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Devastating delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage
Inez Koopman1, Philippine B van Wijngaarden1, Gabriel J E Rinkel1
1Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands.
Frontiers in Neurology
|October 31, 2022
Summary
A small proportion of subarachnoid hemorrhage patients with good initial condition develop devastating delayed cerebral ischemia (DCI). Blood pressure instability was a common factor in these cases, suggesting a potential target for future prevention strategies.
Area of Science:
- Neurology
- Neurosurgery
- Critical Care Medicine
Background:
- Subarachnoid hemorrhage (SAH) can lead to delayed cerebral ischemia (DCI).
- Devastating DCI, defined by prolonged coma and cerebral infarction, can occur even in patients with good initial clinical condition.
- Understanding risk factors for devastating DCI is crucial for improving patient outcomes.
Purpose of the Study:
- To determine the incidence of devastating DCI in patients with aneurysmal subarachnoid hemorrhage (aSAH) who present with a good clinical condition post-treatment.
- To characterize these patients based on aneurysm location, blood pressure instability, and the extent of cerebral ischemia.
Main Methods:
- Retrospective analysis of aSAH patients admitted between 2010 and 2021.
- Inclusion criteria: Glasgow Coma Scale (GCS) ≥ 11 at 24 hours post-treatment and development of devastating DCI.
- Definition of devastating DCI: DCI leading to coma ≥ 48 hours with cerebral infarction.
- Definition of blood pressure instability: nimodipine-induced drops, dosage adjustments, or antihypertensive use prior to DCI.
Main Results:
- Out of 1,211 aSAH patients, 617 had a good initial condition; 16 (3%) developed devastating DCI.
- The majority (88%) of affected patients were women.
- Anterior circulation aneurysms were common (81%).
- Blood pressure instability was prevalent (81%), frequently involving nimodipine-induced drops (75%) and antihypertensive use (69%).
- Bilateral ischemia, primarily in the anterior circulation (56%), was observed in 81% of patients.
Conclusions:
- Devastating DCI is a rare complication in aSAH patients with a good initial clinical status.
- Blood pressure instability emerged as a significant associated factor in these cases.
- Further research is warranted to explore whether managing blood pressure fluctuations can reduce the incidence of devastating DCI.
