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Association of Dose of Intracranial Hypertension with Outcome in Subarachnoid Hemorrhage

The Original Article was published on 02 March 2021

Abstract

Background

In patients with aneurysmal subarachnoid hemorrhage (aSAH) the burden of intracranial pressure (ICP) and its contribution to outcomes remains unclear. In this multicenter study, the independent association between intensity and duration, or “dose,” of episodes of intracranial hypertension and 12-month neurological outcomes was investigated.

Methods

This was a retrospective analysis of multicenter prospectively collected data of 98 adult patients with aSAH amendable to treatment. Patients were admitted to the intensive care unit of two European centers (Medical University of Innsbruck [Austria] and San Gerardo University Hospital of Monza [Italy]) from 2009 to 2013. The dose of intracranial hypertension was visualized. The obtained visualizations allowed us to investigate the association between intensity and duration of episodes of intracranial hypertension and the 12-month neurological outcomes of the patients, assessed with the Glasgow Outcome Score. The independent association between the cumulative dose of intracranial hypertension and outcome for each patient was investigated by using multivariable logistic regression models corrected for age, occurrence of delayed cerebral ischemia, and the Glasgow Coma Scale score at admission.

Results

The combination of duration and intensity defined the tolerance to intracranial hypertension for the two cohorts of patients. A semiexponential transition divided ICP doses that were associated with better outcomes (in blue) with ICP doses associated with worse outcomes (in red). In addition, in both cohorts, an independent association was found between the cumulative time that the patient experienced ICP doses in the red area and long-term neurological outcomes. The ICP pressure–time burden was a stronger predictor of outcomes than the cumulative time spent by the patients with an ICP greater than 20 mmHg.

Conclusions

In two cohorts of patients with aSAH, an association between duration and intensity of episodes of elevated ICP and 12-month neurological outcomes could be demonstrated and was visualized in a color-coded plot.

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Acknowledgments

We acknowledge valuable help in the collection of the data by Federico Magni, MD, and Alessia Vargiolu, PhD.

Funding

GM is supported by the Research Foundation, Flanders (FWO) as senior clinical investigator (1843118N). GM and FG receive project funding from Katholieke Universiteit Leuven (C2 project C24/17/072: A neuromonitor for the twenty-first century). GCa receives funding from the FWO as a PhD fellow (fellowship number: 1S28120N). MF received funding from the FWO as a PhD fellow (fellowship number: 11Y1118N). LH receives funding form the Austrian Scientific Fund. RH reports Grants and other funding from Bard Medical, other funding from Zoll Medical, Grants from Fresenius Kabi, and other funding from Integra Life Sciences, outside the submitted work. BD reports Grants from Medtronic and Johnson & Johnson, outside the submitted work.

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GCa contribute to the design of the study, analysis and interpretation of data, important intellectual content contribution, draft of the manuscript, revision of the manuscipt and final approval of the version to be published. FE, BI, LH and VR contributed to the data acquisition, revision of the manuscipt and final approval of the version to be published. MF contributed to interpretation of data, revision of the manuscipt and final approval of the version to be published. BD contributed to the study design,interpretation of data, revision of the manuscipt and final approval of the version to be published. FG, GM, GCi and RH contributed to the study design,interpretation of data and important intellectual content contribution, revision of the manuscipt and final approval of the version to be published.

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Correspondence to Geert Meyfroidt.

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This article is related to the Invited Commentary available at https://link.springer.com/article/10.1007/s12028-021-01205-4.

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Carra, G., Elli, F., Ianosi, B. et al. Association of Dose of Intracranial Hypertension with Outcome in Subarachnoid Hemorrhage. Neurocrit Care 34, 722–730 (2021). https://doi.org/10.1007/s12028-021-01221-4

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Keywords

  • Subarachnoid hemorrhage
  • Intracranial hypertension
  • Critical care
  • Outcome assessment
  • Decision-making