Lionel J Velly1, Federico Bilotta, Neus Fàbregas, Martin Soehle, Nicolas J Bruder, Michael H Nathanson. 1. From the Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France (LV, NB), Department of Anaesthesiology, Critical Care and Pain Medicine, 'Sapienza' University Rome, Rome, Italy (FB), Anaesthesiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain (NF), Department of Anaesthesiology and Intensive Care Medicine, University Hospital, Bonn, Germany (MS) and Department of Anaesthesia, Queen's Medical Centre, Nottingham University Hospitals, Nottingham, UK (MN).
Abstract
BACKGROUND: Many aspects of the perioperative management of aneurysmal subarachnoid haemorrhage (SAH) remain controversial. It would be useful to assess differences in the treatment of SAH in Europe to identify areas for improvement. OBJECTIVE: To determine the clinical practice of physicians treating SAH and to evaluate any discrepancy between practice and published evidence. DESIGN: An electronic survey. PARTICIPANTS: Physicians identified through each national society of neuroanaesthesiology and neurocritical care. INTERVENTIONS: A 31-item online questionnaire was distributed by the ENIG group. Questions were designed to investigate anaesthetic management of SAH and diagnostic and treatment approaches to cerebral vasospasm. The survey was available from early October to the end of November 2012. RESULTS: Completed surveys were received from 268 respondents, of whom 81% replied that aneurysm treatment was conducted early (within 24 h). Sixty-five percent of centres treated more than 60% of SAH by coiling, 19% had high-volume clipping (>60% of aneurysms clipped) and 16% used both methods equally. No clear threshold for arterial blood pressure target was identified during coiling, temporary clipping or in patients without vasospasm after the aneurysm had been secured. Almost all respondents used nimodipine (97%); 21% also used statins and 20% used magnesium for prevention of vasospasm. A quarter of respondents used intra-arterial vasodilators alone, 5% used cerebral angioplasty alone and 48% used both endovascular methods to treat symptomatic vasospasm. In high-volume clipping treatment centres, 58% of respondents used endovascular methods to manage vasospasm compared with 86% at high-volume coiling treatment centres (P < 0.001). The most commonly used intra-arterial vasodilator was nimodipine (82%), but milrinone was used by 23% and papaverine by 19%. More respondents (44%) selected 'triple-H' therapy over hypertension alone (30%) to treat vasospasm. CONCLUSION: We found striking variability in the practice patterns of European physicians involved in early treatment of SAH. Significant differences were noted among countries and between high and low-volume coiling centres.
BACKGROUND: Many aspects of the perioperative management of aneurysmal subarachnoid haemorrhage (SAH) remain controversial. It would be useful to assess differences in the treatment of SAH in Europe to identify areas for improvement. OBJECTIVE: To determine the clinical practice of physicians treating SAH and to evaluate any discrepancy between practice and published evidence. DESIGN: An electronic survey. PARTICIPANTS: Physicians identified through each national society of neuroanaesthesiology and neurocritical care. INTERVENTIONS: A 31-item online questionnaire was distributed by the ENIG group. Questions were designed to investigate anaesthetic management of SAH and diagnostic and treatment approaches to cerebral vasospasm. The survey was available from early October to the end of November 2012. RESULTS: Completed surveys were received from 268 respondents, of whom 81% replied that aneurysm treatment was conducted early (within 24 h). Sixty-five percent of centres treated more than 60% of SAH by coiling, 19% had high-volume clipping (>60% of aneurysms clipped) and 16% used both methods equally. No clear threshold for arterial blood pressure target was identified during coiling, temporary clipping or in patients without vasospasm after the aneurysm had been secured. Almost all respondents used nimodipine (97%); 21% also used statins and 20% used magnesium for prevention of vasospasm. A quarter of respondents used intra-arterial vasodilators alone, 5% used cerebral angioplasty alone and 48% used both endovascular methods to treat symptomatic vasospasm. In high-volume clipping treatment centres, 58% of respondents used endovascular methods to manage vasospasm compared with 86% at high-volume coiling treatment centres (P < 0.001). The most commonly used intra-arterial vasodilator was nimodipine (82%), but milrinone was used by 23% and papaverine by 19%. More respondents (44%) selected 'triple-H' therapy over hypertension alone (30%) to treat vasospasm. CONCLUSION: We found striking variability in the practice patterns of European physicians involved in early treatment of SAH. Significant differences were noted among countries and between high and low-volume coiling centres.
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