Prophylactic hypervolemia without calcium channel blockers in early aneurysm surgery

Delayed ischemic neurological deficit (DIND) remains a major unsolved problem in the management of aneurysmal subarachnoid hemorrhage (SAH). For many years, the complications reported with acute aneurysm surgery caused surgeons to operate late after SAH. In a 42-month-period, we managed 146 patients with aneurysm and/or SAH. Forty-seven patients were characterized by the following: Hunt and Hess Grades I through III after an aneurysmal SAH; 2) clipping of their aneurysm within 72 hours of their SAH; and (3) prophylactic hypervolemia with a pulmonary artery catheter to optimize their fluid management. Forty of 47 (85%) had an excellent or good outcome, and 3 of 47 (6%) died. All of those who died had DIND. Nine of 47 (19%) patients developed DIND. There were 20 complications, primarily pulmonary edema, in 16 patients and one death related to prophylactic hypervolemia. It is not clear from our experience, when compared with results from other series, that hypervolemia provides any additional benefit to the patient as measured by a reduction in the risk of DIND or improved outcome. Despite aggressive volume expansion to the point of cardiovascular compromise, as evidenced by our high rate of pulmonary edema, we had no appreciable decrease in neurological morbidity and mortality when compared with results from recent reports.