Abstract SNACC-9

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Management of vasospasm after aneurysmal subarachnoid hemorrhage: European and American survey results

1Fabregas N, 2Velly L, 3Bilotta F, 4Soehle M, 2Bruder N, 5Nathanson M
1Hospital Clinic Barcelona, Barcelona, Barcelona, España; 2University Hospital Timone, Marseille, , Francia; 3Sapienza University Rome, Roma, , Italy; 4University Hospital Bonn, Bonn, , Germany; 5University Hospital Queens Medical Centre, Nottingham, , United kingdom

Background and Goal of Study: Many aspects of aneurysmal subarachnoid hemorrhage (SAH) vasospasm therapy remain controversial. The European Neuroanaesthesia and critical care Interest Group (ENIG group) conducted a survey to determine the clinical practices of physicians treating SAH, and to evaluate the discrepancy between practice and published evidence.
Materials and Methods: The research team generated a 31-item online questionnaire, which was distributed by the ENIG Group. Nine questions focused on vasospasm prevention, diagnosis and treatment. The survey remained online from early October to the end of November 2012 in Europe; and from January 6 until February 7 2014 through the SNACC web for its members. Fisher´s exact test was used for the analysis of responder subgroups.
Results and Discussion: There were 262 completed surveys from Europe (ENIG) and 76 from SNACC (mainly United States). In our sample, 44.8% of ENIG respondents worked either in Neuroanaesthesia or Neurointensive Care or both, vs 25% of SNACC (P<0.05); 29.9% were mainly involved in Neuroanaesthesia in ENIG vs 72.4% in SNACC (P<0.05). Regarding vasospasm prevention, near all respondents used nimodipine (96.6% ENIG vs 90.9% SNACC); over 20% statins and Magnesium in both subgroups; Nicardipine in the presence of hypertension was used by 4.9% in ENIG vs 24.7% in SNACC respondents (P<0.05). Regarding neuromonitoring, most respondents (78.4% ENIG vs 77.6% SNACC) routinely used transcranial Doppler ultrasound to monitor vasospasm, whereas CT perfusion and CT angiography were used by 26% vs 17% and 42% vs 47% respectively. Regarding endovascular methods to treat symptomatic vasospasm, 24.6% in ENIG vs 22.4% in SNACC of respondents used intra-arterial vasodilatator alone; 4.5% vs 11.8% cerebral angioplasty alone (P=0.06); 49.6% vs 72.4% (P=0.07) both methods. The most commonly used intra-arterial vasodilator was nimodipine (81.9%) in ENIG respondents vs only 32.8% in SNACC (P<0.05). Papaverine is used by 18.6% of ENIG respondents and by 31.3% in SNACC (P<0.05). Milrinone was used by 23.1% in ENIG and 7.5% in SNACC (P=0.08). More respondents in ENIG than in SNACC (43.7% vs 33.3%) selected triple-H therapy over hypertension alone (30% vs 42.7%) to treat vasospasm. Mean arterial pressure > 110 mmHg was the target for 26.5% in ENIG and 40.3% in SNACC (P=0.10). Noradrenaline was the vasoactive drug mainly used in ENIG (89.9% vs 54.2%, P <0.05); Phenylephrine was used more by SNACC (54.2%) than ENIG (3.4%) respondents. Hypervolemia was not used in 23.5% of ENIG vs 53.6% of SNACC respondents (P<0.05).
Conclusion: This study found striking variability in practice patterns of European and United States physicians involved in SAH. Significant differences were noted between countries, and between high and low-volume coiling centers. The lack of clear evidence on several clinical practices (for example the blood pressure target) would justify prospective trials.

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