Location, Infarct Load, and 3-Month Outcomes of Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage

Abstract

We prospectively enrolled patients with SAH presenting to an academic neurosurgical referral center (Prince of Wales Hospital, the Chinese University of Hong Kong) in Hong Kong during a 3-year period. Joint CUHK-NTEC Clinical Research Ethics Committee approved the study. This study conformed to the Declaration of Helsinki and written informed consent was obtained from all the participants or their next of kin.The patient inclusion criteria were (1) spontaneous SAH with angiography-confirmed intracranial aneurysms; (2) hospital admission Background and Purpose-Aneurysmal subarachnoid hemorrhage is a serious disease with high case fatality and morbidity.Delayed cerebral infarction (DCI) is an important surrogate marker. How location and infarct load affected outcomes was unclear. We aimed to assess the effects of load and location of DCI on outcomes of aneurysmal subarachnoid hemorrhage at 3 months. Methods-We prospectively enrolled patients with subarachnoid hemorrhage presenting to an academic neurosurgical unit in Hong Kong during a 3-year period. DCI was defined by new hypoattenuation on computed tomography at 4 to 6 weeks, which was not present in the postaneurysm-treatment computed tomography at 24 to 48 hours. DCI was assessed for location according to cerebral artery territories and load semiquantitatively. Cognitive and functional outcome assessments were carried out 3 months after ictus. Results-One hundred twenty-six patients with subarachnoid hemorrhage consented for this study. DCI occurred in 56 (44%) patients and was associated with poorer cognitive and functional outcomes (Montreal Cognitive Assessment, MiniMental State Examination, modified Rankin Scale, and Lawton Instrumental Activity of Daily Living) at 3 months. In patients with DCI, the presence of perforator zone infarct was associated with poorer cognitive and functional outcomes, and cortical middle cerebral artery infarct was associated with poorer modified Rankin Scale. After adjustment for age, admission World Federation of Neurosurgical Societies Grade and mode of aneurysm treatment, both middle cerebral artery cortical infarct load and perforator infarct load were independently associated with poor cognitive outcomes (Montreal Cognitive Assessment and Mini-Mental State Examination) and modified Rankin Scale. Conclusions-Middle cerebral artery cortical and perforator zone infarct loads are potential surrogate marker to assess the severity of delayed cerebral ischemia.

Patient Outcomes and Cerebral Infarction after Ruptured Anterior Communicating Artery Aneurysm Treatment

“…Cerebral infarction is common after cerebral aneurysm rupture, 22,23 and prior studies have correlated the cumulative burden of cerebral infarction to poor clinical outcome and cognitive outcomes. 2,3 In this study, we questioned whether differences in cerebral infarction pattern and burden after treatment of ruptured AcomAs by clipping compared with coiling might account for differences in clinical outcome.…”

“…1 Clinical outcomes after aneurysm rupture and treatment are influenced by cumulative cerebral infarction burden. 2,3 Furthermore, patients who recover from aneurysm rupture are often left with disabling cognitive deficits that may result in the patient's dependency on others, which is reflect by higher mRS scores. 4,5 The severity of these cognitive deficits has been correlated to the Hunt and Hess Scale (HHS) grade on admission, older age, aneurysm location, and treatment-related brain injury.…”

Delayed Cerebral Ischemia of the Corpus Callosum: A Case Report

“…Although no such DCI-related infarction has been reported in the literature, recent studies concerning the location of cerebral infarctions secondary to DCI help explain the etiology of our patient's unique case. Of the 126 SAH patients analyzed in a prospective study by Wong et al (2015), the majority of DCI infarctions occurred in the deep penetrating branches of the anterior, middle, and posterior cerebral arteries, which included the pericallosal artery and its associated perforating arteries that directly supply the corpus callosum without collaterals [5,7]. On subsequent univariate analyses, such DCI infarctions of the penetrating arteries were also associated with poorer modified Rankin Scale, Montreal Cognitive Assessment, and Mini-Mental Status Examination results and thus a poorer prognosis [5].…”

“…Of the 126 SAH patients analyzed in a prospective study by Wong et al (2015), the majority of DCI infarctions occurred in the deep penetrating branches of the anterior, middle, and posterior cerebral arteries, which included the pericallosal artery and its associated perforating arteries that directly supply the corpus callosum without collaterals [5,7]. On subsequent univariate analyses, such DCI infarctions of the penetrating arteries were also associated with poorer modified Rankin Scale, Montreal Cognitive Assessment, and Mini-Mental Status Examination results and thus a poorer prognosis [5]. The tendency of DCI infarctions to occur in deep penetrating arteries is supported by Rabinstein et al (2004), who, in studying the topographical pattern of DCI infarctions in SAH patients, found that isolated deep infarcts, although not the most common among the study population, occurred in 18% of patients, with 60% of such lesions being symptomatic [16].…”

“…There is no characteristic radiological or clinical presentation of DCI, although a recent study found that infarctions due to DCI most commonly occur in the deep branches of the anterior, middle, and posterior cerebral arteries supplying the caudate, putamen, thalamus, and corpus callosum [5]. The predilection of DCI infarctions to affect vessels supplying the corpus callosum, in particular, is unique given that the corpus callosum receives a rich vascular supply from both the anterior and posterior cerebral circulation.…”