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Abstract
Objective Delayed cerebral ischemia (DCI) is strongly associated with poor outcome after subarachnoid hemorrhage (SAH). Cerebral vasospasm is a major contributor to DCI and requires special attention. To evaluate the effect of vasospasm management on SAH outcome, we performed a pooled analysis of 2 observational SAH cohorts.
Materials Data from 2 institutional databases with consecutive patients with SAH treated between 2005 and 2012 were pooled. The effect of 2 institutional standards of conservative and endovascular vasospasm treatment (EVT) on the rates of DCI (new cerebral infarcts not visible on the post-treatment imaging) and unfavorable outcome (modified Rankin Scale score >2) at 6 months follow-up was analyzed.
Results The final analysis included 1,057 patients with SAH. There was no difference regarding demographic (age and sex), clinical (Hunt & Hess grades, acute hydrocephalus, treatment modality, and infections), and radiographic (Fisher grades and aneurysm location) characteristics of the populations. However, there was a significant difference in the rate (24.4% [121/495] vs 14.4% [81/562], p < 0.0001) and timing (first treatment on day 6 vs 8.9 after SAH, p < 0.0001) of EVT. The rates of DCI (20.8% vs 29%, p = 0.0001) and unfavorable outcome (44% vs 50.6%, p = 0.04) were lower in the cohort with more frequent and early EVT. Multivariate analysis confirmed independent effect of EVT standard on DCI risk and outcome.
Conclusions A preventive strategy utilizing frequent and early EVT seems to reduce the risk of DCI in patients with SAH and improve their functional outcome. We recommend prospective evaluation of the value of preventive EVT strategy on SAH.
Classification of evidence This study provides Class III evidence that for patients with SAH, a frequent and early EVT to treat vasospasm reduces the risk of DCI and improves functional outcome.
Glossary
- aOR=
- adjusted odds ratio;
- CI=
- confidence interval;
- CohA=
- Cohort A;
- CohB=
- Cohort B;
- DCI=
- delayed cerebral ischemia;
- DIND=
- delayed ischemic neurologic deficit;
- DSA=
- digital subtraction angiography;
- EBI=
- early brain injury;
- EVD=
- external ventricular drainage;
- EVT=
- endovascular vasospasm treatment;
- ICH=
- intracerebral hematoma;
- MAP=
- mean arterial pressure;
- MFV=
- mean flow velocity;
- mRS=
- modified Rankin Scale;
- OR=
- odds ratio;
- SAH=
- subarachnoid hemorrhage;
- SOP=
- standard operating procedure;
- TBA=
- transluminal balloon angioplasty;
- TCD=
- transcranial Doppler
Footnotes
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Editorial, page 192
Class of Evidence: NPub.org/coe
- Received November 19, 2018.
- Accepted in final form March 21, 2019.
- © 2019 American Academy of Neurology
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