Richard L. Applegate, Gang Chen, Hua Feng and John H. Zhang (eds.)Brain Edema XVIActa Neurochirurgica Supplement12110.1007/978-3-319-18497-5_28

Early Cerebral Infarction after Aneurysmal Subarachnoid Hemorrhage

George Kwok Chu Wong^{1, 2}, Joyce Hoi Ying Leung³, Janice Wong Li Yu³, Sandy Wai Lam¹, Emily Kit Ying Chan¹, Wai Sang Poon¹, Jill Abrigo³ and Deyond Yun Woon Siu³

(1)

Division of Neurosurgery, Department of Surgery, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China

(2)

Department of Surgery, Prince of Wales Hospital, 4/F Clinical Science Building, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong, SAR, China

(3)

Department of Diagnostic Radiology and Organ Imaging, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, China

George Kwok Chu Wong

Email: georgewong@surgery.cuhk.edu.hk

Keywords

AneurysmCerebral infarctionStrokeSubarachnoid hemorrhage

Introduction

Aneurysmal subarachnoid hemorrhage (SAH) is a serious disease with high case fatality and morbidity [9, 15–17]. A high rate of hypodense lesions consistent with cerebral infarctions has been evident on follow-up CT scanning among survivors at 3 months [4, 20]. In a post hoc path analysis, cerebral infarction also had a direct effect on outcome independent of angiographic vasospasm [19]. One study suggested that high SAH grade (using the Fisher scale) was related to cerebral infarction [3]. Early cerebral infarction has been recognized as a risk factor for poor outcome at 3 months according to the Glasgow Outcome Scale [3]. In this study, we aimed to assess the pattern of early and delayed cerebral infarction after aneurysmal subarachnoid hemorrhage.

Materials and Methods

We prospectively enrolled consecutive aneurysmal SAH patients presenting to an academic neurosurgical referral center (Prince of Wales Hospital, the Chinese University of Hong Kong) in Hong Kong. The study was approved by the Joint CUHK-NTEC Clinical Research Ethics Committee. This study conformed to the Declaration of Helsinki, and written informed consent was obtained from all of the participants or their next of kin.

The patient inclusion criteria were as follows: (1) spontaneous SAH with angiography-confirmed etiology of intracranial aneurysms; (2) hospital admission within 96 h after ictus; (3) between 21 and 75 years of age; (4) a speaker of Chinese (Cantonese); and (5) informed consent from the patients or their next of kin. The patient exclusion criteria were a history of previous cerebrovascular or neurological disease other than unruptured intracranial aneurysm, a history of neurosurgery before ictus, or inability to cooperate in cognitive assessments (not obeying commands).

All the computed tomography (CT) scans were done on 64-slice scanners and reformatted into 5 mm thicknesses. CT films were categorized into early and delayed. Early CT was defined as post-treatment (clipping or coiling) Day 1 scan. Delayed CT was defined as 4–6 weeks post-treatment. Early cerebral infarction was defined as new parenchymal hypoattenuation on early CT; all cerebral infarction was defined as new parenchymal hypoattenuation on delayed CT; delayed cerebral infarction was defined as new parenchymal hypoattenuation on delayed CT, which was not present in early CT.

Modified Rankin Scale (mRS) [13, 18]

The mRS is a valid and clinically relevant disability scale to assess recovery and is commonly used in stroke trials. mRS identifies activity limitation and does not identify deficits. It ranges from 0 (no symptoms) to 6 (death).

Chinese Lawton Instrumental Activity of Daily Living (IADL) Scale

The Lawton IADL Scale is an appropriate instrument to assess independent living skills [6, 14]. Items assessed include ability to use the telephone, go shopping, prepare food, do the housekeeping, do the laundry, use transportation, be responsible for one’s own medications, and handle finances. The Chinese version has been validated and used previously [14].

Statistical Analysis

The trial data were collected on printed forms and entered into a computer using Access 2003 software (Microsoft Inc., Redmond, WA, USA). Statistical analyses were generated using SPSS for Windows Version 15.0 (SPSS Inc., Chicago, IL, USA) [10]. Categorical data are given as numbers (percentages), unless otherwise specified; numerical data are given as means and standard deviations (SD); and ordinal data are given as medians and interquartile ranges. A difference with a p-value less than 0.05 was regarded as statistically significant (two-tailed test). Categorical data were analyzed using the Fisher’s exact test or Chi-square test, with odds ratios and 95 % confidence intervals (CI) as appropriate. Correlations between numerical or ordinal data were assessed using Kendall’s rank correlation (Kendall’s tau-b coefficient).

Results

Fifty-two consecutive eligible aneurysmal SAH patients were recruited and 2 patients were excluded due to lack of delayed CT. Age was 53±10 years and 32 (62 %) were female. Twenty-two (42 %) patients were hypertensive and 18 (35 %) were smokers. Years of formal education were 9±4 years. World Federation of Neurosurgical Societies (WFNS) Grade was I in 25 (48 %), II in 14 (27 %), III in 3 (6 %), IV in 6 (12 %), and V in 4 (8 %). Clinical rebleeding before aneurysm treatment occurred in 1 (2 %) patient. Aneurysm location was posterior circulation in 11 (22 %) patients with the rest located in anterior circulation: anterior communicating artery: 12 (24 %); internal carotid artery communicating segment or posterior communicating artery: 10 (20 %); internal carotid artery, other segment: 14 (28 %); middle cerebral artery: 9 (18 %). Coiling was performed in 30 (58 %) patients and clipping was performed in 20 (40 %) patients. An external ventricular drain was inserted in 20 (40 %) patients and ventriculoperitoneal shunts were eventually required in 8 (16 %) patients.

Only gold members can continue reading. Log In or Register to continue