Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

Hubert Lee; Jeffrey J Perry; Shane W English; Fahad Alkherayf; Joanne Joseph; Steven Nobile; Linghong Linda Zhou; Howard Lesiuk; Richard Moulton; Charles Agbi; John Sinclair; Dar Dowlatshahi

doi:10.3171/2018.1.JNS172715

Clinical prediction of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage

J Neurosurg. 2018 Jun 1:1-8. doi: 10.3171/2018.1.JNS172715. Online ahead of print.

Authors

Affiliations

¹ 1Division of Neurosurgery, The Ottawa Hospital, Ottawa.
² 2Department of Emergency Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa.
³ 3Department of Critical Care, The Ottawa Hospital, Ottawa.
⁴ 4Faculty of Medicine, University of Ottawa; and.
⁵ 5Division of Neurology, The Ottawa Hospital, Ottawa, Ontario, Canada.

PMID: 29882700
DOI: 10.3171/2018.1.JNS172715

Abstract

OBJECTIVEThe aim of this study was to derive a clinically applicable decision rule using clinical, radiological, and laboratory data to predict the development of delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients.METHODSPatients presenting over a consecutive 9-year period with subarachnoid hemorrhage (SAH) and at least 1 angiographically evident aneurysm were included. Variables significantly associated with DCI in univariate analysis underwent multivariable logistic regression. Using the beta coefficients, points were assigned to each predictor to establish a scoring system with estimated risks. DCI was defined as neurological deterioration attributable to arterial narrowing detected by transcranial Doppler ultrasonography, CT angiography, MR angiography, or catheter angiography, after exclusion of competing diagnoses.RESULTSOf 463 patients, 58% experienced angiographic vasospasm with an overall DCI incidence of 21%. Age, modified Fisher grade, and ruptured aneurysm location were significantly associated with DCI. This combination of predictors had a greater area under the receiver operating characteristic curve than the modified Fisher grade alone (0.73 [95% CI 0.67-0.78] vs 0.66 [95% CI 0.60-0.71]). Patients 70 years or older with modified Fisher grade 0 or 1 SAH and a posterior circulation aneurysm had the lowest risk of DCI at 1.2% (0 points). The highest estimated risk was 38% (17 points) in patients 40-59 years old with modified Fisher grade 4 SAH following rupture of an anterior circulation aneurysm.CONCLUSIONSAmong patients presenting with aSAH, this score-based clinical prediction tool exhibits increased accuracy over the modified Fisher grade alone and may serve as a useful tool to individualize DCI risk.

Keywords: CBF = cerebral blood flow; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; EVD = external ventricular drainage; IVH = intraventricular hemorrhage; ROC = receiver operating characteristic; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler; WFNS = World Federation of Neurosurgical Societies; aSAH = aneurysmal SAH; aneurysm; clinical decision rule; delayed cerebral ischemia; prediction; subarachnoid hemorrhage; vascular disorders; vasospasm.