Lu Victor M, Graffeo Christopher S, Perry Avital, Carlstrom Lucas P, Rangel-Castilla Leonardo, Lanzino Giuseppe, Brinjikji Waleed, Wijdicks Eelco F M, Rabinstein Alejandro A
Departments of1Neurologic Surgery.
2Radiology, and.
J Neurosurg. 2019 Jul 19;133(2):360-368. doi: 10.3171/2019.4.JNS19779. Print 2020 Aug 1.
Delayed cerebral ischemia (DCI) and aneurysm rebleeding contribute to morbidity and mortality in aneurysmal subarachnoid hemorrhage (aSAH); however, the relationship between their impacts on overall functional outcome is incompletely understood.
The authors conducted a cohort study of all aSAH during the study period from 2001 to 2016. Primary end points were overall functional outcome and ischemic aSAH sequelae, defined as delayed cerebral ischemia (DCI), DCI with infarction, symptomatic vasospasm (SV), and global cerebral edema (GCE). Outcomes were compared between the rebleed and nonrebleed cohorts overall and after propensity-score matching (PSM) for risk factors and treatment modality. Univariate and multivariate ordered logistic regression analyses for functional outcomes were performed in the PSM cohort to identify predictors of poor outcome.
Four hundred fifty-five aSAH cases admitted within 24 hours of aneurysm rupture were included, of which 411 (90%) experienced initial aneurysm ruptures only, while 44 (10%) had clinically confirmed rebleeding. In the overall cohort, rebleeding was associated with significantly worse functional outcome, longer intensive care unit length of stay (LOS), and GCE (all p < 0.01); treatment modality, overall LOS, DCI, DCI with infarction, and SV were nonsignificant. In the PSM analysis of 43 matched rebleed and 43 matched nonrebleed cases, only poor functional outcome and GCE remained significantly associated with rebleeding (p < 0.01 and p = 0.02, respectively). Multivariate regression identified that both rebleeding (HR 21.5, p < 0.01) and DCI (HR 10.1, p = 0.01) independently predicted poor functional outcome.
Rebleeding and DCI after aSAH are highly morbid and potentially deadly events after aSAH, which appear to have independent negative impacts on overall functional outcome. Early rebleeding did not significantly affect the risk of delayed ischemic complications.
迟发性脑缺血（DCI）和动脉瘤再出血是导致动脉瘤性蛛网膜下腔出血（aSAH）患者发病和死亡的原因；然而，它们对整体功能结局的影响之间的关系尚未完全明确。
作者对2001年至2016年研究期间的所有aSAH患者进行了一项队列研究。主要终点是整体功能结局和缺血性aSAH后遗症，定义为迟发性脑缺血（DCI）、伴梗死的DCI、症状性血管痉挛（SV）和全脑水肿（GCE）。对再出血组和非再出血组的总体结局以及根据危险因素和治疗方式进行倾向评分匹配（PSM）后的结局进行比较。在PSM队列中对功能结局进行单变量和多变量有序逻辑回归分析，以确定不良结局的预测因素。
纳入了455例在动脉瘤破裂后24小时内入院的aSAH病例，其中411例（90%）仅经历了初次动脉瘤破裂，而44例（10%）有临床确诊的再出血。在总体队列中，再出血与明显更差的功能结局、更长的重症监护病房住院时间（LOS）和GCE相关（所有p<0.01）；治疗方式、总体LOS、DCI、伴梗死的DCI和SV无显著差异。在对43例匹配的再出血病例和43例匹配的非再出血病例进行的PSM分析中，只有不良功能结局和GCE仍与再出血显著相关（分别为p<0.01和p = 0.02）。多变量回归确定，再出血（HR 21.5，p<0.01）和DCI（HR 10.1，p = 0.01）均独立预测不良功能结局。
aSAH后的再出血和DCI是aSAH后高发病率和潜在致命性的事件，似乎对整体功能结局有独立的负面影响。早期再出血并未显著影响迟发性缺血性并发症的风险。
