Ramon Torné1,2, Jhon Hoyos1, Laura Llull2,3, Ana Rodríguez-Hernández4, Guido Muñoz5, Ricard Mellado-Artigas5, Daniel Santana3, Leire Pedrosa2, Alberto Di Somma1, Luis San Roman6, Sergio Amaro2,3, Joaquim Enseñat1,2. 1. Neurological Surgery Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain. 2. Hospital Clinic, University of Barcelona and Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain. 3. Comprehensive Stroke Unit, Neurology Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain. 4. Neurological Surgery Department, Germans Trías i Pujol Hospital, 08916 Badalona, Spain. 5. Intensive Care Unit, Hospital Clinic of Barcelona, 08036 Barcelona, Spain. 6. Radiology Department, Angioradiology Section, Hospital Clinic of Barcelona, 08036 Barcelona, Spain.
Abstract
BACKGROUND: The level of consciousness and cerebral edema are among the indicators that best define the intensity of early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Although these indicators are usually altered in patients with a poor neurological status, their usefulness for selecting patients at risk of cerebral infarction (CI) is not well established. Furthermore, little is known about the evolution of these indicators during the first week of post-ictal events. Our study focused on describing the association of the longitudinal course of these predictors with CI occurrence in patients with severe aSAH. METHODS: Out of 265 aSAH patients admitted consecutively to the same institution, 80 patients with initial poor neurological status (WFNS 4-5) were retrospectively identified. After excluding 25 patients with early mortality, a total of 47 patients who underwent early CT (<3 days) and late CT (<7 days) acquisitions were included in the study. Early cerebral edema and delayed cerebral edema were calculated using the SEBES score, and the level of consciousness was recorded daily during the first week using the Glasgow Coma Scale (GCS). RESULTS: There was a significant improvement in the SEBES (Early-SEBES median (IQR) = 3 (2-4) versus Delayed-SEBES = 2 (1-3); p = 0.001) and in GCS scores (B = 0.32; 95% CI 0.15-0.49; p = 0.001) during the first week. When comparing the ROC curves of Delayed-SEBES vs Early-SEBES as predictors of CI, no significant differences were found (Early-SEBES Area Under the Curve: 0.65; Delayed-SEBES: 0.62; p = 0.17). Additionally, no differences were observed in the relationship between the improvement in the GCS across the first week and the occurrence of CI (p = 0.536). CONCLUSIONS: Edema and consciousness level improvement did not seem to be associated with the occurrence of CI in a surviving cohort of patients with severe aSAH. Our results suggest that intensive monitoring should not be reduced in patients with a poor neurological status regardless of an improvement in cerebral edema and level of consciousness during the first week after bleeding.
BACKGROUND: The level of consciousness and cerebral edema are among the indicators that best define the intensity of early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Although these indicators are usually altered in patients with a poor neurological status, their usefulness for selecting patients at risk of cerebral infarction (CI) is not well established. Furthermore, little is known about the evolution of these indicators during the first week of post-ictal events. Our study focused on describing the association of the longitudinal course of these predictors with CI occurrence in patients with severe aSAH. METHODS: Out of 265 aSAH patients admitted consecutively to the same institution, 80 patients with initial poor neurological status (WFNS 4-5) were retrospectively identified. After excluding 25 patients with early mortality, a total of 47 patients who underwent early CT (<3 days) and late CT (<7 days) acquisitions were included in the study. Early cerebral edema and delayed cerebral edema were calculated using the SEBES score, and the level of consciousness was recorded daily during the first week using the Glasgow Coma Scale (GCS). RESULTS: There was a significant improvement in the SEBES (Early-SEBES median (IQR) = 3 (2-4) versus Delayed-SEBES = 2 (1-3); p = 0.001) and in GCS scores (B = 0.32; 95% CI 0.15-0.49; p = 0.001) during the first week. When comparing the ROC curves of Delayed-SEBES vs Early-SEBES as predictors of CI, no significant differences were found (Early-SEBES Area Under the Curve: 0.65; Delayed-SEBES: 0.62; p = 0.17). Additionally, no differences were observed in the relationship between the improvement in the GCS across the first week and the occurrence of CI (p = 0.536). CONCLUSIONS:Edema and consciousness level improvement did not seem to be associated with the occurrence of CI in a surviving cohort of patients with severe aSAH. Our results suggest that intensive monitoring should not be reduced in patients with a poor neurological status regardless of an improvement in cerebral edema and level of consciousness during the first week after bleeding.
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