gms | German Medical Science

Objective: The role of detection and escalating treatment of patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (SAH) remains controversial. We investigated the efficacy of a standardized protocol for detection of DCI, especially in high-grade SAH patients and a risk-based, escalating protocol for intra-arterial vasodilator therapy in SAH patients with refractory DCI.

Methods: A prospective cohort (I) of 161 consecutive SAH patients admitted to our department between January 2016 and July 2018 was treated by means of a standardized, escalating treatment protocol in case of persistent clinical or radiological (severe CT perfusion impairment and/or severe angiographic vasospasm) features of DCI: 1) induced hypertension >180mmHg systolic, 2) solitary intra-arterial nimodipine bolus applications during catheter angiography, 3) angiographic application of an intra-arterial catheter for continuous nimodipine administration over 48 hours with CT Perfusion imaging in between each escalating step. This group was compared to a historical cohort II (144 patients, from January 2012 to August 2014) where continuous intra-arterial nimodipine catheters were facilitated upon detection of any angiographic vasospasm and irrespective of presence of clinical features of DCI. The two cohorts were compared with respect to functional outcome at discharge and at 3 months using dichotomized extended Glasgow outcome scale (eGOS 1-5: unfavourable and eGOS 6-8: favourable).

Results: Despite generally comparable baseline characteristics, cohort I had a higher proportion of Fisher grade III/IV SAH, compared to cohort II (80.1% vs. 58.3%; p<0.001). The overall incidence of clinical and/or radiological DCI in cohort I was significantly higher compared to cohort II (57.7% vs. 31,9%; p<0.001) whereas the incidence of angiographic vasospasm was comparable (40.3% vs. 47.9%). While there was no difference in clinical outcome at discharge, functional outcome at 3 months for all patients was significantly better in cohort I (70.6% vs 55.0%; p<0.02) (Figure 1 [Fig. 1]) and for those patients with DCI, functional outcome was better at discharge (47.3% vs. 26.1%; p<0.02) and at 3 months (61.3% vs. 34.5%; p<0.02) in cohort I (Figure 2 [Fig. 2]).

Conclusion: Our data highlight that the functional outcome after aSAH can be significantly improved with the use of standardized protocols for the detection of DCI and escalating rescue therapy.