Aneurysmal subarachnoid hemorrhage (aSAH) is a dreadful acute neurological condition with overwhelmingly high rate of associated morbidities and mortality. Despite leaping advancement in neurosurgical techniques and imaging modalities, there is no substantiative improvement in overall prognosis for aSAH. Cerebral vasospasm remains the predominant cause of associated morbidities. Human albumin has been used in different neurological conditions including head trauma, intracerebral hemorrhages, and ischemic strokes with favorable outcome. However, its beneficial use in aSAH has not been sufficiently explored until recently a published systematic review by our team. In view of scarcity of published data and lack of robust evidence, our group has designed for the first ever RCT to compare the use human albumin-enhanced fluid management versus standard fluid therapy with crystalloids in patients with aSAH.
This single center open label, prospective, parallel group randomized control trial will be conducted at Hamad General Hospital, Doha-Qatar from August 2024 to July 2027. A sample size of 84 (42 in each arm) has been calculated to detect as sufficient to detect a clinically significant difference in modified Rankin Scale good score between two groups (human-albumin induced volume expansion therapy versus crystalloid only) for fluid management in aneurysmal subarachnoid hemorrhages patients. Primary outcome will be based on dichotomized modified Rankin scale \[(Good grades (0-2) and poor grades (3-6)\], while secondary outcome will include symptomatic vasospasm, transcranial doppler velocities, and Pulse Index Contour Cardiac Output (PiCCO) parameters.
The trial aims to provide firsthand evidence on the beneficial use of human albumin to achieve optimal fluid management regime to explore its potential role to improve clinical outcome in patients with aSAH.
Age limits of participants will be between 18 and 80 years with either gender (male or female).
Clinical presentation with the first of symptom of aSAH must be within 72 hours before randomization.
Clinical manifestation must be suggestive of aSAH that may include classical thunderclap headache, cranial nerve deficits, changes in level of consciousness, neck rigidity and neurological deficits.
All cases with WFNS grade 1 to 5 (at the time of randomization) will be recruited in the study.
Timing of first symptom of SAH cannot be reliably ascertained.
Cerebral angiogram negative SAH.
Cerebral angiography showing mycotic/traumatic/fusiform aneurysm/s.
Symptomatic vasospasm or angiographic (on TCD or CTA) sets in before recruitment within 72 hours.
Parallel
Human albumin
DrugPatients in intervention arm will also receive intermittent boluses of 20 percent human albumin (in addition to standard fluid therapy) that will be administered with dosage regimen of 1.25gm/kg of body weight per 24 hours. The maximum total calculated dose/volume of albumin for the patient will be infused @ 34 ml/hour (over 3 hours) and will be divided in 3 boluses, spaced at 8 hours intervals. During intervention period, duration of treatment (7-day study period) will cover the peak period of cerebral vasospasm from day 4th until 10th day. Albumin administration will be tailored according to the targeted values set for euvolemic fluid balance in each patient. Before randomization (within 72 hours post-ictus) and after day-10 (from day 11th-14th, patient will only receive standard fluid therapy.
Dichomatized modified Rankin Scale (mRS)
Primary clinical outcome will be based on dichotomized modified Rankin Scale \[(Good grades (0 -2) and poor grades (3-6)\]. Primary outcome measures (values of mRS) will be compared between study arms to assess difference in the effect size of the intervention.
Development of Symptomatic vasospasm (with/without new onset infarctions on unenhanced Computed Tomography scan, transcranial doppler velocities (daily average) and PiCCO parameters (daily average values)
Secondary outcomes will include symptomatic vasospasm (with/without new onset infarctions on unenhanced Computed Tomography scan), transcranial doppler velocities (daily values), and all Pulse index Contour Cardiac Output (PiCCO) parameters (daily average values). On 14th day endpoint, a mean of all cumulative daily averaged values will be recorded for secondary outcome measures for; 1) the study period (4th-10th day) and 2) subsequently without albumin therapy (from day 11th -14th day) on Day-14 end-point. These secondary outcome measures will be compared between study arms to assess difference in the effect size of the intervention.
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