Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands.
Neurocrit Care. 2021 Aug;35(1):172-183. doi: 10.1007/s12028-020-01169-x. Epub 2020 Dec 10.
Good-grade aneurysmal subarachnoid hemorrhage (Hunt and Hess 1-2) is generally associated with a favorable prognosis. Nonetheless, patients may still experience secondary deterioration due to delayed cerebral ischemia (DCI), contributing to poor outcome. In those patients, neurological assessment is challenging and invasive neuromonitoring (INM) may help guide DCI treatment.
An observational analysis of 135 good-grade SAH patients referred to a single tertiary care center between 2010 and 2018 was performed. In total, 54 good-grade SAH patients with secondary deterioration evading further neurological assessment, were prospectively enrolled for this analysis. The cohort was separated into two groups: before and after introduction of INM in 2014 (pre-INM: n = 28; post-INM: n = 26). INM included either parenchymal oxygen saturation measurement (pO), cerebral microdialysis or both. Episodes of DCI (pO < 10 mmHg or lactate/pyruvate > 40) were treated via induced hypertension or in refractory cases by endovascular means. The primary outcome was defined as the extended Glasgow outcome scale after 12 months. In addition, we recorded the amount of imaging studies performed and the occurrence of silent and overall DCI-related infarction.
Secondary deterioration, impeding neurological assessment, occurred in 54 (40.0%) of all good-grade SAH patients. In those patients, a comparable rate of favorable outcome at 12 months was observed before and after the introduction of INM (pre-INM 14 (50.0%) vs. post-INM 16, (61.6%); p = 0.253). A significant increase in good recovery (pre-INM 6 (50.0%) vs. post-INM 14, (61.6%); p = 0.014) was observed alongside a reduction in the incidence of silent infarctions (pre-INM 8 (28.6%) vs. post-INM 2 (7.7%); p = 0.048) and of overall DCI-related infarction (pre-INM 12 (42.8%) vs. post-INM 4 (23.1%); p = 0.027). The number of CT investigations performed during the DCI time frame decreased from 9.8 ± 5.2 scans in the pre-INM group to 6.1 ± 4.0 (p = 0.003) in the post-INM group.
A considerable number of patients with good-grade SAH experiences secondary deterioration rendering them neurologically not assessable. In our cohort, the introduction of INM to guide DCI treatment in patients with secondary deterioration increased the rate of good recovery after 12 months. Additionally, a significant reduction of CT scans and infarction load was recorded, which may have an underestimated impact on quality of life and more subtle neuropsychological deficits common after SAH.
良好分级的蛛网膜下腔出血（Hunt 和 Hess 1-2）通常与良好的预后相关。然而，由于迟发性脑缺血（DCI），患者仍可能出现继发性恶化，导致预后不良。在这些患者中，神经评估具有挑战性，而侵入性神经监测（INM）可能有助于指导 DCI 治疗。
对 2010 年至 2018 年间在一家三级护理中心就诊的 135 例良好分级的蛛网膜下腔出血患者进行了观察性分析。共有 54 例因继发性恶化而无法进一步进行神经评估的良好分级蛛网膜下腔出血患者被前瞻性纳入本分析。该队列分为两组：2014 年引入 INM 之前（预 INM：n=28；后 INM：n=26）。INM 包括局部氧饱和度测量（pO）、脑微透析或两者。DCI 发作（pO<10mmHg 或乳酸/丙酮酸>40）通过诱导高血压或在难治性病例中通过血管内治疗进行治疗。主要结局定义为 12 个月后的扩展格拉斯哥预后量表。此外，我们记录了进行的影像学检查数量以及无症状和总体与 DCI 相关的梗死的发生情况。
继发性恶化，妨碍了神经评估，发生在所有良好分级的蛛网膜下腔出血患者中的 54 例（40.0%）。在这些患者中，引入 INM 前后 12 个月的良好结局发生率相似（预 INM 14 例（50.0%）与后 INM 16 例（61.6%）；p=0.253）。良好恢复的比例显著增加（预 INM 6 例（50.0%）与后 INM 14 例（61.6%）；p=0.014），同时无症状梗死的发生率（预 INM 8 例（28.6%）与后 INM 2 例（7.7%）；p=0.048）和总体与 DCI 相关的梗死发生率（预 INM 12 例（42.8%）与后 INM 4 例（23.1%）；p=0.027）降低。在 DCI 期间进行的 CT 检查次数从预 INM 组的 9.8±5.2 次减少到后 INM 组的 6.1±4.0（p=0.003）。
相当数量的良好分级蛛网膜下腔出血患者会出现继发性恶化，导致无法进行神经评估。在我们的队列中，引入 INM 以指导继发性恶化患者的 DCI 治疗，增加了 12 个月后的良好恢复率。此外，记录到 CT 扫描和梗死负荷的显著减少，这可能对生活质量和蛛网膜下腔出血后常见的更微妙的神经心理缺陷产生被低估的影响。
