Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage: Clinical article

J. Michael Schmidt, Katja E. Wartenberg, Andres Fernandez, Jan Claassen, Fred Rincon, Noeleen D. Ostapkovich, Neeraj Badjatia, Augusto Parra, E. Sander Connolly, Stephan A. Mayer

Research output: Contribution to journalArticle

93 Citations (Scopus)

Abstract

Object. The authors sought to determine frequency, risk factors, and impact on outcome of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage (SAH). Methods. The authors prospectively studied 580 patients with SAH admitted to their center between July 1996 and May 2002. Delayed cerebral ischemia (DCI) from vasospasm was defined as 1) a new focal neurological deficit or decrease in level of consciousness, 2) a new infarct revealed by follow-up CT imaging, or both, after excluding causes other than vasospasm. Outcome at 3 months was assessed using the modified Rankin Scale. Results. Delayed cerebral ischemia occurred in 121 (21%) of 580 patients. Of those with DCI, 36% (44 patients) experienced neurological deterioration without a corresponding infarct, 42% (51 patients) developed an infarct in conjunction with neurological deterioration, and 21% (26 patients) had a new infarct on CT without concurrent neurological deterioration. In a multivariate analysis, risk factors for asymptomatic DCI included coma on admission, placement of an external ventricular drain, and smaller volumes of SAH (all p < 0.03). Patients with asymptomatic DCI were less likely to be treated with vasopressor agents than those with symptomatic DCI (64 vs 86%, p = 0.01). After adjusting for clinical grade, age, and aneurysm size, the authors found that there was a higher frequency of death or moderate-to-severe disability at 3 months (modified Rankin Scale Score 4-6) in patients with asymptomatic DCI than in patients with symptomatic DCI (73 vs 40%, adjusted odds ratio 3.9, 95% confidence interval 1.3-12.0, p = 0.017). Conclusions. Approximately 20% of episodes of DCI after SAH are characterized by cerebral infarction in the absence of clinical symptoms. Asymptomatic DCI is particularly common in comatose patients and is associated with poor outcome. Strategies directed at diagnosing and preventing asymptomatic infarction from vasospasm in patients with poor-grade SAH are needed.

Original languageEnglish (US)
Pages (from-to)1052-1059
Number of pages8
JournalJournal of Neurosurgery
Volume109
Issue number6
DOIs
StatePublished - Dec 2008
Externally publishedYes

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Cerebral Infarction
Subarachnoid Hemorrhage
Brain Ischemia
Coma
Intracranial Vasospasm
Vasoconstrictor Agents
Consciousness
Infarction
Aneurysm
Multivariate Analysis
Odds Ratio
Confidence Intervals

Keywords

  • Cerebral infarction
  • Intracranial aneurysm
  • Outcome
  • Subarachnoid hemorrhage
  • Vasospasm

ASJC Scopus subject areas

  • Clinical Neurology
  • Surgery

Cite this

Schmidt, J. M., Wartenberg, K. E., Fernandez, A., Claassen, J., Rincon, F., Ostapkovich, N. D., ... Mayer, S. A. (2008). Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage: Clinical article. Journal of Neurosurgery, 109(6), 1052-1059. https://doi.org/10.3171/JNS.2008.109.12.1052

Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage : Clinical article. / Schmidt, J. Michael; Wartenberg, Katja E.; Fernandez, Andres; Claassen, Jan; Rincon, Fred; Ostapkovich, Noeleen D.; Badjatia, Neeraj; Parra, Augusto; Connolly, E. Sander; Mayer, Stephan A.

In: Journal of Neurosurgery, Vol. 109, No. 6, 12.2008, p. 1052-1059.

Research output: Contribution to journalArticle

Schmidt, JM, Wartenberg, KE, Fernandez, A, Claassen, J, Rincon, F, Ostapkovich, ND, Badjatia, N, Parra, A, Connolly, ES & Mayer, SA 2008, 'Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage: Clinical article', Journal of Neurosurgery, vol. 109, no. 6, pp. 1052-1059. https://doi.org/10.3171/JNS.2008.109.12.1052
Schmidt, J. Michael ; Wartenberg, Katja E. ; Fernandez, Andres ; Claassen, Jan ; Rincon, Fred ; Ostapkovich, Noeleen D. ; Badjatia, Neeraj ; Parra, Augusto ; Connolly, E. Sander ; Mayer, Stephan A. / Frequency and clinical impact of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage : Clinical article. In: Journal of Neurosurgery. 2008 ; Vol. 109, No. 6. pp. 1052-1059.
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abstract = "Object. The authors sought to determine frequency, risk factors, and impact on outcome of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage (SAH). Methods. The authors prospectively studied 580 patients with SAH admitted to their center between July 1996 and May 2002. Delayed cerebral ischemia (DCI) from vasospasm was defined as 1) a new focal neurological deficit or decrease in level of consciousness, 2) a new infarct revealed by follow-up CT imaging, or both, after excluding causes other than vasospasm. Outcome at 3 months was assessed using the modified Rankin Scale. Results. Delayed cerebral ischemia occurred in 121 (21{\%}) of 580 patients. Of those with DCI, 36{\%} (44 patients) experienced neurological deterioration without a corresponding infarct, 42{\%} (51 patients) developed an infarct in conjunction with neurological deterioration, and 21{\%} (26 patients) had a new infarct on CT without concurrent neurological deterioration. In a multivariate analysis, risk factors for asymptomatic DCI included coma on admission, placement of an external ventricular drain, and smaller volumes of SAH (all p < 0.03). Patients with asymptomatic DCI were less likely to be treated with vasopressor agents than those with symptomatic DCI (64 vs 86{\%}, p = 0.01). After adjusting for clinical grade, age, and aneurysm size, the authors found that there was a higher frequency of death or moderate-to-severe disability at 3 months (modified Rankin Scale Score 4-6) in patients with asymptomatic DCI than in patients with symptomatic DCI (73 vs 40{\%}, adjusted odds ratio 3.9, 95{\%} confidence interval 1.3-12.0, p = 0.017). Conclusions. Approximately 20{\%} of episodes of DCI after SAH are characterized by cerebral infarction in the absence of clinical symptoms. Asymptomatic DCI is particularly common in comatose patients and is associated with poor outcome. Strategies directed at diagnosing and preventing asymptomatic infarction from vasospasm in patients with poor-grade SAH are needed.",
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T2 - Clinical article

