gms | German Medical Science

Objective: To date, management and research in aneurysmal subarachnoid haemorrhage (aSAH) have focused on prevention and treatment of vasospasm to prevent poor outcome. However, mortality and morbidity of aSAH have not been significantly improved. Recently, there has been increasing interest in the concept of early brain injury (EBI). With this work, we aim to identify clinical and radiological features occurring in the first 72 hours after haemorrhage that predict poor outcome and mortality.

Methods: We retrospectively analysed 11 variables that occurred within the first 72 hours after haemorrhage in 144 patients. A multivariable logistic regression model was used to model dichotomised patient outcome according to the mRS (good vs. poor). Fisher’s exact test was used to analyse the significance of these variables on mortality within 30 days (dead vs alive). Odds ratios were calculated from contingency tables and tested with Fisher's exact test. Wilcoxon rank-sum test was used to compare the median of 2 groups. Difference in AUC was tested using Delong's test.

Results: Early changes within the first 72 hours of aSAH can predict poor outcome more reliably than initial WFNS-Score (AUC = 0.94 vs. 0.83, p = 0.0007) and DCI (AUC = 0.94 vs AUC = 0.70, p < 0.0001). The most reliable predictors for a poor outcome were early ischemic lesions without evidence of vasospasm (OR = 16.6, 95% CI = 5.7-59.6, p < 0.0001), early clinical deterioration within the first 24 hours of admission (OR 10.2, 95% CI 4.3-26, p < 0.0001) and signs of increased intracranial pressure such as anisocoria (OR = 6.8, 95% CI = 2.0-29.4, p = 0.0003). Overall mortality in this cohort was 14.6%. Only 5% of these patients had DCI, whereas 95% had early complications occurring within the first 72 hours of bleeding. Patients who died had significantly higher intraparenchymal blood volume (median 14.1 ml vs 0 ml, p = 0.002) and significantly higher midline shift on CT scan at admission (median 3.1 mm vs 0.3 mm, p < 0.0001). Early ischemic lesions were associated with higher mortality (OR = 13, 95% CI = 4.2-52.3, p < 0.0001), while DCI and vasospasm were not (OR = 0.23, 95% CI = 0.005-1.61, p = 0.2).

Conclusion: The severity of EBI appears to be a more important factor contributing to the high morbidity and mortality in aSAH. Future research should focus on the mechanisms contributing to EBI to find a potential therapeutic option to prevent disastrous complications in these patients.