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. 2022 Nov;164(11):2917-2926.
doi: 10.1007/s00701-022-05347-y. Epub 2022 Aug 25.

Multidisciplinary and standardized management of patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Amr Abdulazim  1 , Carla Küppers  2 , Katharina A M Hackenberg  2 , Eva Neumaier-Probst  3 , Mohamad Mansour Alzghloul  3 , Jörg Krebs  4 , Manfred Thiel  4 , Hester Lingsma  5 , Gabriel J E Rinkel  2 , Christoph Groden  3 , Nima Etminan  2
Affiliations

Multidisciplinary and standardized management of patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

Amr Abdulazim et al. Acta Neurochir (Wien). 2022 Nov.

Abstract

Background: The appropriate management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains uncertain. We aimed to evaluate the effect of implementing a standardized protocol for detection and management of DCI after aSAH on cerebral infarction and functional outcome.

Methods: We studied two cohorts of aSAH patients, one before (pre-implementation cohort: January 2012 to August 2014) and one after (post-implementation cohort: January 2016 to July 2018) implementation of a multidisciplinary approach, with standardized neurological and radiological assessment and risk-based medical treatment of DCI. We assessed the presence of new hypodensities on CT within 6 weeks after aSAH and categorized cerebral infarction into overall and DCI-related infarctions (hypodensities not within 48 h after IA repair and not attributable to aneurysm occlusion or intraparenchymal hematoma). Functional outcome was assessed at 3 months using the extended Glasgow outcome scale (eGOS), dichotomized into unfavorable (eGOS: 1-5) and favorable (eGOS: 6-8). We calculated odds ratios (OR) with corresponding 95% confidence intervals (CI's), and adjusted for age, WFNS grade, Fisher score, and treatment modality (aOR).

Results: In the post-implementation (n = 158) versus the pre-implementation (n = 143) cohort the rates for overall cerebral infarction were 29.1% vs 46.9% (aOR: 0.41 [0.24-0.69]), for DCI-related cerebral infarction 17.7% vs. 31.5% (aOR: 0.41 [0.23-0.76]), and for unfavorable functional outcome at 3 months 37.3% vs. 53.8% (aOR: 0.30 [0.17-0.54]). For patients with DCI, the rates for unfavorable functional outcomes at 3 months in the post-implementation versus the pre-implementation cohort were 42.3% vs. 77.8% (aOR: 0.1 [0.03-0.27]).

Conclusions: A multidisciplinary approach with more frequent and standardized neurological assessment, standardized CT and CT perfusion monitoring, as well as tailored application of induced hypertension and invasive rescue therapy strategies, is associated with a significant reduction of cerebral infarction and unfavorable functional outcome after aneurysmal aSAH.

Keywords: Delayed cerebral ischemia; Intra-arterial treatment; Perfusion CT; Subarachnoid hemorrhage; Vasospasm.

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Conflict of interest statement

The authors declare no competing interests.

Figures

Fig. 1
Fig. 1
Clinical and radiological DCI monitoring and screening protocol. Abbreviations: CCT, cranial computed tomography; CTA, CT-angiography; DSA, digital subtraction angiography; i.a., intra-arterial; MTT, mean transit time; Neuro exam, neurological examination every 2 h; PCT, CT perfusion; SAH, subarachnoid hemorrhage
Fig. 2
Fig. 2
Algorithms for the management of patients with DCI. A DCI management algorithm in the pre-implementation cohort. B Escalating treatment protocol for patients with DCI in the post-implementation cohort. Abbreviations: CCT, cranial computed tomography; DSA, digital subtraction angiography; i.a., intra-arterial; MTT, mean transit time; PCT, perfusion computed tomography
Fig. 3
Fig. 3
Stacked histograms of overall and DCI-related cerebral infarction. A Overall cerebral infarction rates after 6 weeks between the pre- and post-implementation cohorts. B DCI-related cerebral infarction rates after 6 weeks between the pre- and post-implementation cohorts. **P < 0.01
Fig. 4
Fig. 4
Stacked histograms of functional outcome. A Overall functional outcome at 3 months. B Functional outcome in patients with DCI at 3 months. Distribution of scores according to the extended Glasgow Outcome Scale between the pre-implementation cohort (January 2012–August 2014) and the post-implementation cohort (January 2016– July 2018) for patients with DCI. Abbreviations: eGOS, extended Glasgow Outcome Scale. *P < 0.05; **P < 0.01
Fig. 5
Fig. 5
Effect of standardization on radiological and functional outcome. Abbreviations: OR, odds ratio; 95% CI, 95% confidence interval; DCI, delayed cerebral ischemia; eGOS, extended Glasgow Outcome Scale. Pre-implementation cohort as reference. Adjustment for age, WFNS, Fisher, and treatment modality
Fig. 6
Fig. 6
Effect of increased monitoring with CT perfusion. Abbreviations: OR, odds ratio; 95% CI, 95% confidence interval; DCI, delayed cerebral ischemia; eGOS, extended Glasgow Outcome Scale. Pre-implementation cohort as reference. Adjustment for age, WFNS, Fisher, and treatment modality
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