Abstract
ObjectiveTo determine the area most at risk of delayed cerebral ischemia (DCI) in relation to the location of the ruptured aneurysm in patients with aneurysmal subarachnoid hemorrhage (aSAH) and, therefore, help to choose the site for focal multimodal neuromonitoring.MethodsWe retrospectively analyzed angiographic findings, CCT scans, and patient charts of patients who were admitted with aSAH to our neurosurgical intensive care unit between 2009 and 2017. DCI was defined as infarction on CCT 2–6 weeks after aSAH.ResultsDCI occurred in 17.9% out of 357 included patients. A DCI occurring in the vascular territory of the artery carrying the ruptured aneurysm was found in 81.0% of patients with anterior circulation aneurysms but only in 16.7% with posterior circulation aneurysms (Fisher’s exact, p=0.003). The vascular territory most frequently showing a DCI was the ipsilateral MCA territory (86.7%) in ICA aneurysms, the contra- (71.4%) and the ipsilateral (64.3%) ACA territory in ACA aneurysms, the right (93.8%) and the left (81.3%) ACA territory in AcomA aneurysms, and the ipsilateral MCA territory in MCA aneurysms (69.2%) as well as in VA/PICA/SCA aneurysms (100.0%). DCI after the rupture of a BA aneurysm occurred with 33.3% in 6 out of 8 vascular territories, respectively. DCI of multiple vascular territories occurred in 100.0% of BA aneurysms, 87.5% of AcomA aneurysms, 71.4% of ACA aneurysms, 40.0% of ICA aneurysms, 38.5% of MCA aneurysms, and 33.3% of VA/PICA/SCA aneurysms.DiscussionFew studies exist that could determine the area most at risk of a DCI after an aSAH. Our data could identify the territory most at risk for DCI with a probability of > 60% except for BA aneurysms, which showed DCI in various areas and patients suffering from multiple DCIs. Either the ipsilateral ACA or MCA were affected by the DCI in about 80% of ACA and more than 90% of AcomA, ICA, MCA, and VA/PICA/SCA aneurysms. Therefore, local intraparenchymal neuromonitoring in the ACA/MCA watershed area might detect the vast majority of DCIs for all aneurysm locations, except for BA aneurysms. In ACA and AcomA aneurysms, bilateral DCI of the ACA territory was common, and bilateral probe positioning might be considered for monitoring high-risk patients. Non-focal monitoring methods might be preferably used after BA aneurysm rupture.
Highlights
Despite highly specialized treatment and optimized management at neurointensive care units, aneurysmal subarachnoid hemorrhage as the main cause of stroke in young patients is still accompanied by a broad spectrum of possible complications that lead to a poor outcome [2, 6, 10]
Our data show the highest rates of delayed cerebral ischemia (DCI) in AcomA and BA aneurysms and the lowest rates in VA/PICA/SCA aneurysms—a difference in the incidence of DCI between anterior and posterior circulation arteries could not be established. This is the largest series of aneurysmal subarachnoid hemorrhage (aSAH) patients investigating the relationship between the location of the ruptured aneurysm and the DCI
Our data showed no difference in the frequency of DCI occurring in anterior or posterior circulation aneurysms
Summary
Despite highly specialized treatment and optimized management at neurointensive care units, aneurysmal subarachnoid hemorrhage (aSAH) as the main cause of stroke in young patients is still accompanied by a broad spectrum of possible complications that lead to a poor outcome [2, 6, 10]. One major risk factor for a poor outcome in patients who survived the initial ictus is the development of a delayed cerebral ischemia (DCI). Intraparenchymal probes for continuous measurement of cerebral tissue oxygen saturation or interstitial tissue metabolism are commonly used for early diagnosis of an impaired brain perfusion [17]. These methods have been shown to be highly sensitive to changes in local brain perfusion, the main limitation is the focal nature of the measurement. Systematic investigations determining the area most at risk for the development of a DCI are rare [13, 21]
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