Abstract
Subarachnoid haemorrhage (SAH) is a form of stroke that is associated with substantial morbidity, often as a result of cerebral ischaemia that occurs in the following days. These delayed deficits in blood flow have been traditionally attributed to cerebral vasospasm (the narrowing of large arteries), which can lead to cerebral infarction and poor neurological outcome. Data from recent studies, however, show that treatment of vasospasm in patients with SAH, using targeted medication, does not translate to better neurological outcomes, and argue against vasospasm being the sole cause of the delayed ischaemic complications. Cerebral autoregulation—a mechanism that maintains stability of cerebral blood flow in response to changes in cerebral perfusion pressure—has been reported to fail after SAH, often before vasospasm becomes apparent. Failure of autoregulation, therefore, has been implicated in development of delayed cerebral ischaemia. In this Review, we summarize current knowledge about the clinical effect of disturbed cerebral autoregulation following aneurysmal SAH, with emphasis on development of delayed cerebral ischaemia and clinical outcome, and provide a critical assessment of studies of cerebral autoregulation in SAH with respect to the method of blood-flow measurement. Better understanding of cerebral autoregulation following SAH could reveal mechanisms of blood-flow regulation that could be therapeutically targeted to improve patient outcome.
Key Points
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Failure of cerebral autoregulation following subarachnoid haemorrhage (SAH) is common, with the severity of dysautoregulation directly linked to the severity of the initial ictus
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Patients with cerebral dysautoregulation are at high risk of developing delayed cerebral ischaemia, particularly when concomitant cerebral vasospasm is present
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In some studies, impaired autoregulation has been associated with poor outcome, but this relationship must be further investigated in a large cohort of patients with SAH
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The exact temporal profile of cerebral autoregulatory failure and its relationship with cerebral vasospasm are poorly defined
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Randomized controlled trials in SAH that used cerebral autoregulation indices as an end point suggest that the duration of dysautoregulation has clinical relevance
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A need exists for prospective studies in SAH that use clearly defined, widely accepted, and comparable methodologies to target and monitor cerebral autoregulatory parameters
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Acknowledgements
J. D. Pickard and M. Czosnyka are supported by the National Institute of Health Research, Biomedical Research Centre (Neuroscience Theme). J. D. Pickard is also supported by the National Institute of Health Research Senior Investigator Award. K. P. Budohoski received a grant from St Catharine's College, University of Cambridge, UK.
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K. P. Budohoski researched data for the article. K. P. Budohoski and M. Czosnyka wrote the article. All authors contributed equally to discussion of content and to the review and/or editing of the manuscript before submission.
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Supplementary Table 1
Cerebral autoregulation following SAH: direct blood-flow methods for measurement of static autoregulation (DOC 70 kb)
Supplementary Table 2
Cerebral autoregulation following SAH: indirect measurements (DOC 54 kb)
Supplementary Table 3
Cerebral autoregulation following SAH: indirect blood-flow methods for measurement of dynamic autoregulation (DOC 118 kb)
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Budohoski, K., Czosnyka, M., Kirkpatrick, P. et al. Clinical relevance of cerebral autoregulation following subarachnoid haemorrhage. Nat Rev Neurol 9, 152–163 (2013). https://doi.org/10.1038/nrneurol.2013.11
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DOI: https://doi.org/10.1038/nrneurol.2013.11
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Intensive Care Medicine Experimental (2022)