Department of Neurology, Columbia University Medical Center, New York, New York.
Department of Neurosurgery, Columbia University Medical Center, New York, New York.
Neurosurgery. 2019 Feb 1;84(2):397-403. doi: 10.1093/neuros/nyy045.
Immune dysregulation has long been implicated in the development of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH).
To determine the relationship of inflammatory cell biomarkers with DCI.
We evaluated 849 aSAH patients who were enrolled into a prospective observational cohort study and had a white blood cell (WBC) differential obtained within 72 h of bleed onset.
WBC count > 12.1 × 109/L (odds ratio 4.6; 95% confidence interval [CI]: 1.9-11, P < 0.001) was the strongest Complete Blood Count (CBC) predictor of DCI after controlling for clinical grade (P < .001), thickness of SAH blood on admission computed tomography (P = .002), and clipping aneurysm repair (P < .001). A significant interaction between clinical grade and WBC count (odds ratio 0.8, 95% CI: 0.6-1.0, P = .02) revealed that good-grade patients with elevated WBC counts (49%: 273/558) had increased odds for DCI indistinguishable from poor-grade patients. Multivariable Cox regression also showed that elevated WBC counts in good-grade patients increased the hazard for DCI to that of poor-grade patients (hazard ratio 2.1, 95% CI 1.3-3.2, P < .001). Receiver operating characteristic curve analysis of good-grade patients revealed that WBC count (area under the curve [AUC]: 0.63) is a stronger DCI predictor than the modified Fisher score (AUC: 0.57) and significantly improves multivariable DCI prediction models (Z = 2.0, P = .02, AUC: 0.73; PPV: 34%; NPV: 92%).
Good-grade patients with early elevations in WBC count have a similar risk and hazard for DCI as poor-grade patients. Good-grade patients without elevated WBC may be candidates to be safely downgraded from the intensive care unit, leading to cost savings for both patient families and hospitals.
免疫失调长期以来一直被认为与蛛网膜下腔出血（aSAH）后迟发性脑缺血（DCI）的发展有关。
确定炎症细胞生物标志物与 DCI 的关系。
我们评估了 849 名接受前瞻性观察队列研究的 aSAH 患者，这些患者在出血发作后 72 小时内获得了白细胞（WBC）差异。
WBC 计数> 12.1×109/L（优势比 4.6；95%置信区间[CI]：1.9-11，P < 0.001）是控制临床分级（P <.001）、入院时 CT 上蛛网膜下腔出血厚度（P =.002）和夹闭动脉瘤修复（P <.001）后 DCI 的最强全血细胞计数（CBC）预测因素。临床分级和 WBC 计数之间存在显著的交互作用（优势比 0.8，95%CI：0.6-1.0，P =.02），表明 WBC 计数升高的良好分级患者（49%：273/558）发生 DCI 的可能性与差级患者相似。多变量 Cox 回归也表明，良好分级患者的白细胞计数升高会增加 DCI 的危险，使其与差级患者相当（危险比 2.1，95%CI 1.3-3.2，P <.001）。对良好分级患者的接受者操作特征曲线分析显示，WBC 计数（曲线下面积[AUC]：0.63）是 DCI 的更强预测因子，比改良 Fisher 评分（AUC：0.57）更强，并显著改善了多变量 DCI 预测模型（Z = 2.0，P =.02，AUC：0.73；PPV：34%；NPV：92%）。
早期白细胞计数升高的良好分级患者发生 DCI 的风险和危险与差级患者相似。没有白细胞计数升高的良好分级患者可能是从重症监护病房安全降级的候选者，这将为患者家庭和医院节省成本。
