Procalcitonin in the context of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage

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  • 1 Departments of Neurosurgery and
  • | 2 Intensive Care and Intermediate Care, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; and
  • | 3 Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège, Belgium
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OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) initiates a deleterious cascade activating multiple inflammatory processes, which can contribute to delayed cerebral ischemia (DCI). Procalcitonin (PCT) is an established marker for sepsis treatment monitoring, and its time course in the context of DCI after aSAH remains unclear. The aim of this trial was to assess the predictive and confirmative value of PCT levels in the context of DCI.

METHODS

All patients admitted to the authors’ institution with aSAH between 2014 and 2018 were prospectively screened for eligibility. Daily PCT levels were recorded alongside relevant aSAH characteristics. The predictive and confirmative values of PCT levels were assessed using a receiver operating characteristic and area under the curve (AUC) analysis. The course of PCT levels around the DCI event was evaluated in an infection-free subgroup of patients.

RESULTS

A total of 132 patients with aSAH were included. Early PCT levels (first 3 days post-aSAH) had a low predictive value for the development of DCI (AUC 0.661, standard error [SE] 0.050; p = 0.003) and unfavorable long-term outcome (i.e., Glasgow Outcome Scale–Extended scores 1–4; AUC 0.674, SE 0.054; p = 0.003). In a subgroup analysis of infection-free patients (n = 72), PCT levels were higher in patients developing DCI (p = 0.001) and DCI-related cerebral infarction (p = 0.002). PCT concentrations increased gradually after DCI and decreased with successful intervention. In refractory cases progressing to cerebral infarction, PCT levels showed a secondary increase.

CONCLUSIONS

Early higher PCT levels were associated with the later development of DCI and unfavorable outcome. Analysis of PCT beyond the first couple of days after hemorrhage is hampered by nosocomial infections. In infection-free patients, however, PCT levels rise during DCI and an additional increase develops in patients developing cerebral infarction.

Clinical trial registration no.: NCT02142166 (clinicaltrials.gov)

ABBREVIATIONS

aSAH = aneurysmal subarachnoid hemorrhage; AUC = area under the curve; CRP = C-reactive protein; DCI = delayed cerebral ischemia; EBI = early brain injury; GOSE = Glasgow Outcome Scale–Extended; HH = Hunt and Hess; IL = interleukin; noDCI = subgroup of aSAH patients without DCI; PCT = procalcitonin; ROC = receiver operating characteristic; SE = standard error; SIRS = systemic inflammatory response syndrome; UTI = urinary tract infection.

Supplementary Materials

    • Supplementary Table 1 (PDF 447 KB)
Illustrations from Marx and Schroeder (pp 318–326). Copyright Henry W. S. Schroeder. Published with permission.

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Contributor Notes

Correspondence Walid Albanna: RWTH Aachen University Hospital, Aachen, Germany. walbanna@ukaachen.de.

INCLUDE WHEN CITING Published online September 4, 2020; DOI: 10.3171/2020.5.JNS201337.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

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