Impairment of Cerebral Autoregulation Predicts Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Abstract

Background and Purpose— Delayed cerebral ischemia (DCI) is a recognized contributor to unfavorable outcome after subarachnoid hemorrhage (SAH). Recent data challenge the concept of vasospasm as the sole cause of ischemia and suggest a multifactorial process with dysfunctional cerebral autoregulation as a component. We tested the hypothesis that early autoregulatory failure, detected using near-infrared spectroscopy–based index, TOxa and transcranial Doppler–based index, Sxa, can predict DCI. Methods— In this prospective observational study we enrolled consecutive patients with aneurysmal SAH that occurred <5 days from admission. The primary end point was the occurrence of DCI within 21 days of ictus. The predictive value of autoregulatory disturbances detected in the first 5 days was assessed using univarate proportional hazards model and a multivariate model. Results— Ninety-eight patients were included. Univariate analysis demonstrated increased odds of developing DCI when early autoregulation failure was detected (odds ratio [OR], 7.46; 95% confidence interval [CI], 3.03–18.40 and OR, 4.52; 95% CI, 1.84–11.07 for Sxa and TOxa, respectively) but not TCD-vasospasm (OR, 1.36; 95% CI, 0.56–3.33). In a multivariate model Sxa and TOxa remained independent predictors of DCI (OR, 12.66; 95% CI, 2.97–54.07 and OR, 5.34; 95% CI, 1.25–22.84 for Sxa and TOxa, respectively). Conclusions— Disturbed autoregulation in the first 5 days after SAH significantly increases the risk of DCI. Autoregulatory disturbances can be detected using near-infrared spectroscopy and transcranial Doppler technologies.