Hemodynamic response and clinical outcome following intravenous milrinone plus norepinephrine-based hyperdynamic hypertensive therapy in patients suffering secondary cerebral ischemia after aneurysmal subarachnoid hemorrhage.

PURPOSE: Intravenous and intra-arterial milrinone as a rescue measure for delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH) has been adopted by several groups, but so far, evidence for the clinical benefit is unclear and effect on brain perfusion is unknown. The aim of the actual analysis was to define cerebral hemodynamic effects and outcome of intravenous milrinone plus norepinephrine supplemented by intra-arterial nimodipine as a rescue strategy for DCI following aneurysmal SAH. METHODS: Of 176 patients with aneurysmal SAH treated at our neurosurgical department between April 2016 and March 2021, 98 suffered from DCI and were submitted to rescue therapy. For the current analysis, characteristics of these patients and clinical response to rescue therapy were correlated with hemodynamic parameters, as assessed by CT angiography (CTA) and perfusion CT. Time to peak (TTP) delay in the ischemic focus and the volume with a TTP delay of more than 4 s (T4 volume) were used as hemodynamic parameters. RESULTS: The median delay to neurological deterioration following SAH was 5 days. Perfusion CT at that time showed median T4 volumes of 40 cc and mean focal TTP delays of 2.5 ± 2.1 s in these patients. Following rescue therapy, median T4 volume decreased to 10 cc and mean focal TTP delay to 1.7 ± 1.9 s. Seventeen patients (17% of patients with DCI) underwent additional intra-arterial spasmolysis using nimodipine. Visible resolution of macroscopic vasospasm on CTA was observed in 43% patients with DCI and verified vasospasm on CTA, including those managed with additional intra-arterial spasmolysis. Initial WFNS grade, occurrence of secondary infarction, ischemic volumes and TTP delays at the time of decline, the time to clinical decline, and the necessity for additional intra-arterial spasmolysis were identified as the most important features determining neurological outcome at 6 months. CONCLUSION: The current analysis shows that cerebral perfusion in the setting of secondary cerebral ischemia following SAH is measurably improved by milrinone and norepinephrine-based hyperdynamic therapy. A long-term clinical benefit by the addition of milrinone appears likely. Separation of the direct effect of milrinone from the effect of induced hypertension is not possible based on the present dataset.

Implications of early respiratory support strategies on disease progression in critical COVID-19: a matched subanalysis of the prospective RISC-19-ICU cohort.

BACKGROUND: Uncertainty about the optimal respiratory support strategies in critically ill COVID-19 patients is widespread. While the risks and benefits of noninvasive techniques versus early invasive mechanical ventilation (IMV) are intensely debated, actual evidence is lacking. We sought to assess the risks and benefits of different respiratory support strategies, employed in intensive care units during the first months of the COVID-19 pandemic on intubation and intensive care unit (ICU) mortality rates. METHODS: Subanalysis of a prospective, multinational registry of critically ill COVID-19 patients. Patients were subclassified into standard oxygen therapy ≥10 L/min (SOT), high-flow oxygen therapy (HFNC), noninvasive positive-pressure ventilation (NIV), and early IMV, according to the respiratory support strategy employed at the day of admission to ICU. Propensity score matching was performed to ensure comparability between groups. RESULTS: Initially, 1421 patients were assessed for possible study inclusion. Of these, 351 patients (85 SOT, 87 HFNC, 87 NIV, and 92 IMV) remained eligible for full analysis after propensity score matching. 55% of patients initially receiving noninvasive respiratory support required IMV. The intubation rate was lower in patients initially ventilated with HFNC and NIV compared to those who received SOT (SOT: 64%, HFNC: 52%, NIV: 49%, p = 0.025). Compared to the other respiratory support strategies, NIV was associated with a higher overall ICU mortality (SOT: 18%, HFNC: 20%, NIV: 37%, IMV: 25%, p = 0.016). CONCLUSION: In this cohort of critically ill patients with COVID-19, a trial of HFNC appeared to be the most balanced initial respiratory support strategy, given the reduced intubation rate and comparable ICU mortality rate. Nonetheless, considering the uncertainty and stress associated with the COVID-19 pandemic, SOT and early IMV represented safe initial respiratory support strategies. The presented findings, in agreement with classic ARDS literature, suggest that NIV should be avoided whenever possible due to the elevated ICU mortality risk.

Quality of life and outcome after treatment of ruptured cerebral aneurysms: results of a single center in Switzerland.

OBJECT: To evaluate the subjective outcome and quality of life (QoL) of patients who suffered from aneurysmal subarachnoid hemorrhage and underwent endovascular coiling or microsurgical clipping in a single center. METHODS: For this retrospective single-center study, we included patients who underwent aneurysm occlusion at the Cantonal Hospital of Aarau between January 2000 and December 2006. The QoL, the functional status, and the level of independence were assessed by means of the Short Form (SF)-12 Health Survey, the modified Rankin Scale (mRS), and the Barthel Index. The questionnaires were sent to and completed by the patients. A total of 104 patients with a mean age of 53.14 years (range, 18-80 years) were included in the study. In 63 (60.6 %) of the cases, the aneurysm was clipped; in 41 (39.4 %) of the cases, endovascular coiling was performed. RESULTS: The SF-12 scores for the PCS (Physical Component Summary) and MCS (Mental Component Summary) were similar for both clipped (PCS 45.35; MCS 46.55) and coiled (PCS 46.31; MCS 47.87) patients. The mean values were, on average, 4.17 points lower for the PCS and 2.79 points lower for the MCS when compared with the mean of the US population, with a mean of 50 (standard deviation (SD) 10). The mean Barthel Index for the entire group was 92.26 (SD 16.8) and was almost identical for both the clipped (92.54; SD 16.21) and coiled (91.83; SD 17.9) patients (p = 0.56). The mean mRS did not differ between the coiled and clipped patients (coiled 1.63; clipped 1.56; p = 0.97) CONCLUSIONS: There were no significant differences in the functional and mental health scores between the two groups of clipped and coiled patients who were treated at our center, but both groups were lower than population-based scores. Although the neurologic condition and the imaging results on admission were worse in the coiled group, the long-term results did not differ significantly.