CCM.0000275392.08410.DD.
Rose JC, Mayer SA. Optimizing blood pressure in neurological emergencies. Neurocrit Care. 2004;1:287–99. doi:10.1385/NCC:1:3:287.
Mayberg MR, Batjer HH, Dacey R, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke. 1994;25:2315–28.
Treggiari MM, Walder B, Suter PM, Romand JA. Systematic review of the prevention of delayed ischemic neurological deficits with hypertension, hypervolemia, and hemodilution therapy following subarachnoid hemorrhage. J Neurosurg. 2003;98:978–84.
Egge A, Waterloo K, Sjøholm H, Solberg T, Ingebrigtsen T, Romner B. Prophylactic hyperdynamic postoperative fluid therapy after aneurysmal subarachnoid hemorrhage: a clinical, prospective, randomized, controlled study. Neurosurgery. 2001;49:593–605. doi:10.1097/00006123-200109000-00012.
Lennihan L, Mayer SA, Fink ME, et al. Effect of hypervolemic therapy on cerebral blood flow after subarachnoid hemorrhage: a randomized controlled trial. Stroke. 2000;31:383–91.
Bederson JB, Connolly S Jr, Batjer HH, et al. (2009) Guidelines for the management of aneurysmal subarachnoid hemorrhage. Stroke 40. doi: 10.1161/STROKEAHA.1108.191395.
Steiner LA, Johnston AJ, Czosnyka M, et al. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med. 2004;32:1049–54. doi:10.1097/01.CCM.0000120054.32845.A6.
Jacques F, Elkouri S, Bracco D, et al. Regional anesthesia for carotid surgery: less intraoperative hypotension and vasopressor requirement. Ann Vasc Surg. 2008. doi:10.1016/j.avsg.2008.05.015.
Brabant SM, Eyraud D, Bertrand MPC. Refractory hypotension after induction of anesthesia in a patient chronically treated with angiotensin receptor antagonists. Anesth Analg. 1999;89:887–8. doi:10.1097/00000539-199910000-00012.
Trocciola SM, Chaer RA, Lin SC, et al. Analysis of parameters associated with hypotension requiring vasopressor support after carotid angioplasty and stenting. J Vasc Surg. 2006;43:714–20. doi:10.1016/j.jvs.2005.12.008.
Greenberg MS. Handbook of neurosurgery. 6th ed. New York: Thieme Medical Publishers; 2006.
Ascher E, Markevich N, Schutzer RW, Kallakuri S, Jacob T, Hingorani AP. Cerebral hyperperfusion syndrome after carotid endarterectomy: predictive factors and hemodynamic changes. J Vasc Surg. 2003;37:769–77. doi:10.1067/mva.2003.231.
Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(S1):S1–106. doi:10.1089/neu.2006.0209.
Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95:560–8.
Stubbe HD, Greiner C, Westphal M, et al. Cerebral response to norepinephrine compared with fluid resuscitation in ovine traumatic brain injury and systemic inflammation. Crit Care Med. 2006;34:2651–7. doi:10.1097/01.CCM.0000239196.17999.B7.
Kroppenstedt SN, Sakowitz OW, Thomale UW, Unterberg AW, Stover JF. Norepinephrine is superior to dopamine in increasing cortical perfusion following controlled cortical impact injury in rats. Acta Neurochir Suppl (Wien). 2002;81:225–7.
Kroppenstedt SN, Thomale UW, Griebenow M, et al. Effects of early and late intravenous norepinephrine infusion on cerebral perfusion, microcirculation, brain-tissue oxygenation, and edema formation in brain-injured rats. Crit Care Med. 2003;31:2211–21. doi:10.1097/01.CCM.0000080482.06856.62.
Ract C, Vigué B, Bodjarian N, Mazoit JX, Samii K, Tadié M. Comparison of dopamine and norepinephrine after traumatic brain injury and hypoxic-hypotensive insult. J Neurotrauma. 2001;18:1247–54. doi:10.1089/089771501317095287.
