Abstract
Objectives:
To examine the possibility of acupuncture as a new promising treatment to prevent delayed cerebral vasospasm, retrospective comparison was done of patient outcomes in patients with subarachnoid hemorrhage (SAH) treated with and without acupuncture.
Materials and methods:
Twenty (20) patients with SAH were treated after their ruptured aneurysms had been secured. Acupuncture treatments were applied to the bilateral Zusanli (ST36) and Neiguan (PC6) once a day for 2 weeks, starting within 3 days of the aneurysm rupture. The incidence of angiographic vasospasm and delayed ischemic neurological deficit (DIND), the patient's functional status at discharge, and mortality rate were analyzed. Patient outcomes were compared with those of an age- and severity-matched comparison group composed of patients treated in the hospital without acupuncture.
Results:
None of the patients who received acupuncture died. Angiographic vasospasms occurred in 5 patients (25.0%) and DIND in 2 (10%). In terms of functional impairment, the modified Rankin score at discharge was ≤2 in 7 patients (35%). In the control group, angiographic vasospasms occurred in 10 patients (55.6%) and DIND in 7 (38.9%), similar to the reported incidence in conventionally treated patients.
Conclusions:
Patients with SAH who received acupuncture had a significantly lower incidence of DIND and significantly improved function at discharge, suggesting that acupuncture is effective in preventing cerebral vasospasm. In light of these promising results, a randomized controlled trial is warranted to determine the efficacy of acupuncture in a clinical setting.
Introduction
Subjects and Methods
The authors' institution treated 20 patients with SAH between December 2009 and November 2010. All patients were referred to the Department of Korean Medicine after their ruptured aneurysms had been secured by endovascular coiling or surgical clipping. Prophylactic HHH therapy and nimodipine were initiated immediately after arrival in the intensive care unit after surgery. Acupuncture treatments were applied once a day for 2 weeks, starting within 3 days of the aneurysm rupture. Sterile, disposable, stainless steel acupuncture needles (length, 4 cm; diameter, 0.25 mm) were bilaterally inserted at the acupuncture points Zusanli (ST36) and Neiguan (PC6). The acupuncture points were selected based on the authors' previous study. 3 The acupuncture treatment at ST36 and PC6 significantly improved hypertensive patients' endothelial dysfunction, which is assumed to be a cause of cerebral vasospasm after SAH. After insertion to a depth of approximately 2 cm, needles were manually stimulated until de qi (a subjective experience in which patients feel a radiating sensation considered to be indicative of effective needling) was achieved. The needles were left in place for 20 minutes and then removed. The incidence of angiographic vasospasm and DIND, the patient's functional status at discharge, and mortality rate were analyzed. Angiographic vasospasm was defined as focal or generalized reduction of cerebral arterial caliber on conventional cerebral angiogram or computed tomographic angiography confirmed by a neuroradiologist and a neurocritical care physician. DIND was defined as an unaccountable new focal neurological deficit lasting ≥2 hours. Patient outcomes were compared with those of an age- and severity-matched comparison group composed of patients treated in the authors' hospital without acupuncture.
Results
Subject characteristics are summarized in Table 1. Acupuncture was performed on 20 patients with SAH to prevent delayed cerebral vasospasm; their mean age was 56±10.33 years. Of the 20 patients, 18 (90%) were women and 17 (85.0%) had undergone surgical clipping. None of the patients who received acupuncture died. Angiographic vasospasms occurred in 5 (25.0%) and DIND in 2 (10%). In terms of functional impairment, the modified Rankin score at discharge was ≤2 in 7 patients (35%). In the control group, angiographic vasospasms occurred in 10 patients (55.6%) and DIND in 7 (38.9%), similar to the reported incidence in conventionally treated patients. Statistical analysis revealed significant differences in the incidence of DIND and functional status at discharge between groups (Table 1).
Indicates significant difference between acupuncture and control groups by two-sample t-test or Fisher's exact test (p<0.05).
SD, standard deviation; ICU, intensive care unit.
Discussion
This case series shows promising results of acupuncture for the prevention of delayed cerebral vasospasm in SAH. Acupuncture treatment was performed without any substantial adverse events. The mechanisms by which acupuncture prevents delayed cerebral vasospasm remain unclear. It has been hypothesized that cerebral vasospasm results from an imbalance in vasodilation and vasoconstriction. 4 The vascular endothelium regulates smooth-muscle tone by generating nitric oxide (NO) 5 and endothelial-derived constriction factors. 6 Disruption of the endothelium or its relaxing factors may alter this balance, initiating vasospasm. 7 Interestingly, acupuncture was recently reported to enhance the generation of NO 8 and improve abnormal endothelium-dependent vasomotor function, 3 alluding to a possible mechanism by which acupuncture prevents vasospasm. In conclusion, this is a small case–control study, so a definite conclusion cannot be drawn from these results. However, patients with SAH who received acupuncture had a significantly lower incidence of DIND and significantly improved function at discharge, suggesting that acupuncture is effective in preventing cerebral vasospasm. In light of these promising results, a randomized controlled trial is warranted to determine the efficacy of acupuncture in a clinical setting.
Footnotes
Acknowledgments
This work was supported by a grant from the Integrative Medicine Center, Kyung Hee University Hospital at Gangdong in 2011.
Disclosure Statement
All the authors declare no competing financial interests exist.