Edema Resolution and Clinical Assessment in Poor-Grade Subarachnoid Hemorrhage: Useful Indicators to Predict Delayed Cerebral Infarctions?

Abstract

Background: 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. Methods: 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). Results: There was a significant improvement in the SEBES (Early-SEBES median (IQR) = 3 (2–4) versus Delayed-SEBES = 2 (1–3); p = 0.001) and in GCS scores (B = 0.32; 95% CI 0.15–0.49; p = 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; p = 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 (p = 0.536). Conclusions: 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.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

“…246,251,[255][256][257] The duration of frequent assessments also varied, with a range of at least 48 hours to 7 days after the bleed. 245,246,[254][255][256][257] One study observed neurological deterioration in 42.6% of patients after aneurysm clipping using the GCS and NIHSS as the frequent assessment tool every hour up to 72 hours. 256 There are a lack of consensus and wide variability in the timing and duration of frequent assessments, allowing more individualized care plans based on the complexity and needs of the patient.…”

“…The studies reviewed include both RCTs and non-RCTs with a consistent recommendation for nurses to provide frequent assessments in the acute phase. [244][245][246][254][255][256][257] Frequent assessments ranged from every 15 minutes to every 4 hours. 246,251,[255][256][257] The duration of frequent assessments also varied, with a range of at least 48 hours to 7 days after the bleed.…”

“…242 Knowledge Gaps and Future Research 244,246,251,[253][254][255][256]258 The literature identifies frequent assessments by nurses as a key component in prevention strategies. 244,246,[255][256][257] The use of validated tools such as the NIHSS or GCS and validated dysphagia screening scales is shown to positively affect earlier intervention for vasospasm and DCI and decrease rates of pneumonia. 246,251,254,[256][257][258] Furthermore, nursing activities provided by certified and competent stroke-trained nurses are suggested to have a positive impact on patient outcomes.…”

“…244,246,[255][256][257] The use of validated tools such as the NIHSS or GCS and validated dysphagia screening scales is shown to positively affect earlier intervention for vasospasm and DCI and decrease rates of pneumonia. 246,251,254,[256][257][258] Furthermore, nursing activities provided by certified and competent stroke-trained nurses are suggested to have a positive impact on patient outcomes. [262][263][264] Use of and adherence to aSAH order sets and protocols help to improve standardization of care and reduce mortality.…”

Vasospasm-Related Death after Aneurysmal Subarachnoid Hemorrhage: A Retrospective Case–Control Study

“…Earlier detection and intensive monitoring are only the initial steps in the paradigm shift that is needed for treatment to prevent poor outcomes following aSAH [ 49 ]. Adequate EVT is also necessary with a variety of treatment options, ranging from balloon angioplasty [ 19 , 20 , 21 , 22 , 23 , 24 ] and stentoplasty [ 25 , 26 , 27 , 28 , 29 ] to IA medicinal vessel dilatation, in addition to combined approaches.…”