Crobeddu, Emanuela

INTRODUCTION After aneurysm treatment, patients with subarachnoid hemorrhage (SAH) are typically kept in the intensive care unit (ICU) to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at very low risk of developing this complication who could be safely transferred out of the ICU early could have a very positive financial impact. METHOD We analyzed 307 consecutive patients admitted to the intensive care unit from October 2001 to June 2011. Demographic, clinical and neuroimaging data were recorded. The relationship between these variables and absent DCI was analyzed using univariate and multivariate logistic regression models. RESULTS DCI did not develop in 169 patients (57.9%). Among factors at admission, age ≥ 68 years (p=0.0003; OR 3.16, 95% CI 1.67-6.39), WFNS I-III at presentation (p= 0.0003;OR 2.73, 95% CI 1.57-4.79), WFNS I-III at worst (p= 0.0003; OR 2.39, 95% CI 1.48-3.87), WFNS I-III post resuscitation (p= 0.0006; OR 2.85 95% 1.56-5.32), modified Fisher grade 1-2 (p= 0.0021; OR 2.43, 95% CI 1.37-4.47), absence of intracranial hematoma (p= 0.0042; OR 2.26, 95% CI 1.29-4.01), absence of intraventricular hematoma (p=0.045; OR 1.61, 95% CI 1.01-2.58), absence of cerebrospinal fluid diversion (p= 0.0002; OR 2.54, 95% CI 1.56-4.20) and aneurysm in the posterior circulation (p=0.0253; OR 1.74, 95% CI 1.07-2.87) were associated with absence of DCI. On multivariate analysis, a model including age ≥ 68 years (p= 0.0003; OR 3.23, 95% CI 1.68-6.62), WFNS at presentation I-III (p= 0.0092; OR 2.18, 95% CI 1.21-3.99) and modified Fisher grade 1-2 (p=0.02; OR 2.04, 95% CI 1.11-3.89) was independently uniformly predictive of the absence of DCI (specificity and positive predictive value of 100%; p<0.0001). CONCLUSION We propose a new model that can reliably identify a group of patients with aneurysmal SAH who have very low risk of developing DCI. These patients could be candidates for early transfer to the general ward after treatment of the ruptured aneurysm.

OBJECT Vasopressor-induced hypertension (VIH) is an established treatment for patients with aneurysmal subarachnoid hemorrhage (SAH) who develop vasospasm and delayed cerebral ischemia (DCI). However, the safety of VIH in patients with coincident, unruptured, unprotected intracranial aneurysms is uncertain. METHODS This retrospective multiinstitutional study identified 1) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who required VIH therapy (VIH group), and 2) patients with aneurysmal SAH and 1 or more unruptured, unprotected aneurysms who did not require VIH therapy (non-VIH group). All patients had previously undergone surgical or endovascular treatment for the presumed ruptured aneurysm. Comparisons between the VIH and non-VIH patients were made in terms of the patient characteristics, clinical and radiographic severity of SAH, total number of aneurysms, number of ruptured/unruptured aneurysms, aneurysm location/size, number of unruptured and unprotected aneurysms during VIH, severity of vasospasm, degree of hypervolemia, and degree and duration of VIH therapy. RESULTS For the VIH group (n = 176), 484 aneurysms were diagnosed, 231 aneurysms were treated, and 253 unruptured aneurysms were left unprotected during 1293 total days of VIH therapy (5.12 total years of VIH therapy for unruptured, unprotected aneurysms). For the non-VIH group (n = 73), 207 aneurysms were diagnosed, 93 aneurysms were treated, and 114 unruptured aneurysms were left unprotected. For the VIH and non-VIH groups, the mean sizes of the ruptured (7.2 ± 0.3 vs 7.8 ± 0.6 mm, respectively; p = 0.27) and unruptured (3.4 ± 0.2 vs 3.2 ± 0.2 mm, respectively; p = 0.40) aneurysms did not differ. The authors observed 1 new SAH from a previously unruptured, unprotected aneurysm in each group (1 of 176 vs 1 of 73 patients; p = 0.50). Baseline patient characteristics and comorbidities were similar between groups. While the degree of hypervolemia was similar between the VIH and non-VIH patients (fluid balance over the first 10 days of therapy: 3146.2 ± 296.4 vs 2910.5 ± 450.7 ml, respectively; p = 0.67), VIH resulted in a significant increase in mean arterial pressure (mean increase over the first 10 days of therapy relative to baseline: 125.1% ± 1.0% vs 98.2% ± 1.2%, respectively; p < 0.01) and systolic blood pressure (125.6% ± 1.1% vs. 104.1% ± 5.2%, respectively; p < 0.01). CONCLUSIONS For small, unruptured, unprotected intracranial aneurysms in SAH patients, the frequency of aneurysm rupture during VIH therapy is rare. The authors do not recommend withholding VIH therapy from these patients.

Background and Purpose— Patients with aneurysmal subarachnoid hemorrhage are typically kept in the intensive care unit to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at lower risk for DCI could have a positive financial impact by allowing earlier transfer from the intensive care unit. Methods— We analyzed 307 consecutive patients admitted to the intensive care unit. Demographic, clinical, and neuroimaging data were recorded. The relationship with absent DCI was analyzed using univariate and multivariate logistic regression models. Results— DCI did not develop in 169 patients (57.9%). Among factors at admission, age 68 years or older ( P =0.0003; OR, 3.16; 95% CI, 1.66–6.39), World Federation of Neurological Surgeons (WFNS) I to III at presentation ( P =0.0003; OR, 2.73; 95% CI, 1.57–4.79), WFNS I to III at worst ( P =0.0003; OR, 2.39; 95% CI, 1.48–3.87), WFNS I to III after resuscitation ( P =0.0006; OR, 2.85; 95% CI, 1.56–5.32), modified Fisher grade 1 to 2 ( P =0.0021; OR, 2.43; 95% CI, 1.37–4.47), absence of intracranial hematoma ( P =0.0042; OR, 2.26; 95% CI, 1.29–4.01), and aneurysm in the posterior circulation ( P =0.025; OR, 1.74; 95% CI, 1.07–2.87) were associated with absence of DCI. On multivariate analysis, a model including age 68 years or older, WFNS I to III at presentation and a modified Fisher grade 1 to 2 were independently predictive of the absence of DCI, with a specificity of 100% and a positive predictive value of 100%. Conclusions— We propose a new model that can reliably identify patients with aneurysmal subarachnoid hemorrhage who are at very low risk for DCI. These patients could be candidates for early transfer to the general ward.