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Researchers call for new strategies to diagnose, prevent asymptomatic infarction from vasospasm in patients with poor-grade subarachnoid hemorrhage

Monday, December 15 2008 | Comments
Evidence Grade 0 What's This?
New approaches are needed to diagnose and prevent asymptomatic infarction in patients with subarachnoid hemorrhage (SAH), according to the authors of a study conducted at the Columbia University Medical Center.

The researchers noted that delayed cerebral ischemia (DCI) resulting from vasospasm contributes significantly to poor outcomes in this population and that diagnosing DCI can be especially difficult in patients with depressed levels of consciousness.

To identify the frequency, risk factors, clinical features, and impact on outcome of clinically asymptomatic infarction resulting from vasospasm after SAH, the investigators prospectively enrolled 580 patients with SAH who were admitted consecutively to their center between July 1996 and May 2002.

For their purposes, the researchers defined DCI as clinical deterioration (a new focal neurological deficit, a decrease in level of consciousness, or both) and/or a new infarct discovered by follow-up computed tomography (CT) imaging, as long as the cause was deemed to be vasospasm. They used a 7-point modified Rankin Scale (mRS; 0=full recovery and 6=death) to assess outcomes at 14 days and 3 months after the onset of SAH. A poor outcome was defined as moderate to severe disability, such as the inability to walk or tend to bodily needs, or death (mRS score of >=4).

DCI was diagnosed in 21% (n=121) of the 580 patients enrolled in the study. Of these 121 patients, 42% (n=51) developed >=1 symptomatic infarct in conjunction with neurological deterioration, 36% (n=44) experienced neurological deterioration without infarction, and 21% (n=26) developed asymptomatic infarction (a new infarct found on CT without concurrent neurological deterioration).

According to a multivariate analysis, the patients with asymptomatic DCI were more likely to be comatose (Glasgow Coma Scale score of 3-8; adjusted OR, 7.9; 95% CI, 2.0-31.6; P=.004), require placement of an external ventricular drain (adjusted OR, 3.8; 95% CI, 1.1-13.0; P=.03), and have a median SAH sum score of <=15 (adjusted OR, 0.1; 95% CI, 0.02-0.4; P=.001) relative to the patients with symptomatic DCI.

The patients with asymptomatic DCI were also less likely to be treated with vasopressors than were those with symptomatic DCI (64% vs 86%; P=.01).

After adjustments were made for clinical grade, age, and aneurysm size, significantly more of the patients with asymptomatic DCI than of those with symptomatic DCI had an mRS score of >=4 at 3 months (73% vs 40%; adjusted OR, 3.9; 95% CI, 1.3-12.0; P=.017). In addition, 46% of the patients with asymptomatic DCI had died at 3 months, compared with 20% of those with symptomatic DCI (adjusted OR, 2.5; 95% CI, 0.9-7.1; P=.07).

"Invasive neuromonitoring and other strategies directed at diagnosing and preventing asymptomatic infarction due to vasospasm in poor-grade SAH cases are needed," the authors concluded. (Schmidt JM, et al. J Neurosurg 2008;109:1052-1059.)

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