Miscellaneous

Although triple-H therapy has been used in cerebral ischemia other than in the setting of aneurysmal subarachnoid hemorrhage, the available literature does not provide consistent objective evidence for such an approach. However, if intracranial hemorrhage is excluded, maintenance of relatively high mean arterial pressure values may maximize collateral supply and minimize or prevent neuronal loss. This approach must be seen as an adjunct to specific treatment where available, such as thrombolysis for hyperacute ischemic stroke, anticoagulation and/or thrombolysis for vascular occlusion during the course of interventional neuroradiological procedures, and re-exploration of a thrombosed vessel following carotid endarterectomy.

Rarely, patients exhibit persistent cerebral hyperemia (by transcranial Doppler or cerebral blood flow measurement) following carotid endarterectomy, because postoperative increases in perfusion pressure in a previously ischemic cerebrovascular bed exceed the upper limit of autoregulation. Such patients are at high risk of cerebral edema or hemorrhage, and may require a short period of careful blood pressure control at the lower end of their normal range while normal cerebrovascular reactivity is restored.

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