Induced Hypertension for Treatment of Delayed Cerebral Ischaemia After Aneurysmal Subarachnoid Haemorrhage

The objective of this multi-centre, randomized controlled trial is to investigate the outcome after induced hypertension versus no induced hypertension in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH), and to assess whether induced hypertension results in improved cerebral blood flow (CBF) as measured by means of perfusion-CT.

Background

Subarachnoid haemorrhage (SAH) from a ruptured cerebral aneurysm is a subset of stroke with a poor prognosis. Delayed cerebral ischemia (DCI) is a major complication after SAH in around 30% of SAH patients and increases case fatality 1.5 - 3 fold. One option to treat DCI is to use induced hypertension, alone or in combination with haemodilution and hypervolemia, so called Triple-H, but the efficacy of induced hypertension in reducing DCI is based on case series only, and not on a randomised clinical trial.

Objective

To investigate the outcome after induced hypertension versus no induced hypertension in patients with DCI after aneurysmal SAH.

Study design

A multi-centre, single blinded, randomized controlled trial.

Study population

Patients admitted to one of the participating centres after recent SAH with a treated aneurysm and DCI based on the onset of a new focal deficit and/or a decrease of the level of consciousness of at least 1 point of the Glasgow Coma Scale with exclusion of other causes of deterioration, will be randomized to either hypertension (n=120) or no hypertension (n=120).

Interventions

Patients in arm 1 will have their blood pressure raised in order to improve cerebral blood flow (CBF). In case of a low cardiac output, inotropics will be added. Induced hypertension will be continued for at least 48 hours when patients show some improvement within the first 24 hours. After 48 hours, the dose of vasopressor will be tapered daily, and resumed in case of clinical deterioration. In patients who do not show any improvement within 24 hours, induced hypertension will not be continued. In patients in arm 2 of the trial, hypertension will not be induced. Patients in both arms of the trial will be treated with oral nimodipine and normovolaemia without haemodilution. In some selected centres, an extra perfusion CT scan is performed 24-36 hours after instalment of the treatment. Measurement of CBF is performed in all participants with perfusion CT-scanning of the brain at the beginning of the study (as part of regular patient care), and after 24-36 hours.

Main outcome measurement

The modified Rankin scale at 3 months after the SAH, will be compared between patients who were randomized to induced hypertension and patients who were randomized to no induced hypertension.

Eligibility Criteria:
Inclusion criteria for eligibility

1. Admission to one of the participating study centres.
2. Age 18 years or over.
3. SAH with an aneurysmatic bleeding pattern.

Exclusion criteria for eligibility

1. Evidence of DCI after the SAH, defined as any decrease in the level of consciousness or the development of new focal neurological deficits after the onset of the SAH that is not due to increasing hydrocephalus, rebleeding of the aneurysm, epileptic seizure, septic- or metabolic encephalopathy, unless symptoms of DCI started within 3 hours.
2. Co-existing severe head injury.
3. Perimesencephalic haemorrhage (perimesencephalic bleeding pattern and no aneurysm on CT-angiography).
4. A history of a ventricular cardiac rhythm disorder, necessitating medical treatment.
5. A history of a left ventricular heart failure, necessitating medical treatment.
6. Likely transfer to another hospital, not participating in the trial, soon after treatment for the aneurysm.
7. Moribund.
8. Pregnancy.

   And furthermore, in selected centres where the sub study with CT perfusion will be performed:
9. Known allergy for CT-contrast agents.
10. Renal failure, defined as a serum creatinine \> 150 µmol/l, because of the risk of contrast nephropathy.
11. Diabetes mellitus.

Inclusion criteria for trial participation

1. Informed consent to participate in the proposed trial when DCI will develop.
2. DCI based on a decrease of at least one point on the Glasgow Coma Scale sum score unless the decrease doesn't reflect DCI as evaluated by the treating physician, and/or the development of new focal neurological deficits, diagnosed by a neurologist, neurosurgeon or intensivist.

Exclusion criteria for trial participation:

1. Another cause for neurological deterioration including.
2. A symptomatic aneurysm not yet treated by coiling or clipping.
3. Severe hypertension, defined as a spontaneous MAP of 120 mmHg or more at the moment of evaluation for trial participation.
4. Any contraindication for induced hypertension (such as a cardiac complication necessitating medical treatment) as evaluated by the treating physician.

   And furthermore, in selected centres where the sub study with CT perfusion will be performed:
5. No CTP scan at time of neurological deterioration.
6. More than 3 CTP scans since admission.