Invasive neuromonitoring with an extended definition of delayed cerebral ischemia is associated with improved outcome after poor-grade subarachnoid hemorrhage

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  • 1 Departments of Neurosurgery,
  • 2 Intensive Care Medicine, and
  • 3 Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
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OBJECTIVE

The current definition of delayed cerebral ischemia (DCI) is based on clinical characteristics precluding its use in patients with poor-grade subarachnoid hemorrhage (SAH). Additional concepts to evaluate the unconscious patient are required. Invasive neuromonitoring (INM) may allow timely detection of metabolic and oxygenation crises before irreversible damage has occurred.

METHODS

The authors present a cohort analysis of all consecutive SAH patients referred to a single tertiary care center between 2010 and 2018. The cohort (n = 190) was split into two groups: one before (n = 96) and one after (n = 94) the introduction of INM in 2014. A total of 55 poor-grade SAH patients were prospectively monitored using parenchymal oxygen saturation measurement and cerebral microdialysis. The primary outcome was the Glasgow Outcome Scale–Extended (GOSE) score after 12 months.

RESULTS

With neuromonitoring, the first DCI event was detected earlier (mean 2.2 days, p = 0.002). The overall rate of DCI-related infarctions decreased significantly (from 44.8% to 22.3%; p = 0.001) after the introduction of invasive monitoring. After 12 months, a higher rate of favorable outcome was observed in the post-INM group, compared to the pre-INM group (53.8% vs 39.8%), with a significant difference in the GOSE score distribution (OR 4.86, 95% CI −1.17 to −0.07, p = 0.028).

CONCLUSIONS

In this cohort analysis of poor-grade SAH patients, the introduction of INM and the extension of the classic DCI definition toward a functional dimension resulted in an earlier detection and treatment of DCI events. This led to an overall decrease in DCI-related infarctions and an improvement in outcome.

ABBREVIATIONS CLINA = continuous local intraarterial nimodipine application; CMD = cerebral microdialysis; DCI = delayed cerebral ischemia; GOSE = Glasgow Outcome Scale–Extended; H&H = Hunt and Hess; iHTN = induced euvolemic arterial hypertension; INM = invasive neuromonitoring; ptiO2 = brain tissue oxygenation; SAH = subarachnoid hemorrhage.

Supplementary Materials

    • Supplementary Tables 1 and 2 (PDF 466 KB)

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Contributor Notes

Correspondence Michael Veldeman: RWTH Aachen University, Aachen, Germany. mveldeman@ukaachen.de.

INCLUDE WHEN CITING Published online May 15, 2020; DOI: 10.3171/2020.3.JNS20375.

Disclosures Dr. Wiesmann is a consultant for Stryker Neurovascular. He receives honoraria from Braco Imaging, Medtronic, Penumbra, Siemens Healthcare, and Stryker Neurovascular. He receives support of non–study-related clinical or research efforts that he oversees from the following: Abbott, ab medica, Acandis, Asahi Intecc, Bayer, Bracco Imaging, B. Braun, Cerenovus, Codman Neurovascular, Dahlhausen, Kaneka Pharmaceuticals, Medtronic, Mentice AB, MicroVention, Penumbra, Phenox, Philips Healthcare, Route 92, Siemens Healthcare, SilkRoad Medical, St. Jude, and Stryker Neurovascular.

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