Impact of clipping versus coiling on postoperative hemodynamics and pulmonary edema after subarachnoid hemorrhage

Abstract

Volume management is critical for assessment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). This multicenter prospective cohort study compared the impact of surgical clipping versus endovascular coiling on postoperative hemodynamics and pulmonary edema in patients with SAH. Hemodynamic parameters were measured for 14 days using a transpulmonary thermodilution system. The study included 202 patients, including 160 who underwent clipping and 42 who underwent coiling. There were no differences in global ejection fraction (GEF), cardiac index, systemic vascular resistance index, or global end-diastolic volume index between the clipping and coiling groups in the early period. However, extravascular lung water index (EVLWI) and pulmonary vascular permeability index (PVPI) were significantly higher in the clipping group in the vasospasm period. Postoperative C-reactive protein (CRP) level was higher in the clipping group and was significantly correlated with postoperative brain natriuretic peptide level. Multivariate analysis found that PVPI and GEF were independently associated with high EVLWI in the early period, suggesting cardiogenic edema, and that CRP and PVPI, but not GEF, were independently associated with high EVLWI in the vasospasm period, suggesting noncardiogenic edema. In conclusion, clipping affects postoperative CRP level and may thereby increase noncardiogenic pulmonary edema in the vasospasm period. His trial is registered with University Hospital Medical Information Network UMIN000003794.

Figure 1

Values for GEF (a), CI (b), SVRI (c), and GEDI (d) for 14 days after SAH. The dotted lines indicate the upper and lower limits of the normal ranges. *P < 0.05, **P < 0.01, ***P < 0.001, Mann-Whitney test. GEF: global ejection fraction; CI: cardiac index; SVRI: systemic vascular resistance index; and GEDI: global end-diastolic volume index.

Figure 2

Values for EVLWI (a) and PVPI (b) for 14 days after SAH. The dotted lines indicate the upper and lower limits of the normal ranges. The colored lines show EVLWI and PVPI according to the WFNS grade. *P < 0.05, comparison between the clipping and coiling groups in WFNS grades 1–3; ^# P < 0.05, comparison between the clipping and coiling groups in WFNS grades 4-5, Mann-Whitney test. EVLWI: extravascular lung water index and PVPI: pulmonary vascular permeability index.

Figure 3

(a) CRP levels for 14 days after SAH. The colored lines show CRP level according to the WFNS grade. *P < 0.05, **P < 0.01, comparison between the clipping and coiling groups in WFNS grades 1–3; ^# P < 0.05, ^## P < 0.01, ^### P < 0.001, comparison between the clipping and coiling groups in WFNS grades 4-5, Mann-Whitney test. (b) Linear regression curves for correlation between the CRP and BNP levels in WFNS grades 4-5. Pearson rank correlation test. CRP: C-reactive protein and BNP: brain natriuretic peptide.

Figure 4

CRP level and EVLWI according to Glasgow Outcome Scale score after SAH. *P < 0.05, one-way analysis of variance, Tukey-Kramer multiple comparisons test. GR: good recovery; MD: moderate disability; SD: severe disability; VS: vegetative state; and D: death.