Application of Intracranial Pressure-Directed Therapy on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Runting Li,Fa Lin,Zhipeng Li,Heze Han,Guangzhi Shi,Yu Chen,Kexin Yuan,Shuo Wang,Yuanli Zhao,Debin Yan,Ruinan Li,Junlin Lu,Jun Yang,Jianxin Zhou,Linlin Zhang,Haibin Zhang,Xiaolin Chen,Hongliang Li

doi:10.3389/fnagi.2022.831994

Abstract

ObjectiveElevated ICP is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Delayed cerebral ischemia (DCI) is the most important reason for a poor clinical outcome after a subarachnoid hemorrhage. DCI is understood as a multifactorial process that evolves over time, largely caused by the sequelae of increased intracranial pressure (ICP). The study aimed to assess how to better define the association between ICP and DCI, and whether rational ICP management can improve the outcome of aSAH patients.MethodsWe prospectively reviewed patients diagnosed with aSAH and received microsurgery clipping at our department from December 2019 to January 2021. Subdural ICP monitoring devices were kept to monitor the ICP. The ICP values were recorded every 1-h epochs. ICP -guided dehydration treatments were routinely performed to control the ICP level of patients after surgery. To evaluate whether the subdural ICP-directed management improved the prognosis of the aSAH patients, we compared the outcome data of the patients in our cohort with those treated at another ward of our hospital at the same period.ResultsIn total, 144 consecutive aSAH patients received microsurgery clipping at our department, 68 of whom underwent ICP monitoring. A total of 11,424 1-h ICP measurements were recorded for the included patients (1.30 years of recordings). Of 68 patients with ICP monitoring, 27 (27/68, 39.7%) patients developed DCI. Univariate analysis showed that higher Hunt-Hess grade (OR 2.138, 95% CI 1.025–4.459, p = 0.043), higher preoperative modified Rankin Scale score (OR 1.534, 95% CI 1.033–2.276, p = 0.034), and the max ICP value of each day value >28.5 mmHg (OR 4.442, 95% CI 1.509–13.082, p = 0.007) were associated with DCI. Also, patients with ICP-directed treatment showed a significantly lower DCI incidence than patients without ICP monitoring.ConclusionOur study suggests that I less than 15 mmHg possibly constitute normal values and that 28.5 mmHg is the ICP threshold most strongly associated with the occurrence of DCI in aSAH patients. Patients who received the ICP-directed treatment presented a lower incidence of DCI. Our findings provide a basis for the recommendation of ICP-directed treatment after aSAH.Trial Registration NumberNCT04785976.

Highlights

Aneurysmal subarachnoid hemorrhage constitutes a life-threatening subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life, which account for more than 85% of all subarachnoid hemorrhage without preceding trauma (Macdonald and Schweizer, 2017)
If the neurological function of patients deteriorated, computed tomography (CT) scans or angiography were performed to detect the occurrence of delayed cerebral ischemia (DCI)
We recorded data of 144 consecutive aSAH patients who received microsurgery clipping at our department, 68 of whom underwent intracranial pressure (ICP) monitoring

Summary

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) constitutes a life-threatening subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life, which account for more than 85% of all subarachnoid hemorrhage without preceding trauma (Macdonald and Schweizer, 2017). There are no consensus guidelines devoted to the management of elevated ICP in the setting of aSAH. Most centers extrapolate their treatment algorithms from studies and published guidelines for traumatic brain injuries to treat ICP elevation in aSAH (Alotaibi et al, 2017). The threshold at which ICP begins to exhibit detrimental effects is not known with certainty Likewise, it remains unclear what the ideal treatment threshold for ICP is and whether a common threshold should be used for all patients and pathologies. Using our prospective database of high-frequency physiologic data, our group has endeavored to better define the association between ICP and DCI, and whether rational ICP management can improve the outcome of aSAH patients

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Results

Conclusion