Efficacy of Step-down Infusion Method of a Novel Barbiturate Therapy for Severe Subarachnoid Hemorrhage with Intracerebral Hematoma

Currently, there is no effective treatment for elevated intracranial pressure in the acute phase of subarachnoid hemorrhage. Recently, we developed "step-down infusion of barbiturate," a therapeutic strategy for severe traumatic brain injury, which decreased intracranial pressure and significantly reduced mortality without serious side effects. This study aimed to examine the efficacy of step-down infusion of barbiturate in patients with severe subarachnoid hemorrhage. Of the 342 patients with subarachnoid hemorrhage treated surgically at our hospital from January 2010 to May 2022, 17 with ruptured middle cerebral artery aneurysms and intracerebral hematoma graded as World Federation of Neurosurgical Societies Grade IV or V underwent hematoma removal, aneurysmal clipping or coiling, and external decompression. These patients were divided into 2 groups: the step-down infusion of barbiturate group and the control group, which was treated without step-down infusion of barbiturate. Thiamylal sodium was initiated immediately after surgery at 4 mg/kg/h and tapered to 3, 2, 1.5, and 1 mg/kg/h every 24 hrs after the start of normothermia administration. We evaluated the modified Rankin scale and Extended Glasgow Outcome Scale scores 1 year after admission. The step-down infusion of barbiturate group showed significantly better outcomes and well-controlled intracranial pressure (<20 mm Hg); moreover, cerebral perfusion pressure was maintained above 50 mm Hg, and there were no deaths or serious side effects associated with barbiturate use. Our novel method of prophylactic step-down infusion of barbiturate with normothermia for severe subarachnoid hemorrhage can safely lower intracranial pressure while maintaining cerebral perfusion pressure without serious side effects. This method may improve the outcomes in severe subarachnoid hemorrhage with intracerebral hematoma, although further studies are needed to confirm its efficacy and safety.