Article
Complication rates of rescue therapies for delayed cerebral ischemia after aneurysmal subarachnoid haemorrhage
Komplikationsrate von Rescue Therapiestrategien bei verzögerter zerberaler Ischämie nach aneurysmatischer Subarachnoidalblutung
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Authors
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MIlad Neyazi
- Universitätsklinikum Mannheim, Klinik für Neurochirurgie, Mannheim, Deutschland
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Amr Abdulazim
- Universitätsklinikum Mannheim, Klinik für Neurochirurgie, Mannheim, Deutschland
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Katharina Hackenberg
- Universitätsklinikum Mannheim, Klinik für Neurochirurgie, Mannheim, Deutschland
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Eva Neumaier-Probst
- Universitätsklinikum Mannheim, Abteilung für Neuroradiologie, Mannheim, Deutschland
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Christoph Groden
- Universitätsklinikum Mannheim, Abteilung für Neuroradiologie, Mannheim, Deutschland
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Daniel Hänggi
- Universitätsklinikum Mannheim, Klinik für Neurochirurgie, Mannheim, Deutschland
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Nima Etminan
- Universitätsklinikum Mannheim, Klinik für Neurochirurgie, Mannheim, Deutschland
| Published: | June 26, 2020 |
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Outline
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Objective: The appropriate management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (SAH) remains controversial, especially in view of increasing data on extracranial complications of DCI treatment. We recently described the efficacy of a standardized protocol for detection and treatment of DCI. However, the risk benefit ratio of such standardized protocols, especially with respect to extracranial complications remains uncertain. Here, we investigated specific complications of rescue therapy for DCI after SAH.
Methods: A prospective cohort (I) of 158 consecutive SAH patients admitted to our department between January 2016 and July 2018 was managed according to a standardized, escalating treatment protocol comprising serial perfusion-CT imaging, induced hypertension and intra-arterial vasodilator therapy in high-grade SAH patients with refractory DCI. This group was compared to a historical cohort II (144 patients, from January 2012 to August 2014) where continuous intra-arterial nimodipine catheters were facilitated in patients with any angiographic vasospasm. The two cohorts were compared with respect to treatment-associated extracranial complication rates, including pulmonary and cardiac dysfunction, gastrointestinal ischemia, renal failure as well as thromboembolic complications. Further, the rates of DCI-treatment associated complications were evaluated.
Results: Despite generally comparable baseline characteristics, cohort I had a higher proportion of Fisher grade III/IV SAH, compared to cohort II (79.7% vs. 59.4%; p < 0.01) and thereby a higher risk for DCI. The overall incidence of clinical DCI in cohort I was significantly higher compared to cohort II (44.3% vs. 31.5%; p < 0.05) whereas the incidence of angiographic vasospasm was comparable (42.4% vs. 48.3%). In cohort I, 98.4% of patients with confirmed DCI received induced hypertension, 46.8% intraarterial nimodipine bolus application, and 11.1% a continuous nimodipine catheter compared to 6.7%, 4.4%, and 84.4% in cohort II. The overall treatment associated complication rates between the two cohorts was comparable (32.8% vs. 52.1%, p = 0.076). However, DCI-treatment associated complication rates were significantly lower in cohort I (4.1% vs. 60.7%, p < 0.01).
Conclusion: Our data highlight that the DCI-treatment associated complication rates may be significantly reduced with the use of standardized protocols for escalating rescue therapy, whereas the incidence of extracranial complications seems comparable.
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