Comparison of postoperative volume status and hemodynamics between surgical clipping and endovascular coiling in patients after subarachnoid hemorrhage.

BACKGROUND: Recent clinical data suggest that postoperative hemodynamic profile and fluid management may differ in aneurysmal subarachnoid hemorrhage patients depending on the treatment option: surgical clipping or endovascular coiling. Our aim was to determine the differences in hemodynamic parameters between the 2 modalities using an advanced transpulmonary thermodilution technique.

METHODS: We studied 73 consecutive aneurysmal subarachnoid hemorrhage patients treated with either clipping or coiling. Transpulmonary thermodilution was established for monitoring cardiac index, global end-diastolic volume index (GEDI), and extravascular lung water index (ELWI). Blood biochemical markers were sampled in parallel.

RESULTS: Hypovolemia (GEDI: 656±72 vs. 713±40 mL/m; P=0.0001) and elevated plasma brain natriuretic peptide (114.0±56.7 vs. 68.6±47.4 pg/mL; P=0.0004) were evident on initial measurements in the clipping group. The number of fluid challenges until normalization of GEDI and ROC-based prediction of the responders (GEDI≥10%) during vasospasm risk period (day 4 to 14 of ictus) were less with coiling than with clipping (P<0.05). Therapy-related pulmonary edema was detected only in the clipping group (8%, n=3). Although length of intensive care unit stay was shorter in the coiling group (P=0.016), incidences of delayed ischemia (13% vs. 11%; P=0.50) and poor functional outcome on modified Rankin Scale score 4 to 6 at 1 month (37% vs. 46%; P=0.30) were not statistically different.

CONCLUSIONS: Surgical clipping is associated with higher cardiac output and hypovolemia in the early postoperative stage and poorer preload responsiveness to volume therapy during the vasospasm risk period compared with endovascular coiling.