Effect of different components of triple-H therapy on cerebral perfusion in patients with aneurysmal subarachnoid haemorrhage: a systematic review

Abstract

Introduction: Triple-H therapy and its separate components (hypervolemia, hemodilution, and hypertension) aim to increase cerebral perfusion in subarachnoid haemorrhage (SAH) patients with delayed cerebral ischemia. We systematically reviewed the literature on the effect of triple-H components on cerebral perfusion in SAH patients.

Methods: We searched medical databases to identify all articles until October 2009 (except case reports) on treatment with triple-H components in SAH patients with evaluation of the treatment using cerebral blood flow (CBF in ml/100 g/min) measurement. We summarized study design, patient and intervention characteristics, and calculated differences in mean CBF before and after intervention.

Results: Eleven studies (4 to 51 patients per study) were included (one randomized trial). Hemodilution did not change CBF. One of seven studies on hypervolemia showed statistically significant CBF increase compared to baseline; there was no comparable control group. Two of four studies applying hypertension and one of two applying triple-H showed significant CBF increase, none used a control group. The large heterogeneity in interventions and study populations prohibited meta-analyses.

Conclusions: There is no good evidence from controlled studies for a positive effect of triple-H or its separate components on CBF in SAH patients. In uncontrolled studies, hypertension seems to be more effective in increasing CBF than hemodilution or hypervolemia.

Figure 1

Flow chart showing the search process for included studies. Subscript: * Joseph et al [31] and Egge et al [9], # Hadeishi et al [32].

Figure 2

Mean CBF (ml/100 g/min) difference between start of intervention and follow-up within 24 hours.

Figure 3

Mean CBF difference between start of intervention and follow-up within 5-7 days and 12-14* days.