Magnesium sulfate in the management of patients with Fisher Grade 3 subarachnoid hemorrhage: A pilot study

OBJECTIVE: To evaluate the effect of magnesium sulfate (MgSO4) on the clinical course of patients with severe aneurysmal subarachnoid hemorrhage (SAH). METHODS: Ten patients with Fisher Grade 3 aneurysmal SAH were evaluated. The patients were given a bolus as well as a constant infusion of intravenous MgSO4 up to 10 days postictus. Blood magnesium levels were obtained to adjust the daily requirement of MgSO4. The goal was to raise the serum level to 2.0 to 2.5 mmol/L or twice the baseline serum level. Daily transcranial Doppler (TCD) ultrasonography was performed on each patient, insonating both anterior cerebral and middle cerebral arteries. Further management followed standard protocols, including the use of nimodipine and hypervolemic therapy. TCD ultrasonographic findings, as well as clinical evidence of cerebral vasospasm, were documented. All patients had a 3-month assessment using the Glasgow Outcome Scale. RESULTS: After administration of a 20 mmol MgSO4 bolus infusion and an average daily continuous infusion of 84.7 mmol, 8 of 10 patients achieved the predetermined serum magnesium levels. No adverse affects were noted during the infusions. Five patients exhibited evidence of vasospasm on TCD ultrasonography; vasospasm was severe in two patients (velocities, >200 cm/s). Three patients, including the two patients in whom TCD ultrasonography demonstrated severe vasospasm, exhibited clinical evidence of vasospasm. Two patients had a Glasgow Outcome Scale score of 3; the remainder had Glasgow Outcome Scale scores of 5. CONCLUSION: Administration guidelines for the use of MgSO4 in aneurysmal SAH were established. A prospective double-blind placebo-controlled trial is required to establish the effectiveness of MgSO4 for treating vasospasm in aneurysmal SAH.