AU - Schmidt, J. Michael

AU - Wartenberg, Katja E.

AU - Fernandez, Andres

AU - Claassen, Jan

AU - Rincon, Fred

AU - Ostapkovich, Noeleen D.

AU - Badjatia, Neeraj

AU - Parra, Augusto

AU - Connolly, E. Sander

AU - Mayer, Stephan A.

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N2 - Object. The authors sought to determine frequency, risk factors, and impact on outcome of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage (SAH). Methods. The authors prospectively studied 580 patients with SAH admitted to their center between July 1996 and May 2002. Delayed cerebral ischemia (DCI) from vasospasm was defined as 1) a new focal neurological deficit or decrease in level of consciousness, 2) a new infarct revealed by follow-up CT imaging, or both, after excluding causes other than vasospasm. Outcome at 3 months was assessed using the modified Rankin Scale. Results. Delayed cerebral ischemia occurred in 121 (21%) of 580 patients. Of those with DCI, 36% (44 patients) experienced neurological deterioration without a corresponding infarct, 42% (51 patients) developed an infarct in conjunction with neurological deterioration, and 21% (26 patients) had a new infarct on CT without concurrent neurological deterioration. In a multivariate analysis, risk factors for asymptomatic DCI included coma on admission, placement of an external ventricular drain, and smaller volumes of SAH (all p < 0.03). Patients with asymptomatic DCI were less likely to be treated with vasopressor agents than those with symptomatic DCI (64 vs 86%, p = 0.01). After adjusting for clinical grade, age, and aneurysm size, the authors found that there was a higher frequency of death or moderate-to-severe disability at 3 months (modified Rankin Scale Score 4-6) in patients with asymptomatic DCI than in patients with symptomatic DCI (73 vs 40%, adjusted odds ratio 3.9, 95% confidence interval 1.3-12.0, p = 0.017). Conclusions. Approximately 20% of episodes of DCI after SAH are characterized by cerebral infarction in the absence of clinical symptoms. Asymptomatic DCI is particularly common in comatose patients and is associated with poor outcome. Strategies directed at diagnosing and preventing asymptomatic infarction from vasospasm in patients with poor-grade SAH are needed.

AB - Object. The authors sought to determine frequency, risk factors, and impact on outcome of asymptomatic cerebral infarction due to vasospasm after subarachnoid hemorrhage (SAH). Methods. The authors prospectively studied 580 patients with SAH admitted to their center between July 1996 and May 2002. Delayed cerebral ischemia (DCI) from vasospasm was defined as 1) a new focal neurological deficit or decrease in level of consciousness, 2) a new infarct revealed by follow-up CT imaging, or both, after excluding causes other than vasospasm. Outcome at 3 months was assessed using the modified Rankin Scale. Results. Delayed cerebral ischemia occurred in 121 (21%) of 580 patients. Of those with DCI, 36% (44 patients) experienced neurological deterioration without a corresponding infarct, 42% (51 patients) developed an infarct in conjunction with neurological deterioration, and 21% (26 patients) had a new infarct on CT without concurrent neurological deterioration. In a multivariate analysis, risk factors for asymptomatic DCI included coma on admission, placement of an external ventricular drain, and smaller volumes of SAH (all p < 0.03). Patients with asymptomatic DCI were less likely to be treated with vasopressor agents than those with symptomatic DCI (64 vs 86%, p = 0.01). After adjusting for clinical grade, age, and aneurysm size, the authors found that there was a higher frequency of death or moderate-to-severe disability at 3 months (modified Rankin Scale Score 4-6) in patients with asymptomatic DCI than in patients with symptomatic DCI (73 vs 40%, adjusted odds ratio 3.9, 95% confidence interval 1.3-12.0, p = 0.017). Conclusions. Approximately 20% of episodes of DCI after SAH are characterized by cerebral infarction in the absence of clinical symptoms. Asymptomatic DCI is particularly common in comatose patients and is associated with poor outcome. Strategies directed at diagnosing and preventing asymptomatic infarction from vasospasm in patients with poor-grade SAH are needed.

KW - Cerebral infarction

KW - Intracranial aneurysm

KW - Outcome

KW - Subarachnoid hemorrhage

KW - Vasospasm

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