Duration of Intracranial Pressure Increase after Aneurysmal Subarachnoid Hemorrhage: Prognostic Factors and Association with the Outcome

Abstract

aims: Analysis of risk factors associated with the duration of pathological ICP rise and the relationship between ICP exposure and outcome of subarachnoid haemorrhage (SAH). background: For SAH cases, sudden rise of ICP has been found to be one of the strongest predictors of poor outcome. objective: Rupture of intracranial aneurysm is frequently complicated with an increase of intracranial pressure (ICP) requiring conservative and/or surgical treatment. We analyzed the risk factors related to the duration of pathologic ICP increase and the relationship between ICP burden and outcome of subarachnoid hemorrhage (SAH). method: Consecutive cases with aneurysmal SAH treated at our institution between 01/2003 and 06/2016 were eligible for this study. Different admission variables were evaluated with regard to the prediction of duration of ICP increase >20 mmHg in univariate and multivariate analyses. The association of ICP course with SAH outcome parameters (risk of cerebral infarction, in-hospital mortality and unfavorable outcome at 6 months defined as modified Rankin scale >3) were adjusted for major outcome-relevant confounders. result: Of 820 SAH patients, 378 individuals (46.1%) developed at least one ICP increase requiring conservative and/or surgical management after aneurysm treatment (mean duration: 1.76 days, range: 1 – 14 days). In the multivariable linear regression analysis, patients’ age (unstandardized coefficient [UC]=-0.02, p<0.0001), WFNS grade 4-5 at admission (UC=0.71, p<0.004), regular medication with the angiotensin converting enzyme inhibitors (UC=-0.61, p=0.01), and presence of intracerebral hemorrhage (UC=0.59, p=0.002) were associated with the duration of ICP increase. In turn, patients with longer ICP elevations were at higher risk for cerebral infarction (adjusted odds ratio [aOR]=1.32 per-day-increase, p<0.0001), in-hospital mortality (aOR=1.30, p<0.0001) and unfavorable outcome (aOR=1.43, p<0.0001). SAH patients who underwent primary decompressive craniectomy showed shorter period of ICP increase than patients with secondary decompression (mean: 2.8 vs 4.9 days, p<0.0001). conclusion: The duration of ICP increase after aneurysm rupture is a strong outcome predictor and related to younger age and higher initial severity of SAH. Further analysis of the factors impacting the course of ICP after SAH is essential for the optimization of ICP management and outcome improvement. other: -