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

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Abstract

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 ICP 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.

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Authors and Affiliations

  1. Neuroradiology department, University Hospital Güi-de-Chauliac, CHU de Montpellier, 80 Avenue Augustin Fliche, 34000, Montpellier, France

    Federico Cagnazzo, Pierre-Henri Lefevre, Imad Derraz, Cyril Dargazanli, Gregory Gascou, Carlos Riquelme, Alain Bonafe & Vincent Costalat

  2. Department of Anesthesia and Critical Care Medicine, Montpellier University Hospital Gui de Chauliac, Montpellier, France

    Kevin Chalard, Ocean Garnier, Frederique Pavillard & Pierre-Francois Perrigault

  3. Department of Neurosurgery, University of Pisa, Pisa, Italy

    Paolo Perrini & Davide Tiziano Di Carlo

  4. Statistic Analysis Unit, Pisa University Hospital, Pisa, Italy

    Riccardo Morganti

  5. Service de neurochirurgie, Centre hospitalier universitaire de Montpellier, Hôpital Gui de Chauliac, Montpellier, France

    Marine Le Corre

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  1. Federico Cagnazzo
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Correspondence to Federico Cagnazzo.

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This study was approved by the Institutional Review Board of Montpellier (ID-RCB: 2018_IRB-MTP_02-11). The information was delivered with a simplified information note. Because the trial used non-invasive procedures along with standard care provided in French intensive care units, only verbal consent was required from the patient or relatives, according to French law [23].

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Cagnazzo, F., Chalard, K., Lefevre, PH. et al. Optimal intracranial pressure in patients with aneurysmal subarachnoid hemorrhage treated with coiling and requiring external ventricular drainage. Neurosurg Rev 44, 1191–1204 (2021). https://doi.org/10.1007/s10143-020-01322-2

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  • DOI: https://doi.org/10.1007/s10143-020-01322-2

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