Delayed cerebral ischemia following severe subarachnoid hemorrhage is difficult to prevent or treat in those not treated by surgery early after the onset. We examined the effectiveness as well as limitations of albumin therapy in the prophylaxis and treatment of delayed cerebral ischemia.
We studied 47 patients with severe subarachnoid hemorrhage classified as Group 3 by Fisher's CT grading encountered during the past 4 years who received albumin therapy but did not undergo early surgery for various reasons. The patients consisted of 22 males and 25 females ranging in age from 28-76 years (mean, 52.7 years). On the initial examination, 8 patients were classified as Grade I or II by the scale of Hunt & Kosnik, 6 as Grade III, 14 as Grade IV, and 19 as Grade V. The site of the aneurysm was in the anterior cerebral artery in 19 patients, middle cerebral artery in 8, internal carotid artery in 10, vertebral-basilar system in 2, and indeterminate in 8. The dose of albumin was 1.0g/kg/day prophylactically, but was increased to 1.5-3.0g/kg/day with the appearance of symptomatic vasospasm. The hypertensive tendency was controlled with various hypotensive agents.
Eleven of the patients showed good recovery, 6 were moderately disabled, 3 were severely disabled, 3 exhibited vegetative states, and 21 died. Of the 18 patients operated on, 11 showed good recovery, 4 were moderately disabled, 3 were severely disabled, but none showed a vegetative state or died. Symptomatic vasospasm occurred in 20 patients (42.6%), but the albumin therapy was ineffective in only 5 patients. Twenty-one patients died before surgery, 14 of them due to rerupture, 3 due to vasospasm, 2 due to sepsis or DIC, and 2 due to cerebral edema complicated or uncomplicated by spasm.
Although delayed cerebral vasospasm occurred after severe subarachnoid hemorrhage in 42.6% of the patients not undergoing early surgery, it was refractory to increased albumin doses in only 5 patients, suggesting the effectiveness of the therapy. Patients in whom increases is blood pressure could not be managed with hypotensive agents often suffered from rerupture and were associated with poor outcomes.
