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The incidence of hemorrhagic stroke in the general population accounts for approximately 20% of all the strokes, with 5% due to subarachnoid hemorrhage (SAH). The morbidity and mortality remains high for this patient population. For aneurysmal SAH, 30% of patients die and 50% of survivors have long-term cognitive deficits that preclude their return to work. The two most important determinants of outcome after SAH are initial hemorrhage severity and secondary brain injury due to early brain injury (EBI) and delayed cerebral ischemia (DCI). EBI occurs in 12% of patients, develops 1–3 days after SAH and is characterized by blood–brain barrier (BBB) disruption, neuronal cell death, neuroinflammation and cerebral edema. DCI occurs in ~30% of patients, develops 4–12 days after SAH and is characterized by large artery vasospasm, distal autoregulatory dysfunction, microvessel thrombosis and cortical spreading depression. Though many strategies to prevent EBI and DCI have been explored over the years, none have proven efficacious. New therapies are desperately needed to treat these conditions.
Aneurysmal rupture accounts for the majority of subarachnoid hemorrhage and is responsible for most cerebrovascular deaths with high mortality and morbidity. Initial hemorrhage severity and secondary brain injury due to early brain injury and delayed cerebral ischemia are the major determinants of outcomes after aneurysmal subarachnoid hemorrhage. Several therapies have been explored to prevent these secondary brain injury processes after aneurysmal subarachnoid hemorrhage with limited clinical success. Experimental and clinical studies have shown a neuroprotective role of certain anesthetics in cerebrovascular disorders including aneurysmal subarachnoid hemorrhage. The vast majority of aneurysmal subarachnoid hemorrhage patients require general anesthesia for surgical or endovascular repair of their aneurysm. Given the potential impact certain anesthetics have on secondary brain injury after SAH, appropriate selection of anesthetics may prove impactful on overall outcome of these patients. This narrative review focuses on the available evidence of anesthetics and their adjuvants in neurovascular protection in aneurysmal subarachnoid hemorrhage and discusses current impact on clinical care and future investigative directions.
2. Hemorrhagic Stroke
5. Future Studies
Based on the breadth of experimental and clinical data implicating certain anesthetics and anesthetic adjuvants with reducing EBI and DCI and improving neurological outcome after SAH, additional studies examining the impact of these agents in SAH are warranted. In particular, studies designed to address the following would be especially impactful: (1) determining the differential benefit of various anesthetics on SAH outcome; (2) defining optimal dosing and effective therapeutic window for SAH; (3) elucidating underlying mechanisms of anesthetic-induced neurovascular protection in SAH; and (4) exploring the impact of anesthetic treatment on long-term neurobehavioral and cognitive outcomes after SAH.
The entry is from 10.3390/ijms22126550
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