Predictors of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Cardiac Focus

Myocardial injury after aneurysmal subarachnoid hemorrhage (aSAH) is associated with poor outcomes. Delayed cerebral ischemia (DCI) is also a complication of aSAH. We sought to determine whether (1) DCI could be predicted by demographics, aSAH severity/aneurysm location, or aSAH-associated myocardial injury (SAHMI), and (2) DCI is associated with increased mortality after aSAH.

Prospective longitudinal study of 149 aSAH subjects with definitive DCI evaluation, age 18–75 years, Hunt and Hess (HH) ≥ 3, and/or Fisher ≥ 2, and admitted to the Neurovascular ICU. DCI was defined by the presence of neurological deterioration accompanied by evidence of abnormal cerebral blood flow.

Subjects were 48% DCI(+) and 52% DCI(−). DCI(+) subjects had more severe aSAH [HH (P = 0.002), Fisher (P = 0.004), admission Glasgow Coma Scale (P = 0.018)]. More DCI(+) subjects had pulmonary congestion than DCI(−) subjects (63 vs. 39%, P = 0.003). On echocardiogram, cardiac output (CO, liters per minute [LPM]) was significantly higher in DCI(+) than in DCI(−) subjects (6 ± 2 vs. 5 ± 1 LPM; P = 0.015). Multivariate analysis identified CO and Fisher grade as independent predictors of DCI (P = 0.02, 0.019). For each 1 LPM increase in CO, the odds of DCI increased by 1.5 (95% CI: 1.1–2.1). Fisher grade 4 increased the odds of DCI by 6.5 compared to Fisher grade 2 (95% CI: 1.6–25.8). After controlling for Fisher grade, CO remained an independent predictor of DCI (P = 0.02). Three-month mortality rate was not significantly different between DCI groups, P = 0.786.

Elevated CO and Fisher grade are predictors of DCI after aSAH. However, prevention of DCI may not decrease mortality.