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Published on: June 18, 2021
Impaired cerebrovascular reactivity may predict delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage
Marianne L Bøthun1, Øystein A Haaland2, Gunnar Moen3
1Department of Clinical Medicine, University of Bergen, 5021 Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, 5021 Bergen, Norway.
Insights
Impaired cerebrovascular reactivity (CVR) predicts delayed cerebral ischemia (DCI) after brain aneurysm treatment. Incorporating CVR into prediction models improves accuracy for identifying patients at risk of DCI, aiding clinical management.
Area of Science:
- Neurology
- Neurosurgery
- Vascular Medicine
Background:
- Delayed cerebral ischemia (DCI) is a significant cause of death and disability following aneurysmal subarachnoid hemorrhage.
- Impaired cerebrovascular reactivity (CVR) is suggested as a predictor of DCI, but no CVR-based predictive model currently exists.
- Identifying DCI predictors can optimize patient management and reduce hospital stays.
Purpose of the Study:
- To investigate the predictive value of CVR for DCI after aneurysmal subarachnoid hemorrhage.
- To develop and evaluate CVR-based prediction models for DCI.
Main Methods:
- Cerebrovascular reactivity (CVR) was assessed using the acetazolamide test and transcranial Doppler in 42 patients with aneurysmal subarachnoid hemorrhage and 37 with unruptured intracranial aneurysms.
- Patients were monitored for clinical deterioration and radiographic infarction indicative of DCI.
- Two prediction models for DCI-induced clinical deterioration were constructed and compared.
Main Results:
- CVR was reduced by 5.5 percentage points on the ipsilateral side of aneurysm treatment in all patients.
- Patients experiencing DCI-related clinical deterioration exhibited lower CVR, particularly on the contralateral side (33.9% vs. 49.2%).
- A prediction model incorporating CVR achieved a higher area under the receiver operating characteristic curve (0.86) compared to a model using established predictors (0.82).
Conclusions:
- Impaired CVR is an independent predictor of clinical deterioration due to DCI after aneurysmal subarachnoid hemorrhage.
- Separate evaluation of ipsilateral and contralateral CVR is necessary due to universal ipsilateral reduction post-treatment.
- CVR assessment can aid in identifying high-risk patients for DCI.
Introduction:
Delayed cerebral ischemia (DCI) is a major cause of disability and death after aneurysmal subarachnoid hemorrhage. The literature suggests that impaired cerebrovascular reactivity (CVR) may be a predictor for DCI; still no CVR based prediction model has been developed. Increased knowledge about possible predictors of DCI can improve patient management in high-risk patients and allow for shorter hospital stay in low-risk patients.
Method:
CVR was examined in 42 patients with aneurysmal subarachnoid hemorrhage and 37 patients treated for unruptured intracranial aneurysm, using acetazolamide test with transcranial Doppler monitoring of blood flow velocities. Patients were followed for development of DCI, separated into clinical deterioration and radiographic infarction.
Results:
For all patients, regardless of aneurysm rupture status, CVR was on average 5.5 percentage points lower on the ipsilateral side of aneurysm treatment. Patients with clinical deterioration due to DCI had lower CVR than patients without DCI, and the difference was larger on the contralateral side (33.9% vs. 49.2%). Two prediction models were constructed for clinical deterioration due to DCI. The area under the receiver operating characteristic curve was 0.82 in the model using established predictors, and 0.86 in the model that also included CVR.
Conclusion:
Our findings support the hypothesis that impaired CVR may be an independent predictor of clinical deterioration due to DCI, and may assist in identifying patients at risk after aneurysmal subarachnoid hemorrhage. Ipsilateral CVR reduction occurs in all patients after aneurysm treatment, regardless of DCI development, thus highlighting the need to evaluate ipsi- and contralateral CVR separately.
