Abstract 51: Strict Blood Pressure Control with Intravenous Nicardipine is Associated with Lower Risk of Acute Re-bleeding after Aneurysmal Subarachnoid Hemorrhage.

Abstract

Background: Re-bleeding from ruptured intracranial aneurysm is a major cause of death and disability. Although the risk has been significantly decreased with the practice of early aneurysm treatment within 72 hours, re-bleeding is still reported as 4-13% in the first 24 hours. American Heart Association guidelines recommend decreasing the systolic blood pressure (SBP) to less than 160 mmHg to decrease the risk of re-bleeding and neurologic decline. We examined the rate of re-bleeding prior to aneurysm treatment in our SAH population by targeting a strict SBP goal of less than 140 mmHg using IV nicardipine infusion. Method: All patients with aneurysmal SAH admitted between August 2003 and March 2012 were included in the study. Re-bleeding was defined by clinical neurological deterioration and radiographic evidence of new blood on CT prior to aneurysm treatment. In addition to presence of re-bleeding, patient demographics, clinical and radiographic grade on admission, aneurysm location, treatment modality, and complications such as hydrocephalus, hyponatremia, and cerebral vasospasm were abstracted from patient charts. Our blood pressure management protocol is used to keep SBP < 140 mmHg for all SAH patients before aneurysm treatment with labetalol IV 5-10mg every 15 minutes and nicardipine IV infusion starting at 5mg/hour. Patients with evidence of vasospasm or elevated intracranial pressure were excluded from our blood pressure protocol. Result: Of 1357 patients admitted with aneurismal SAH, re-bleeding occurred in 17 cases (1.32%) prior to aneurysm treatment. Ten patients (59%) with early re-bleed died before hospital discharge. We found three patients with side effects from nicardipine infusion , two with phlebitis, and one with tachycardia. Conclusion: Our study showed lower re-bleeding rates compared to other studies of aneurysmal SAH. We attribute the lower rates in part to aggressive blood pressure lowering with early use of nicardipine infusion to keep SBP 140 mmHg. The use of nicardipine infusion appears to be safe and may decrease morbidity and mortality associated with early re-bleeding.