Article
Delayed cerebral ischemia – contemporary incidence, predictors, management and outcomes based on the Swiss Study on Subarachnoid hemorrhage (Swiss SOS)
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Authors
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Ali-Reza Fathi
- Hirslanden Klinik Aarau, Aarau, Switzerland
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Martin N. Stienen
- Klinik für Neurochirurgie, UniversitätsSpital Zürich, Zürich, Switzerland
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Christian Fung
- Inselspital Universität Bern, Klinik für Neurochirurgie, Bern, Switzerland
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Jan-Karl Burkhardt
- Zürich, Switzerland
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Jürgen Beck
- Inselspital Universität Bern, Klinik für Neurochirurgie, Bern, Switzerland
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Veit Rohde
- Universitätsmedizin Göttingen, Klinik und Poliklinik für Neurochirurgie, Göttingen, Deutschland
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Astrid Weyerbrock
- Kantonsspital St. Gallen, Klinik für Neurochirurgie, St. Gallen, Switzerland
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Philippe Bijlenga
- Neurochirurgie, Dpt de Neurosciences cliniques, Genf, Switzerland
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Karl Schaller
- Hôpitaux Universitaires de Genève, Neurochirurgie, Genève, Switzerland
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Bawarjan Schatlo
- Universitätsklinik Göttingen, Klinik f. Neurochirurgie, Göttingen, Deutschland
| Published: | June 9, 2017 |
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Outline
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Objective: Delayed cerebral ischemia (DCI) remains a feared complication of aneurysmal subarachnoid hemorrhage (SAH). In order to account for novel insights into its pathophysiology, improved interventional management and advances in neurointensive care over the past decade, we reassessed the incidence, predictors and management of DCI based on a contemporary unselected patient population.
Methods: The Swiss study on subarachnoid hemorrhage (Swiss SOS) includes all patients treated for SAH since 1st of January 2009 in all eight neurovascular centers in Switzerland. DCI was defined based on a 2010 consensus as “The occurrence of focal neurological impairment (such as hemiparesis, aphasia, apraxia, hemianopia, or neglect), or a decrease of at least 2 points on the Glasgow Coma Scale (either on the total score or on one of its individual components [eye, motor on either side, verbal]). This should last for at least 1 hour.”. In addition to descriptive statistics, predictive factors were identified based on chi2 and multivariate binary regression analysis.
Results: 1087 datasets matched the inclusion criteria for the current analysis. DCI occurred in 310 patients (28.6%). After multivariate correction, predictors of DCI included poor WFNS status (3-5) [OR 1.48, CI95% 1.06-2.06, p=0.02], high Fisher grade (3,4) [OR 3.1, CI95% 1.70-5.74, p<0.001] and surgical aneurysm treatment [OR 1.50, CI95% 1.12-2.01, p=0.01]. Interventional balloon or chemical dilation was performed in 127 of 310 cases with DCI (41%). Hemicraniectomy was necessary in 73/310 patients with DCI (23.5%) and 79 out of 774 patients without DCI (10.2%; p<0.001). Outcomes after DCI were worse with higher dependency (166; 53.5%) and mortality (58; 18.7%) compared to patients without DCI (25.5% and 15.5% respectively; p<0.001). Length of stay was longer in patients with DCI (29±16 days) than in those without DCI (22±13 days; p<0.05).
Conclusion: Despite advances in neurointensive care management of SAH, DCI affects more than one in four patients. Besides poor clinical status and amount of blood, our data confirm an association between surgical management and the occurrence of DCI. Interventional dilation appears to play a pivotal role in its management in our cohort. It remains an important factor associated with longer hospital stay, poor outcome and mortality.
