title: Ultra-early angiographic vasospasm associated with delayed cerebral ischemia and infarction following aneurysmal subarachnoid hemorrhage.
abstract: OBJECTIVE The clinical significance of cerebral ultra-early angiographic vasospasm (UEAV), defined as cerebral arterial narrowing within the first 48 hours of aneurysmal subarachnoid hemorrhage (aSAH), remains poorly characterized. The authors sought to determine its frequency, predictors, and impact on functional outcome. METHODS The authors prospectively studied UEAV in a cohort of 1286 consecutively admitted patients with aSAH between August 1996 and June 2013. Admission clinical, radiographic, and acute clinical course information was documented during patient hospitalization. Functional outcome was assessed at 3 months using the modified Rankin Scale. Logistic regression and Cox proportional hazards models were generated to assess predictors of UEAV and its relationship to delayed cerebral ischemia (DCI) and outcome. Multiple imputation methods were used to address data lost to follow-up. RESULTS The cohort incidence rate of UEAV was 4.6%. Multivariable logistic regression analysis revealed that younger age, sentinel bleed, and poor admission clinical grade were significantly associated with UEAV. Patients with UEAV had a 2-fold increased risk of DCI (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.4-3.9, p = 0.002) and cerebral infarction (OR 2.0, 95% CI 1.0-3.9, p = 0.04), after adjusting for known predictors. Excluding patients who experienced sentinel bleeding did not change this effect. Patients with UEAV also had a significantly higher hazard for DCI in a multivariable model. UEAV was not found to be significantly associated with poor functional outcome (OR 0.8, 95% CI 0.4-1.6, p = 0.5). CONCLUSIONS UEAV may be less frequent than has been reported previously. Patients who exhibit UEAV are at higher risk for refractory DCI that results in cerebral infarction. These patients may benefit from earlier monitoring for signs of DCI and more aggressive treatment. Further study is needed to determine the long-term functional significance of UEAV.
authors.affiliation: Departments of Neurology and.
authors.forename: Fawaz
authors.initials: F
authors.lastname: Al-Mufti
authors.affiliation: Departments of Neurology and.
authors.forename: David
authors.initials: D
authors.lastname: Roh
authors.affiliation: Departments of Neurology and.
authors.forename: Shouri
authors.initials: S
authors.lastname: Lahiri
authors.affiliation: Departments of Neurology and.
authors.forename: Emma
authors.initials: E
authors.lastname: Meyers
authors.affiliation: Departments of Neurology and.
authors.forename: Jens
authors.initials: J
authors.lastname: Witsch
authors.affiliation: Departments of Neurology and.
authors.forename: Hans-Peter
authors.initials: HP
authors.lastname: Frey
authors.affiliation: Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Neha
authors.initials: N
authors.lastname: Dangayach
authors.affiliation: Departments of Neurology and.
authors.forename: Cristina
authors.initials: C
authors.lastname: Falo
authors.affiliation: Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.
authors.forename: Stephan A
authors.initials: SA
authors.lastname: Mayer
authors.affiliation: Departments of Neurology and.|Neurosurgery, Columbia University Medical Center; and.
authors.forename: Sachin
authors.initials: S
authors.lastname: Agarwal
authors.affiliation: Departments of Neurology and.|Neurosurgery, Columbia University Medical Center; and.
authors.forename: Soojin
authors.initials: S
authors.lastname: Park
authors.affiliation: Departments of Neurology and.|Neurosurgery, Columbia University Medical Center; and.
authors.forename: Philip M
authors.initials: PM
authors.lastname: Meyers
authors.affiliation: Neurosurgery, Columbia University Medical Center; and.
authors.forename: E Sander
authors.initials: ES
authors.lastname: Connolly
authors.affiliation: Departments of Neurology and.|Neurosurgery, Columbia University Medical Center; and.
authors.forename: Jan
authors.initials: J
authors.lastname: Claassen
authors.affiliation: Departments of Neurology and.
authors.forename: J Michael
authors.initials: JM
authors.lastname: Schmidt
mesh_terms: D002545:Brain Ischemia; D002544:Cerebral Infarction; D006760:Hospitalization; D006801:Humans; D007238:Infarction; D013345:Subarachnoid Hemorrhage; D020301:Vasospasm, Intracranial
keywords: ACA = anterior cerebral artery; APACHE-II = Acute Physiology and Chronic Health Evaluation-II; CI = confidence interval; CTA = CT angiography; DCI = delayed cerebral ischemia; DSA = digital subtraction angiography; HR = hazard ratio; ICA = internal carotid artery; MAP = mean arterial pressure; MCA = middle cerebral artery; OR = odd ratio; PCoA = posterior communicating artery; SAH = subarachnoid hemorrhage; UEAV = ultra-early angiographic vasospasm; cerebral infarction; cerebral vasospasm; delayed cerebral ischemia; functional recovery; mRS = modified Rankin Scale; subarachnoid hemorrhage; vascular disorders