Kaitlyn A Stoehr, David Bartolome, Sithmi Jayasundara, Pwint Thinzar, David Vargas, Jennifer Kim, Jessica Magid-Bernstein, Lena M O'Keefe, Adam de Havenon, Ryan Hebert, Charles Matouk, Kevin N Sheth, Emily J Gilmore, Santiago Ortega-Gutierrez, Nils H Petersen
{"title":"尼莫地平诱导的血压降低对动脉瘤性蛛网膜下腔出血后大脑自动调节和功能结局的影响。","authors":"Kaitlyn A Stoehr, David Bartolome, Sithmi Jayasundara, Pwint Thinzar, David Vargas, Jennifer Kim, Jessica Magid-Bernstein, Lena M O'Keefe, Adam de Havenon, Ryan Hebert, Charles Matouk, Kevin N Sheth, Emily J Gilmore, Santiago Ortega-Gutierrez, Nils H Petersen","doi":"10.1007/s12028-025-02338-6","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>Impairment of cerebral autoregulation following aneurysmal subarachnoid hemorrhage (aSAH) increases susceptibility to secondary injury from blood pressure (BP) fluctuations. Although nimodipine is recommended to improve neurological outcomes, it is frequently associated with BP reduction. In this observational cohort study, we examined the effect of nimodipine-induced BP reductions that exceed autoregulatory capacity on functional outcome following aSAH.</p><p><strong>Methods: </strong>Autoregulatory function was measured continuously following aneurysm securement by correlating near-infrared spectroscopy-derived regional oxygen saturation with mean arterial pressure (MAP). The resulting autoregulatory index was used to derive the lower and upper limits of autoregulation (LLA and ULA). Physiologic parameters were compared between the hour before and the hour after nimodipine administration using linear mixed-effects models. Ordinal regression was used to assess the relationship between time with MAP below the LLA and functional outcome, as measured by the modified Rankin scale at 90 days post discharge.</p><p><strong>Results: </strong>Analysis included 682 nimodipine administrations among 31 patients with moderate to severe aSAH (mean age 57 ± 14 years, 71% female, median Hunt & Hess score 4 [interquartile range (IQR) 2-4], modified Fisher grade 4 [IQR 3-4], monitoring time 5.5 ± 4.7 days). Following nimodipine, MAP decreased from a mean ± SEM of 105.9 ± 0.7 to 100.1 ± 0.7 mm Hg (p < 0.001), resulting in increased time below the LLA from a mean ± SEM of 5.3 ± 0.5 to 13.9 ± 0.7 min (p < 0.001). Mean time below the LLA was significantly associated with worse functional outcome at 90 days (odds ratio for 10-min increase 3.6, 95% confidence interval 1.6-8.0, p = 0.0015). This association remained significant after adjusting separately for age, Hunt & Hess score, modified Fisher grade, delayed cerebral ischemia, and the magnitude of BP response to nimodipine.</p><p><strong>Conclusions: </strong>Nimodipine-induced BP reductions below personalized limits of autoregulation may be associated with worse functional outcome after aSAH. Further prospective studies are warranted to explore how autoregulatory sensitivity to nimodipine can be used to identify vulnerable patients and maximize benefits from current clinical interventions.</p>","PeriodicalId":19118,"journal":{"name":"Neurocritical Care","volume":" ","pages":""},"PeriodicalIF":3.6000,"publicationDate":"2025-08-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Impact of Nimodipine-Induced Blood Pressure Reductions on Cerebral Autoregulation and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage.\",\"authors\":\"Kaitlyn A Stoehr, David Bartolome, Sithmi Jayasundara, Pwint Thinzar, David Vargas, Jennifer Kim, Jessica Magid-Bernstein, Lena M O'Keefe, Adam de Havenon, Ryan Hebert, Charles Matouk, Kevin N Sheth, Emily J Gilmore, Santiago Ortega-Gutierrez, Nils H Petersen\",\"doi\":\"10.1007/s12028-025-02338-6\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>Impairment of cerebral autoregulation following aneurysmal subarachnoid hemorrhage (aSAH) increases susceptibility to secondary injury from blood pressure (BP) fluctuations. Although nimodipine is recommended to improve neurological outcomes, it is frequently associated with BP reduction. In this observational cohort study, we examined the effect of nimodipine-induced BP reductions that exceed autoregulatory capacity on functional outcome following aSAH.</p><p><strong>Methods: </strong>Autoregulatory function was measured continuously following aneurysm securement by correlating near-infrared spectroscopy-derived regional oxygen saturation with mean arterial pressure (MAP). The resulting autoregulatory index was used to derive the lower and upper limits of autoregulation (LLA and ULA). Physiologic parameters were compared between the hour before and the hour after nimodipine administration using linear mixed-effects models. Ordinal regression was used to assess the relationship between time with MAP below the LLA and functional outcome, as measured by the modified Rankin scale at 90 days post discharge.</p><p><strong>Results: </strong>Analysis included 682 nimodipine administrations among 31 patients with moderate to severe aSAH (mean age 57 ± 14 years, 71% female, median Hunt & Hess score 4 [interquartile range (IQR) 2-4], modified Fisher grade 4 [IQR 3-4], monitoring time 5.5 ± 4.7 days). Following nimodipine, MAP decreased from a mean ± SEM of 105.9 ± 0.7 to 100.1 ± 0.7 mm Hg (p < 0.001), resulting in increased time below the LLA from a mean ± SEM of 5.3 ± 0.5 to 13.9 ± 0.7 min (p < 0.001). Mean time below the LLA was significantly associated with worse functional outcome at 90 days (odds ratio for 10-min increase 3.6, 95% confidence interval 1.6-8.0, p = 0.0015). This association remained significant after adjusting separately for age, Hunt & Hess score, modified Fisher grade, delayed cerebral ischemia, and the magnitude of BP response to nimodipine.