Aggressive management of aneurysmal subarachnoid haemorrhage based on a papaverine angioplasty protocol

The aim of this study was to analyse the results of intensive therapy unit management of aneurysmal subarachnoid haemorrhage incorporating angioplasty in the protocol. Two hundred consecutive patients were treated using a det ailed protocol that included nimodipine, early aneurysm repair, and surveil lance angiography. Angiography was performed on days 5 to 7 (or when the cl inical state suggested the presence of vasospasm). If angiographic vasospas m was identified, irrespective of whether clinical vasospasm was present or absent, papaverine was selectively administered. In patients with vasospas m blood pressure was elevated to 160-180 mmHg and selective papaverine admi nistration was repeated daily until vasospasm resolved. In cases requiring more frequent administration of papaverine, or in whom papaverine failed to adequately reverse spasm, balloon angioplasty was considered and for clini cally refractory cases barbiturate coma was introduced. 43% of patients und erwent papaverine administration and of these the average number of separat e papaverine procedures was four (maximum 23). 26% of patients developed ne urological deficits though to be due to vasospasm whilst 17% underwent papa verine angioplasty without clinical signs of vasospasm. Twelve patients (6% ) were entered into barbiturate coma. There was a 5.5% mortality and no dif ference in outcome between patients who developed angiographic vasospasm an d those who did not. For those developing clinical vasospasm, 71% were inde pendent and 10% were dead at follow up compared with 84% reaching independe nt grades and 4% dead in those not developing clinical vasospasm. These dif ferences failed to reach a significant difference. The average Intensive Th erapy Unit stay for aneurysmal subarachnoid haemorrhage patients was 13.1 d ays with a mean cost to the hospital of $AUD 24,379. This protocol appears to be both a clinically and cost effective method of managing aneurysmal su barachnoid haemorrhage. (C) 2000 Harcourt Publishers Ltd.