Optimal intracranial pressure in patients with aneurysmal subarachnoid hemorrhage treated with coiling and requiring external ventricular drainage

Optimal management of intracranial pressure (ICP) among aneurysmal subarachnoid hemorrhage (aSAH) patients requiring external ventricular drainage (EVD) is controversial. To analyze predictors of delayed cerebral ischemia (DCI)-related cerebral infarction after aSAH and the influence of IC P values...

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Published in:	Neurosurgical review Vol. 44; no. 2; pp. 1191 - 1204
Main Authors:	Cagnazzo, Federico, Chalard, Kevin, Lefevre, Pierre-Henri, Garnier, Ocean, Derraz, Imad, Dargazanli, Cyril, Gascou, Gregory, Riquelme, Carlos, Bonafe, Alain, Perrini, Paolo, Di Carlo, Davide Tiziano, Morganti, Riccardo, Le Corre, Marine, Pavillard, Frederique, Perrigault, Pierre-Francois, Costalat, Vincent
Format:	Journal Article
Language:	English
Published:	Berlin/Heidelberg Springer Berlin Heidelberg 01-04-2021 Springer Verlag
Subjects:	Adult Aged Bioengineering Drainage Endovascular Procedures Female Human health and pathology Humans Imaging Intracranial Pressure Life Sciences Male Medicine Medicine & Public Health Middle Aged Neurons and Cognition Neurosurgery Original Article Prospective Studies Subarachnoid Hemorrhage Surgery Time Factors Tomography, X-Ray Computed Cerebral infarction Vasospasm Delayed cerebral ischemia Intracranial pressure External ventricular drainage
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Summary:	Optimal management of intracranial pressure (ICP) among aneurysmal subarachnoid hemorrhage (aSAH) patients requiring external ventricular drainage (EVD) is controversial. To analyze predictors of delayed cerebral ischemia (DCI)-related cerebral infarction after aSAH and the influence of IC P values on DCI, we prospectively collected consecutive patients with aSAH receiving coiling and requiring EVD. Predictors of DCI-related cerebral infarction (new CT hypodensities developed within the first 3 weeks not related to other causes) were studied. Vasospasm and brain hypoperfusion were studied with CT angiography and CT perfusion (RAPID-software). Among 50 aSAH patients requiring EVD, 21 (42%) developed DCI-related cerebral infarction, while 27 (54%) presented vasospasm. Mean ICP ranged between 2 and 19 mmHg. On the multivariate analysis, the mean ICP (OR = 2, 95%CI = 1.01–3.9, p = 0.042) and the mean hypoperfusion volume on Tmax delay > 6 (OR = 1.2, 95%CI = 1.01–1.3, p = 0.025) were independent predictors of DCI. To predict DCI-related cerebral infarction, Tmax delay > 6 s presented the highest AUC (0.956, SE = 0.025), with a cutoff value of 18 ml showing sensitivity, specificity, PPV, NPV, and accuracy of 90.5% (95%CI = 69–98.8%), 86.2% (95%CI = 68.4–96%), 82.6% (95%CI = 65.4–92%), 92.5% (95%CI = 77–98%), and 88% (95%CI = 75–95%), respectively. The AUC of the mean ICP was 0.825 (SE = 0.057), and the best cutoff value was 6.7 mmHg providing sensitivity, specificity, PPV, NPV, and accuracy of 71.4% (95%CI = 48–89%), 62% (95%CI = 42–79%), 58% (95%CI = 44–70%), 75% (95%CI = 59–86%), and 66% (95%CI = 51–79%) for the prediction of DCI-related cerebral infarction, respectively. Among aSAH patients receiving coiling and EVD, lower ICP (< 6.7 mmHg in our study) could potentially be beneficial in decreasing DCI-related cerebral infarction. Brain hypoperfusion with a volume > 18 ml at Tmax delay > 6 s presents a high sensibility and specificity in prediction of DCI-related cerebral infarction.
Bibliography:	ObjectType-Article-1 SourceType-Scholarly Journals-1 ObjectType-Feature-2 content type line 23
ISSN:	0344-5607 1437-2320
DOI:	10.1007/s10143-020-01322-2