Predictors of Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage

Rabinstein, Alejandro A.; Friedman, Jonathan A.; Weigand, Stephen D.; McClelland, Robyn L.; Fulgham, Jimmy R.; Manno, Edward M.; Atkinson, John L.D.; Wijdicks, Eelco F. M.

doi:10.1161/01.str.0000133132.76983.8e

Cited by 369 publications

(231 citation statements)

References 17 publications

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“…The associations of radiological infarctions and transfusion with worse outcomes have been previously reported by our group and other investigators. 3,10,20,24 Nonetheless, these results highlight the need to treat cerebral ischemia aggressively and to favor a conservative transfusion strategy to maximize the chances of attaining an excellent outcome, although the exact cutoff for considering transfusion needs to be better studied.…”

Section: Discussionmentioning

confidence: 99%

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Pegoli¹,

Mandrekar²,

Rabinstein

et al. 2015

JNS

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121

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A lthough the incidence of aneurysmal subarachnoid hemorrhage (aSAH) has remained stable over time, case fatality rates have decreased by 17% during the last three decades. 11,18 In parallel with refinements in endovascular and surgical treatment and advances in neurocritical care, there has also been an improvement in functional outcome. 2,16,19,23 There are many studies on factors predictive of poor functional and cognitive outcome after aSAH, 5,6,22,25 but much less information on predictors of excellent outcome. In this study, we analyzed predictors of excellent functional outcome in a contemporary series of patients with aSAH. Methods Study PopulationAfter Institutional Review Board approval from the Mayo Clinic, we performed a retrospective chart review of adult patients with aSAH admitted to St. Mary's HospitalMayo Medical Center in Rochester, Minnesota, between February 2001 and June 2013. Subarachnoid hemorrhage (SAH) was confirmed radiologically or by the presence of xanthochromia in the CSF. Only patients with a documented aneurysm on cerebral angiography that was considered to be the cause of the SAH were included.abbreviatioNS aSAH = aneurysmal SAH; DCI = delayed cerebral ischemia; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies. reSultS Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. coNcluSioNS Excellent outcomes (mRS score 0-1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.

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Section: Discussionmentioning

confidence: 99%

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Pegoli¹,

Mandrekar²,

Rabinstein

et al. 2015

JNS

Self Cite

121

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“…This association supports the notion that vasospasm and cerebral ischemia are significant contributors to early and late SAH-related morbidity. 18,22,26,28,29,31,42,43 It also suggests that maneuvers to avoid cerebral ischemia during hospitalization are critical in optimizing the capacity for continued long-term clinical improvement.…”

Section: Figmentioning

confidence: 99%

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Wilson¹,

Nakaji²,

Albuquerque³

et al. 2013

JNS

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Object Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement. Methods The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval. Results The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6–12 months and 12–36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11–18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02–7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89–14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17–26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10–15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65–30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46–14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55–37.30, p < 0.01). Conclusions A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

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“…In patients experiencing DCI, positron emission tomographic cerebral perfusion patterns do not correlate with increased blood flow velocities at TCD (Minhas et al, 2003). Finally, patients with SAH may also develop ischemia and cortical band-like infarctions without any evidence of vasospasm (Rabinstein et al, 2004;Naidech et al, 2006;Lee et al, 2006;Weidauer et al, 2007Weidauer et al, , 2008.…”

Section: Introductionmentioning

confidence: 96%

“…The positive predictive value of angiography and TCD combined to predict cerebral infarction is 67% (Rabinstein et al, 2004). The location of angiographic vasospasm correlates with the location of cerebral infarction in 25% to 81% cases (Rabinstein et al, 2004(Rabinstein et al, , 2005Weidauer et al, 2007).…”

Section: Introductionmentioning

confidence: 98%

Microthrombosis after Aneurysmal Subarachnoid Hemorrhage: An Additional Explanation for Delayed Cerebral Ischemia

Vergouwen

Vermeulen

Coert

et al. 2008

J Cereb Blood Flow Metab

289

195

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Patients with aneurysmal subarachnoid hemorrhage (SAH) who experience delayed cerebral ischemia (DCI) have an increased risk of poor outcome. Delayed cerebral ischemia is considered to be caused by vasospasm. However, not all patients with DCI have vasospasm. Inversely, not all patients with vasospasm develop clinical symptoms and signs of DCI. In the past, treatments aiming at vasospasm were not successful in preventing ischemia. The purpose of this review is to give an overview of clinical data showing that DCI cannot always be attributed to vasospasm, and to present an in-depth analysis of clinical and autopsy studies on the role of microthrombosis in the pathogenesis of DCI. Clinical studies show that DCI is associated with an activation of the coagulation cascade within a few days after SAH, preceding the time window during which vasospasm occurs. Furthermore, impaired fibrinolytic activity, and inflammatory and endotheliumrelated processes, lead to the formation of microthrombi, which ultimately result in DCI. The presence of microthrombi is confirmed by autopsy studies. Insight in the pathophysiology of DCI is crucial for the development of effective therapies against this complication. Because multiple pathways are involved, future research should focus on drugs with pleiotropic effects.

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Predictors of Cerebral Infarction in Aneurysmal Subarachnoid Hemorrhage

Cited by 369 publications

References 17 publications

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

Microthrombosis after Aneurysmal Subarachnoid Hemorrhage: An Additional Explanation for Delayed Cerebral Ischemia

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