Abstract
Background: The level of consciousness and cerebral edema are among the indicators that best define the intensity of early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Although these indicators are usually altered in patients with a poor neurological status, their usefulness for selecting patients at risk of cerebral infarction (CI) is not well established. Furthermore, little is known about the evolution of these indicators during the first week of post-ictal events. Our study focused on describing the association of the longitudinal course of these predictors with CI occurrence in patients with severe aSAH. Methods: Out of 265 aSAH patients admitted consecutively to the same institution, 80 patients with initial poor neurological status (WFNS 4–5) were retrospectively identified. After excluding 25 patients with early mortality, a total of 47 patients who underwent early CT (<3 days) and late CT (<7 days) acquisitions were included in the study. Early cerebral edema and delayed cerebral edema were calculated using the SEBES score, and the level of consciousness was recorded daily during the first week using the Glasgow Coma Scale (GCS). Results: There was a significant improvement in the SEBES (Early-SEBES median (IQR) = 3 (2–4) versus Delayed-SEBES = 2 (1–3); p = 0.001) and in GCS scores (B = 0.32; 95% CI 0.15–0.49; p = 0.001) during the first week. When comparing the ROC curves of Delayed-SEBES vs Early-SEBES as predictors of CI, no significant differences were found (Early-SEBES Area Under the Curve: 0.65; Delayed-SEBES: 0.62; p = 0.17). Additionally, no differences were observed in the relationship between the improvement in the GCS across the first week and the occurrence of CI (p = 0.536). Conclusions: Edema and consciousness level improvement did not seem to be associated with the occurrence of CI in a surviving cohort of patients with severe aSAH. Our results suggest that intensive monitoring should not be reduced in patients with a poor neurological status regardless of an improvement in cerebral edema and level of consciousness during the first week after bleeding.
Highlights
Between 10 and 30% of patients who suffer from an aneurysmal subarachnoid hemorrhage will develop cerebral infarctions (CIs) that are unrelated to aneurysm exclusion procedures
A recent hypothesis predicted that the initial inflammatory response—which occurs due to aneurysmal rupture—could be the cause [2], as this phenomenon seems to have a direct relationship with the intensity of initial damage during bleeding, which results in so-called early brain injury (EBI)
In aneurysmal subarachnoid hemorrhage (aSAH) patients, EBI resulting from the initial bleed is believed to be a precursor to the pathophysiological cascade that could result in delayed infarction [8]
Summary
Between 10 and 30% of patients who suffer from an aneurysmal subarachnoid hemorrhage (aSAH) will develop cerebral infarctions (CIs) that are unrelated to aneurysm exclusion procedures. In patients with a poor initial clinical status such as those with a World Federation Neurosurgical Score (WFNS) of 4 or 5, these indicators may lose their discriminative usefulness mainly because both cerebral edema and a low level of consciousness are common conditions in most of these patients at the time of hospital admission [3] The behavior of these predictors in the days following aneurysm rupture has been poorly studied. The level of consciousness and cerebral edema are among the indicators that best define the intensity of early brain injury following aneurysmal subarachnoid hemorrhage (aSAH) These indicators are usually altered in patients with a poor neurological status, their usefulness for selecting patients at risk of cerebral infarction (CI) is not well established. Our results suggest that intensive monitoring should not be reduced in patients with a poor neurological status regardless of an improvement in cerebral edema and level of consciousness during the first week after bleeding
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