Torné Ramon, Hoyos Jhon, Llull Laura, Rodríguez-Hernández Ana, Muñoz Guido, Mellado-Artigas Ricard, Santana Daniel, Pedrosa Leire, Di Somma Alberto, San Roman Luis, Amaro Sergio, Enseñat Joaquim
Neurological Surgery Department, Hospital Clinic of Barcelona, 08036 Barcelona, Spain.
Hospital Clinic, University of Barcelona and Institut d'Investigació Biomèdica August Pi i Sunyer (IDIBAPS), 08036 Barcelona, Spain.
J Clin Med. 2021 Jan 17;10(2):321. doi: 10.3390/jcm10020321.
The level of consciousness and cerebral edema are among the indicators that best define the intensity of early brain injury following aneurysmal subarachnoid hemorrhage (aSAH). Although these indicators are usually altered in patients with a poor neurological status, their usefulness for selecting patients at risk of cerebral infarction (CI) is not well established. Furthermore, little is known about the evolution of these indicators during the first week of post-ictal events. Our study focused on describing the association of the longitudinal course of these predictors with CI occurrence in patients with severe aSAH.
Out of 265 aSAH patients admitted consecutively to the same institution, 80 patients with initial poor neurological status (WFNS 4-5) were retrospectively identified. After excluding 25 patients with early mortality, a total of 47 patients who underwent early CT (<3 days) and late CT (<7 days) acquisitions were included in the study. Early cerebral edema and delayed cerebral edema were calculated using the SEBES score, and the level of consciousness was recorded daily during the first week using the Glasgow Coma Scale (GCS).
There was a significant improvement in the SEBES (Early-SEBES median (IQR) = 3 (2-4) versus Delayed-SEBES = 2 (1-3); = 0.001) and in GCS scores (B = 0.32; 95% CI 0.15-0.49; = 0.001) during the first week. When comparing the ROC curves of Delayed-SEBES vs Early-SEBES as predictors of CI, no significant differences were found (Early-SEBES Area Under the Curve: 0.65; Delayed-SEBES: 0.62; = 0.17). Additionally, no differences were observed in the relationship between the improvement in the GCS across the first week and the occurrence of CI ( = 0.536).
Edema and consciousness level improvement did not seem to be associated with the occurrence of CI in a surviving cohort of patients with severe aSAH. Our results suggest that intensive monitoring should not be reduced in patients with a poor neurological status regardless of an improvement in cerebral edema and level of consciousness during the first week after bleeding.
意识水平和脑水肿是最能界定动脉瘤性蛛网膜下腔出血（aSAH）后早期脑损伤严重程度的指标。尽管这些指标在神经功能状态较差的患者中通常会发生改变，但其在筛选有脑梗死（CI）风险患者方面的效用尚未明确确立。此外，对于发作后第一周内这些指标的变化情况知之甚少。我们的研究聚焦于描述这些预测指标的纵向变化过程与重症aSAH患者CI发生之间的关联。
在连续入住同一机构的265例aSAH患者中，回顾性确定80例初始神经功能状态较差（世界神经外科联盟分级4 - 5级）的患者。排除25例早期死亡患者后，共有47例接受了早期CT（<3天）和晚期CT（<7天）检查的患者纳入研究。使用SEBES评分计算早期脑水肿和延迟性脑水肿，并在第一周每天使用格拉斯哥昏迷量表（GCS）记录意识水平。
第一周内，SEBES评分（早期SEBES中位数（四分位间距）=3（2 - 4），延迟性SEBES =2（1 - 3）；P =0.001）和GCS评分（B =0.32；95%置信区间0.15 - 0.49；P =0.001）有显著改善。比较延迟性SEBES与早期SEBES作为CI预测指标的ROC曲线时，未发现显著差异（早期SEBES曲线下面积：0.65；延迟性SEBES：0.62；P =0.17）。此外，第一周内GCS评分的改善与CI发生之间的关系也未观察到差异（P =0.536）。
在重症aSAH存活患者队列中，水肿和意识水平的改善似乎与CI的发生无关。我们的结果表明，对于神经功能状态较差的患者，无论出血后第一周脑水肿和意识水平是否改善，都不应减少强化监测。
