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Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage

Winberg, Jakob ; Holm, Isabella LU ; Cederberg, David LU ; Rundgren, Malin LU ; Kronvall, Erik LU and Marklund, Niklas LU orcid (2022) In Neurocritical Care 37(1). p.255-266
Abstract

Background: Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. Methods: Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3–15), and... (More)

Background: Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. Methods: Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3–15), and World Federation of Neurosurgical Societies scale 4 (range 1–5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h. Results: We analyzed 7,223 CMD samples over a median of 6 days (5–8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region. Conclusions: Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.

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author
; ; ; ; and
organization
publishing date
type
Contribution to journal
publication status
published
subject
keywords
Cerebral microdialysis, Clinical application, Delayed cerebral ischemia, Subarachnoid hemorrhage
in
Neurocritical Care
volume
37
issue
1
pages
255 - 266
publisher
Humana Press
external identifiers
  • scopus:85129050664
  • pmid:35488171
ISSN
1541-6933
DOI
10.1007/s12028-022-01492-5
language
English
LU publication?
yes
id
ef1d5e4e-37cb-42af-bfbf-5d3c25ab3945
date added to LUP
2022-07-01 14:18:23
date last changed
2024-09-06 01:58:36
@article{ef1d5e4e-37cb-42af-bfbf-5d3c25ab3945,
  abstract     = {{<p>Background: Delayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH. Methods: Between 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3–15), and World Federation of Neurosurgical Societies scale 4 (range 1–5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h. Results: We analyzed 7,223 CMD samples over a median of 6 days (5–8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR &lt; 30 for minor and LPR &lt; 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region. Conclusions: Active interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.</p>}},
  author       = {{Winberg, Jakob and Holm, Isabella and Cederberg, David and Rundgren, Malin and Kronvall, Erik and Marklund, Niklas}},
  issn         = {{1541-6933}},
  keywords     = {{Cerebral microdialysis; Clinical application; Delayed cerebral ischemia; Subarachnoid hemorrhage}},
  language     = {{eng}},
  number       = {{1}},
  pages        = {{255--266}},
  publisher    = {{Humana Press}},
  series       = {{Neurocritical Care}},
  title        = {{Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage}},
  url          = {{http://dx.doi.org/10.1007/s12028-022-01492-5}},
  doi          = {{10.1007/s12028-022-01492-5}},
  volume       = {{37}},
  year         = {{2022}},
}