Introduction of cisternal lavage leads to avoidance of induced hypertension and reduced cardiovascular complications in patients with subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe cerebrovascular disease with high morbidity and case fatality [1,2]. Inpatients who survive the initial bleeding, delayed cerebral infarction(DCI) is one of the leading causes of poor outcome. The pathogenesis of DCI is hypothesized to be multifactorial and includes angiographic vasospasm, but also cortical spreading ischemia, microthrombosis and microcirculation constriction [3,4]. Seventy percent of a SAH patients develop angiographic vasospasm and20-30% progress to develop DCI [5]. Effective therapies are lacking. Since the middle of the 1970s, hypertension, hypervolemia and hemodilution (triple-H) therapy has been used with the aim of restoring impaired cerebral perfusion and, thereby, improving outcome[6]. The concept has been reshaped and hypertension (iHTN) alone has prevailed as the mainstay of therapy in neurointensive care units to treat delayed ischemia after aSAH1. Medical evidence for this therapy is lacking [1,6]. Recently, safety and efficacy of iHTN have been challenged by results from a randomized trial (HIMALAIA)[7]. Although prematurely terminated the study indicated that iHTN may be associated with adverse events (AE). In addition, the trial showed that improvement of symptomatic delayed ischemia also occurs without using iHTN [15].We introduced stereotactic catheter ventriculocisternostomy(STX-VCS) and fibrinolytic/spasmolytic lavage as a new method for DCI prevention[8,9] in 2015. Implementation of STX-VCS lead to a reduction of the DCI rate from 18% to 7.9% and the burden of delayed infarction was reduced by 64% in the unselected aSAH patient population. Further, both endovascular interventions and iHTN were largely withheld following STX-VCS introduction[8].In this monocentric retrospective study, we present new data on the effects of avoiding iHTN in our consecutive and unselected aSAH patient cohort and compare patients admitted in the 3.5 years before STX-VCS became available to patients admitted in the3.5 years after introduction of this therapy.