A randomized controlled trial of prophylactic intra-aortic balloon counterpulsation in high-risk aneurysmal subarachnoid hemorrhage

Background and Purpose— To assess whether prophylactic postoperative intraaortic balloon counterpulsation (IABC) reduces the risk of poor outcome because of vasospasm following aneurysmal subarachnoid haemorrhage relative to conventional hypervolemic therapy (HT). Methods— This was a single-center, parallel group randomized controlled trial. Patients suffering a subarachnoid hemorrhage at high risk of vasospasm were eligible. Patients were randomly allocated to receive prophylactic IABC (n=35) or HT (n=36). The primary end point was Glasgow Outcome and SF-36 scores assessed at 6 months by a blinded and independent observer and analyzed by intention to treat. Secondary analysis of physiological parameters was by treatment performed. Results— Twenty-seven patients in each arm had a good outcome ( P =0.55). There was no statistical difference in mean SF-36 score (t=0.39, P =0.70). There were no long-term complications secondary to IABC. There were no differences in preload (pulmonary artery wedge pressure, P =0.97) or afterload (mean arterial pressure, P =0.97). IABC was associated with a lower cardiac output ( P =0.002) and higher systemic vascular resistance ( P =0.005), although for both groups mean cardiac output was >6 L/min. Cerebral blood flow was not different between groups: HT=41.5 (SD 7.2), IABP=44.9 (SD 8.6) mL/100 g/min ( P =0.14). Conclusions— In this study, prophylactic IABC did not improve perfusion indices or confer any clinical benefit following subarachnoid haemorrhage in patients with normal cardiac function. The study was small, however, and cannot be extrapolated to patients with cardiac failure and medically refractory symptomatic cerebral vasospasm. Clinical Trial Registration— This trial was not registered because enrolment began prior to July 1, 2005.