Feinstein AJ, Patel MB, Sanui M, Cohn SM, Majetschak M, Proctor KG. Resuscitation with pressors after traumatic brain injury. J Am Coll Surg. 2005;201:536–45. doi:10.1016/j.jamcollsurg.2005.05.031.
Cherian L, Chacko G, Goodman JC, Robertson CS. Cerebral hemodynamic effects of phenylephrine and L-arginine after cortical impact injury. Crit Care Med. 1999;27:2512–7. doi:10.1097/00003246-199911000-00031.
Ract C, Vigué B. Comparison of the cerebral effects of dopamine and norepinephrine in severely head-injured patients. Intensive Care Med. 2001;27:101–6. doi:10.1007/s001340000754.
Steiner LA, Coles JP, Johnston AJ, et al. Responses of posttraumatic pericontusional cerebral blood flow and blood volume to an increase in cerebral perfusion pressure. J Cereb Blood Flow Metab. 2003;23:1371–7. doi:10.1097/01.WCB.0000090861.67713.10.
Robertson CS, Valadka AB, Hannay HJ, et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med. 1999;27:2086–95. doi:10.1097/00003246-199910000-00002.
Bouma GJ, Muizelaar JP. Relationship between cardiac output and cerebral blood flow in patients with intact and with impaired autoregulation. J Neurosurg. 1990;73:368–74.
Hadley MN. Blood pressure management after acute spinal cord injury. Neurosurgery. 2002;50(Suppl 3):S58–62. doi:10.1097/00006123-200203001-00012.
Mukand J, Karlin L, Barrs K, Lublin P. Midodrine for the management of orthostatic hypotension in patients with spinal cord injury: a case report. Arch Phys Med Rehabil. 2001;82:694–6. doi:10.1053/apmr.2001.22350.
Vaidyanathan S, Soni BM, Hughes PL. Midodrine: insidious development of urologic adverse effects in patients with spinal cord injury: a report of 2 cases. Adv Ther. 2007;24:712–20. doi:10.1007/BF02849965.
Pfister D, Strebel SP, Steiner LA. Effects of catecholamines on cerebral blood vessels in patients with traumatic brain injury. Eur J Anaesthesiol Suppl. 2008;42:98–103.
Schubert A. Cardiovascular therapy of neurosurgical patients. Best Pract Res Clin Anaesthesiol. 2007;21:483–96. doi:10.1016/j.bpa.2007.06.003.
Schwarz S, Georgiadis D, Aschoff A, Schwab S. Effects of induced hypertension on intracranial pressure and flow velocities of the middle cerebral arteries in patients with large hemispheric stroke. Stroke. 2002;33:998–1004. doi:10.1161/01.STR.0000014584.17714.2E.
Marzan AS, Hungerbühler HJ, Studer A, Baumgartner RW, Georgiadis D. Feasibility and safety of norepinephrine-induced arterial hypertension in acute ischemic stroke. Neurology. 2004;62:1193–5.
Meier F, Wessel G, Thiele R, Gottschild D, Brandstatt H. Induced hypertension as an approach to treating acute cerebrovascular ischaemia: possibilities and limitations. Exp Pathol. 1991;42:257–63.
Oliveira-Filho J, Pedreira BB, Jesus PA, Souza PE, Bacellar AS. Pharmacologically-induced hypertension in a patient with vertebro-basilar territory ischemia associated with bilateral vertebral stenosis. Arq Neuropsiquiatr. 2002;60:498–501. doi:10.1590/S0004-282X2002000300031.
Broderick J, Connolly S, Feldmann E, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults. Stroke. 2007;38:2001–23. doi:10.1161/STROKEAHA.107.183689.
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Muzevich, K.M., Voils, S.A. Role of Vasopressor Administration in Patients with Acute Neurologic Injury. Neurocrit Care 11, 112–119 (2009). https://doi.org/10.1007/s12028-009-9214-z
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DOI: https://doi.org/10.1007/s12028-009-9214-z