Key result
Early onset of delayed cerebral ischemia (< day 7) yielded comparable rates of favorable functional outcome at 12 months to late onset (41.1% vs. 37.3%, p=0.987), despite higher DCI-related mortality.
Why the study?
The classical description of risk for delayed cerebral ischemia over time relies on the outdated concept of angiographic vasospasm rather than extended clinical and radiological criteria.
What is the temporal risk profile of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, and how does the timing of DCI onset affect clinical outcomes?
Cohort (n=341)
No
What is the temporal risk profile of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage, and how does the timing of DCI onset affect clinical outcomes?
Absolute Event Rate: 41.1% vs 37.3%
p-value: p=0.987
The risk of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage follows a bimodal temporal distribution, with early onset (< day 7) predicting worse clinical outcomes and higher mortality.
Early DCI onset yields comparable 12-month outcomes despite higher mortality; leaves open timing-specific interventions in aneurysmal subarachnoid hemorrhage.
BACKGROUND: Delayed cerebral ischemia (DCI) is one of the main determinants of clinical outcome after aneurysmal subarachnoid hemorrhage (SAH). The classical description of risk for DCI over time is currently based on the outdated concept of angiographic vasospasm. The goal of this study was to assess the temporal risk profile of DCI, defined by extended clinical and radiological criteria, as well as the impact the time point of DCI onset has on clinical outcome. METHODS: All patients with aneurysmal SAH referred to a single tertiary care center between 2010 and 2018 were considered for inclusion. This study was designed as a retrospective cohort analysis and data were extracted from existing patient files. In conscious patients, DCI was diagnosed clinically, and in unconscious patients, diagnosis was based on perfusion computed tomography imaging and multimodal neuromonitoring. Extended Glasgow Outcome Scale scores were assessed after 12 months and compared between patients with early (< day 7) and late (≥ day 7) DCI onset. RESULTS: The median delay from day of the hemorrhage (day 0) until detection of the first DCI event was 7.0 days, with an interquartile range of 5 days. The probability of DCI development over time demonstrated a bimodal distribution with a peak risk on day 5 (0.084; confidence interval 0.05.5-0.122) and a second peak on day 9 (0.077; confidence interval 0.045-0.120). A total of 27 patients (15.6%) suffered dominant hemispheric or severe bilateral DCI-related infarctions, resulting in the withdrawal of technical life support. Of those, the majority (20 patients, 22.2%) presented with early DCI onset (vs. late onset: 7 patients, 8.4%; p = 0.013). CONCLUSIONS: The risk profile of DCI over time mirrors the description of angiographic vasospasm; however, it comes with an added timely delay of 1 to 2 days. Early occurrence of DCI (before day 7) is associated with a higher infarct load and DCI-related mortality. Although the exact causal relationship remains to be determined, the time point of DCI onset may serve as an independent prognostic criterion in decision-making.
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Schmidt et al. (2022) conducted a cohort in Aneurysmal subarachnoid hemorrhage (n=341). Early onset of delayed cerebral ischemia (< day 7) vs. Late onset of delayed cerebral ischemia (≥ day 7) was evaluated on Favorable functional outcome (Extended Glasgow Outcome Scale scores 5-8) at 12 months (p=0.987). Early onset of delayed cerebral ischemia (< day 7) yielded comparable rates of favorable functional outcome at 12 months to late onset (41.1% vs. 37.3%, p=0.987), despite higher DCI-related mortality.
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