</p><p><strong>Conclusions: </strong>Nimodipine-induced BP reductions below personalized limits of autoregulation may be associated with worse functional outcome after aSAH. Further prospective studies are warranted to explore how autoregulatory sensitivity to nimodipine can be used to identify vulnerable patients and maximize benefits from current clinical interventions.</p>\",\"PeriodicalId\":19118,\"journal\":{\"name\":\"Neurocritical Care\",\"volume\":\" \",\"pages\":\"\"},\"PeriodicalIF\":3.6000,\"publicationDate\":\"2025-08-22\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Neurocritical Care\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1007/s12028-025-02338-6\",\"RegionNum\":3,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q2\",\"JCRName\":\"CLINICAL NEUROLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Neurocritical Care","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1007/s12028-025-02338-6","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q2","JCRName":"CLINICAL NEUROLOGY","Score":null,"Total":0}
引用次数: 0
摘要
背景:动脉瘤性蛛网膜下腔出血(aSAH)后大脑自身调节功能的损害增加了血压(BP)波动引起的继发性损伤的易感性。虽然尼莫地平被推荐用于改善神经系统预后,但它经常与血压降低有关。在这项观察性队列研究中,我们研究了尼莫地平诱导的血压降低超过自身调节能力对aSAH后功能结局的影响。方法:通过近红外光谱衍生的区域氧饱和度与平均动脉压(MAP)的相关性,连续测量动脉瘤固定后的自调节功能。得到的自调节指数用于推导自调节的下限和上限(LLA和ULA)。采用线性混合效应模型比较尼莫地平给药前后1h的生理参数。使用有序回归评估MAP低于LLA的时间与功能结局之间的关系,在出院后90天使用改进的Rankin量表测量。结果:分析了31例中重度aSAH患者的682例尼莫地平用药情况(平均年龄57±14岁,71%为女性,Hunt & Hess评分中位数为4[四分位间距(IQR) 2-4],修正Fisher评分4 [IQR 3-4],监测时间5.5±4.7天)。尼莫地平治疗后,MAP从平均±SEM(105.9±0.7)降至100.1±0.7 mm Hg (p)。结论:尼莫地平诱导的低于个性化自动调节极限的血压降低可能与aSAH后更差的功能预后有关。进一步的前瞻性研究是有必要的,以探索如何利用尼莫地平的自我调节敏感性来识别易感患者,并从当前的临床干预中最大限度地获益。
Impact of Nimodipine-Induced Blood Pressure Reductions on Cerebral Autoregulation and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage.
Background: Impairment of cerebral autoregulation following aneurysmal subarachnoid hemorrhage (aSAH) increases susceptibility to secondary injury from blood pressure (BP) fluctuations. Although nimodipine is recommended to improve neurological outcomes, it is frequently associated with BP reduction. In this observational cohort study, we examined the effect of nimodipine-induced BP reductions that exceed autoregulatory capacity on functional outcome following aSAH.
Methods: Autoregulatory function was measured continuously following aneurysm securement by correlating near-infrared spectroscopy-derived regional oxygen saturation with mean arterial pressure (MAP). The resulting autoregulatory index was used to derive the lower and upper limits of autoregulation (LLA and ULA). Physiologic parameters were compared between the hour before and the hour after nimodipine administration using linear mixed-effects models. Ordinal regression was used to assess the relationship between time with MAP below the LLA and functional outcome, as measured by the modified Rankin scale at 90 days post discharge.
Results: Analysis included 682 nimodipine administrations among 31 patients with moderate to severe aSAH (mean age 57 ± 14 years, 71% female, median Hunt & Hess score 4 [interquartile range (IQR) 2-4], modified Fisher grade 4 [IQR 3-4], monitoring time 5.5 ± 4.7 days). Following nimodipine, MAP decreased from a mean ± SEM of 105.9 ± 0.7 to 100.1 ± 0.7 mm Hg (p < 0.001), resulting in increased time below the LLA from a mean ± SEM of 5.3 ± 0.5 to 13.9 ± 0.7 min (p < 0.001). Mean time below the LLA was significantly associated with worse functional outcome at 90 days (odds ratio for 10-min increase 3.6, 95% confidence interval 1.6-8.0, p = 0.0015). This association remained significant after adjusting separately for age, Hunt & Hess score, modified Fisher grade, delayed cerebral ischemia, and the magnitude of BP response to nimodipine.
Conclusions: Nimodipine-induced BP reductions below personalized limits of autoregulation may be associated with worse functional outcome after aSAH. Further prospective studies are warranted to explore how autoregulatory sensitivity to nimodipine can be used to identify vulnerable patients and maximize benefits from current clinical interventions.
期刊介绍:
Neurocritical Care is a peer reviewed scientific publication whose major goal is to disseminate new knowledge on all aspects of acute neurological care. It is directed towards neurosurgeons, neuro-intensivists, neurologists, anesthesiologists, emergency physicians, and critical care nurses treating patients with urgent neurologic disorders. These are conditions that may potentially evolve rapidly and could need immediate medical or surgical intervention. Neurocritical Care provides a comprehensive overview of current developments in intensive care neurology, neurosurgery and neuroanesthesia and includes information about new therapeutic avenues and technological innovations. Neurocritical Care is the official journal of the Neurocritical Care Society.