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Early global brain oedema in relation to clinical admission parameters and outcome in patients with aneurysmal subarachnoid haemorrhage

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Abstract

Background

Previous studies on spontaneous aneurysmal subarachnoid haemorrhage (SAH) treatment have found the presence of global cerebral oedema on the first CT scan to be a predictor of poor outcome. We have reviewed our own experience with SAH in order to evaluate the relation of global cerebral oedema to clinical parameters at admission and to functional outcome.

Methods

One hundred ninety patients with spontaneous aneurysmal SAH were included in the study. The first CT scan for each patient was evaluated for signs of global cerebral oedema. Clinical status on admission was assessed according to the Hunt & Hess score and the World Federation of Neurosurgical Societies (WFNS) grade and functional outcome using the Glasgow Outcome Scale (GOS). Clinical condition at admission was dichotomised as ‘better’ (Hunt & Hess 1–2, WFNS 1–2) or ‘worse’ (Hunt & Hess 3–5, WFNS 3–5) and outcome as ‘favourable’ (GOS 4–5) or ‘poor’ (GOS 1–3). The amount of blood on the CT scan was assessed using the Fisher scale. Comparisons were made between patients with and without global cerebral oedema on the first CT regarding clinical condition, age, gender, mode of aneurysm treatment, outcome, 6-month mortality, amount of blood on the CT scan and time lag to the first CT scan.

Results

Global cerebral oedema was observed in 57% of patients admitted with aneurysmal SAH, which is a much higher frequency than has been reported previously. Patients with oedema were admitted in a worse clinical status, but there was no difference between patients with and without oedema regarding other clinical parameters or outcome. The median time between the haemorrhage and the first CT scan was short compared to earlier studies, 2.5 h for those with oedema and 3.4 for those without. This difference was significant, suggesting that global cerebral oedema can be a very early phenomenon after SAH, and may be missed in later CT scans.

Summary

Early global brain oedema, occurring within a few hours of bleeding, may be more common than previously thought. In aneurysmal SAH patients, the presence of global cerebral oedema was associated with a worse clinical condition at admission which in turn could indicate a more severe initial injury. The clinical significance of early oedema may differ from that of late oedema, which may explain the lack of an association between global oedema and poor outcome in this study. However, the nature of the oedema as well as its relation to the clinical course has to be further studied in separate studies.

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Authors and Affiliations

  1. Department of Neurosurgery, Division of Neuroscience, Uppsala University, Uppsala University Hospital, 751 85, Uppsala, Sweden

    Maria Zetterling & Elisabeth Ronne-Engström

  2. Department of Neuroradiology, Karolinska University Hospital, 14 186, Huddinge, Sweden

    Lena Hallberg

Authors
  1. Maria Zetterling
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  2. Lena Hallberg
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  3. Elisabeth Ronne-Engström
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Corresponding author

Correspondence to Elisabeth Ronne-Engström.

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Comment

This is a retrospective study of a SAH patient population in Sweden looking for evidence of brain oedema (GCE) on CT scans and possible consequences that this purportedly oedematous state may have in longer term clinical follow-up. The article is based on the assumption that 'oedema' carries a significant deleterious impact in the clinical outcome of patients with SAH as verified in other studies.

The authors found that earlier scanned patients (who were in worse clinical condition) had a higher percentage of oedematous signs on CT. No difference in outcome could however be demonstrated in the long run. Still it is inferred that oedema is a noxious element for patients with SAH. However, several clinical variables may blur the effect that oedema may possibly have on the outcome.

There is recognisably also an issue with the definition and quantification of what is being called oedema, essentially an image based on a CT representation of the brain (and not on an MRI which is somewhat more sophisticated for the purpose).

Finally, one is forced to be cautious in the interpretation of data because we do not really know what this imaging effect is all about. It is being interpreted and valued as an alteration of the Hounsfield scale along with direct and indirect signs of mechanical displacement of the brain. However, as stated by the authors, there is no truly reliable and definitive information as to what these changes relate in terms of the neurochemical and blood flow changes of the affected brain areas.

In fact, the results of this series demonstrated no long-term outcome difference between the two patient populations.

Because it was found that earlier scanned patients had a much higher incidence of GCE and that this difference was not present in patients who have their scans done at a later date, it would be interesting and a challenge to the authors to try to understand if the GCE findings demonstrated in early scanned patients persists in follow-up CTS.

Concomitantly, it would be important to assess what percentage (if any) of those early scanned patients with no GCE findings end up developing these signs at a later date. These patterns may help us further understand the real clinical meaning and impact of the described changes.

Manuel Cunha e Sá, M.D.

Department of Neurosurgery

Hospital Garcia de Orta

Almada, Portugal

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Zetterling, M., Hallberg, L. & Ronne-Engström, E. Early global brain oedema in relation to clinical admission parameters and outcome in patients with aneurysmal subarachnoid haemorrhage. Acta Neurochir 152, 1527–1533 (2010). https://doi.org/10.1007/s00701-010-0684-8

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  • DOI: https://doi.org/10.1007/s00701-010-0684-8

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