Increased risk of delayed cerebral ischemia in subarachnoid hemorrhage patients with additional intracerebral hematoma

J Neurosurg. 2017 Feb;126(2):504-510. doi: 10.3171/2015.12.JNS151563. Epub 2016 Mar 11.


OBJECTIVE Delayed cerebral ischemia (DCI) has a major impact on the outcome of patients suffering from aneurysmal subarachnoid hemorrhage (SAH). The aim of this study was to assess the influence of an additional intracerebral hematoma (ICH) on the occurrence of DCI. METHODS The authors conducted a single-center retrospective analysis of cases of SAH involving patients treated between 2006 and 2011. Patients who died or were transferred to another institution within 10 days after SAH without the occurrence of DCI were excluded from the analysis. RESULTS Additional ICH was present in 123 (24.4%) of 504 included patients (66.7% female). ICH was classified as frontal in 72 patients, temporal in 24, and perisylvian in 27. DCI occurred in 183 patients (36.3%). A total of 59 (32.2%) of these 183 patients presented with additional ICH, compared with 64 (19.9%) of the 321 without DCI (p = 0.002). In addition, DCI was detected significantly more frequently in patients with higher World Federation of Neurosurgical Societies (WFNS) grades. The authors compared the original and modified Fisher Scales with respect to the occurrence of DCI. The modified Fisher Scale (mFS) was superior to the original Fisher Scale (oFS) in predicting DCI. Furthermore, they suggest a new classification based on the mFS, which demonstrates the impact of additional ICH on the occurrence of DCI. After the different scales were corrected for age, sex, WFNS score, and aneurysm site, the oFS no longer was predictive for the occurrence of DCI, while the new scale demonstrated a superior capacity for prediction as compared with the mFS. CONCLUSIONS Additional ICH was associated with an increased risk of DCI in this study. Furthermore, adding the presence or absence of ICH to the mFS improved the identification of patients at the highest risk for the development of DCI. Thus, a simple adjustment of the mFS might help to identify patients at high risk for DCI.

Keywords: ACoA = anterior communicating artery; CVS = cerebral vasospasm; DCI = delayed cerebral ischemia; ICA = internal carotid artery; ICH = intracerebral hematoma; ICP = intracranial pressure; IVH = intraventricular hemorrhage; MCA = middle cerebral artery; PCoA = posterior communicating artery; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler ultrasound; WFNS = World Federation of Neurosurgical Societies; aneurysm treatment; aneurysmal subarachnoid hemorrhage; delayed cerebral ischemia; intracerebral hematoma; mFS = modified Fisher Scale; oFS = original Fisher Scale; vascular disorders.

MeSH terms

  • Adult
  • Aged
  • Brain Ischemia / diagnostic imaging
  • Brain Ischemia / etiology*
  • Cerebral Hemorrhage / complications*
  • Cerebral Hemorrhage / diagnostic imaging
  • Female
  • Hematoma / complications*
  • Hematoma / diagnostic imaging
  • Humans
  • Male
  • Middle Aged
  • Retrospective Studies
  • Risk Factors
  • Subarachnoid Hemorrhage / complications*
  • Subarachnoid Hemorrhage / diagnostic imaging