Abstract
BackgroundHigh intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome.MethodsIn this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008–2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP–CPPopt) < − 10 mm Hg (%).ResultsOf the 242 patients, 63 (26%) had favorable (GOS-E 5–8) and 179 (74%) had unfavorable (GOS-E 1–4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5–10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups.ConclusionsAvoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.
Highlights
Aneurysmal subarachnoid hemorrhage constitutes 5% of all cases of stroke and is associated with high mortality and severe neurological sequelae [1]
In TBI, we have previously found that cerebral perfusion pressure (CPP) between 60 and 70 mm Hg is associated with favorable outcome and CPP above 70 mm Hg is associated with worse clinical outcome [13, 29], whereas we found that higher CPP above 70 mm Hg was better in our aneurysmal subarachnoid hemorrhage (aSAH) patients in the current study
The incidence of secondary insults including intracranial pressure above 20 mm Hg and cerebral perfusion insults below 60–70 mm Hg was higher for patients with unfavorable clinical outcome after aneurysmal subarachnoid hemorrhage
Summary
Aneurysmal subarachnoid hemorrhage (aSAH) constitutes 5% of all cases of stroke and is associated with high mortality and severe neurological sequelae [1]. E.g., when a decrease in MAP leads to cerebral vasodilation to maintain CBF with a corresponding increase in cerebral blood volume and ICP, indicate preserved pressure autoregulation and are strongly associated with favorable outcome in TBI [12, 13]. Some studies suggest that disturbed PRx values and deviation from CPPopt targets are associated with low CBF in aSAH [16, 17], but their ability to predict DCI and clinical outcome are less clear [16,17,18,19,20,21,22]. We aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome
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