Application of Intracranial Pressure-Directed Therapy on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Abstract

Objective: Elevated ICP is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Delayed cerebral ischemia (DCI) is the most important reason for a poor clinical outcome after a subarachnoid hemorrhage. DCI is understood as a multifactorial process that evolves over time, largely caused by the sequelae of increased intracranial pressure (ICP). The study aimed to assess how to better define the association between ICP and DCI, and whether rational ICP management can improve the outcome of aSAH patients.

Methods: We prospectively reviewed patients diagnosed with aSAH and received microsurgery clipping at our department from December 2019 to January 2021. Subdural ICP monitoring devices were kept to monitor the ICP. The ICP values were recorded every 1-h epochs. ICP -guided dehydration treatments were routinely performed to control the ICP level of patients after surgery. To evaluate whether the subdural ICP-directed management improved the prognosis of the aSAH patients, we compared the outcome data of the patients in our cohort with those treated at another ward of our hospital at the same period.

Results: In total, 144 consecutive aSAH patients received microsurgery clipping at our department, 68 of whom underwent ICP monitoring. A total of 11,424 1-h ICP measurements were recorded for the included patients (1.30 years of recordings). Of 68 patients with ICP monitoring, 27 (27/68, 39.7%) patients developed DCI. Univariate analysis showed that higher Hunt-Hess grade (OR 2.138, 95% CI 1.025-4.459, p = 0.043), higher preoperative modified Rankin Scale score (OR 1.534, 95% CI 1.033-2.276, p = 0.034), and the max ICP value of each day value >28.5 mmHg (OR 4.442, 95% CI 1.509-13.082, p = 0.007) were associated with DCI. Also, patients with ICP-directed treatment showed a significantly lower DCI incidence than patients without ICP monitoring.

Conclusion: Our study suggests that I less than 15 mmHg possibly constitute normal values and that 28.5 mmHg is the ICP threshold most strongly associated with the occurrence of DCI in aSAH patients. Patients who received the ICP-directed treatment presented a lower incidence of DCI. Our findings provide a basis for the recommendation of ICP-directed treatment after aSAH.

Trial registration number: NCT04785976.

Keywords: aneurysmal subarachnoid hemorrhage; dehydration; delayed cerebral ischemia; delayed neurological deterioration; intracranial pressure.

Conflict of interest statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Copyright © 2022 Yang, Lu, Li, Lin, Chen, Han, Yan, Li, Li, Zhang, Yuan, Li, Zhang, Shi, Zhou, Wang, Zhao and Chen.

Figures

FIGURE 1

Distribution of intracranial pressure measures in studied patients. Values obtained between days 1 and 8 following microsurgery to the neurocritical care unit are reported. The most common ICP (nearest integer) measured in all patients from day 1 to 8 was 14 mmHg (8.44% of all measures). Given the robust mode demonstrated by these distributions, ICP values less than 15 mmHg may be normal.

FIGURE 2

Association of ICP values with the outcome. (A) The most common mean ICPmax over time measured in all patients from day 1 to 8 was 18 mmHg, while in patients with DCI it was 24 mmHg, and non-DCI was 16 mmHg. All groups had the peak value at about the 5th day. Patients with DCI had higher mean values than those with non-DCI. (B) Mean ICPmax values are shown for decreasing function from the Intracranial pressure threshold increasing, especially at the point of 30 mmHg. For all patients, n = 68; DCI = 27, non-DCI = 41.

FIGURE 3

ROC analysis shows the AUC of the ICPmax values for the prediction of DCI. The AUC of the ICPmax values was 0.6874. The best cutoff value was 28.5 mmHg providing sensitivity and specificity of 51.85 and 80.49%, respectively. The red dashed line between location (0,0) and (1,1) is a baseline. AUC above this line means above 0.5 and means a better outcome.

FIGURE 4

Bubble chart of ICPmax values and pre-operation status with the outcome. This Bubble chart shows that patients with higher ICPmax values and H-H grade more than two scores and older are more likely to develop DCI than those with lower Hunt-Hess grade and lower ICPmax values.