Intraparenchymal near-infrared spectroscopy for detection of delayed cerebral ischemia in poor-grade aneurysmal subarachnoid hemorrhage

Abstract

Objective: Detection of delayed cerebral ischemia (DCI) is challenging in comatose patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Brain tissue oxygen pressure (PbtO2) monitoring may allow early detection of its occurrence. Recently, a probe for combined measurement of intracranial pressure (ICP) and intraparenchymal near-infrared spectroscopy (NIRS) has become available. In this pilot study, the parameters PbtO2, Hboxy, Hbdeoxy, Hbtotal and rSO2 were measured in parallel and evaluated for their potential to detect perfusion deficits or cerebral infarction.

Methods: In patients undergoing multimodal neuromonitoring due to poor neurological condition after aSAH, Clark oxygen probes, microdialysis and NIRS-ICP probes were applied. DCI was suspected when the measured parameters in neuromonitoring deteriorated. Thus, perfusion CT scan was performed as follow up, and DCI was confirmed as perfusion deficit. Median values for PbtO2, Hboxy, Hbdeoxy, Hbtotal and rSO2 in patients with perfusion deficit (Tmax > 6 s in at least 1 vascular territory) and/or already demarked infarcts were compared in 24- and 48-hour time frames before imaging.

Results: Data from 19 patients (14 University Hospital Zurich, 5 Charité Universitätsmedizin Berlin) were prospectively collected and analyzed. In patients with perfusion deficits, the median values for Hbtotal and Hboxy in both time frames were significantly lower. With perfusion deficits, the median values for Hboxy and Hbtotal in the 24 h time frame were 46,3 [39.6, 51.8] µmol/l (no perfusion deficits 53 [45.9, 55.4] µmol/l, p = 0.019) and 69,3 [61.9, 73.6] µmol/l (no perfusion deficits 74,6 [70.1, 79.6] µmol/l, p = 0.010), in the 48 h time frame 45,9 [39.4, 51.5] µmol/l (no perfusion deficits 52,9 [48.1, 55.1] µmol/l, p = 0.011) and 69,5 [62.4, 74.3] µmol/l (no perfusion deficits 75 [70,80] µmol/l, p = 0.008), respectively. In patients with perfusion deficits, PbtO2 showed no differences in both time frames. PbtO2 was significantly lower in patients with infarctions in both time frames. The median PbtO2 was 17,3 [8,25] mmHg (with no infarctions 29 [22.5, 36] mmHg, p = 0.006) in the 24 h time frame and 21,6 [11.1, 26.4] mmHg (with no infarctions 31 [22,35] mmHg, p = 0.042) in the 48 h time frame. In patients with infarctions, the median values of parameters measured by NIRS showed no significant differences.

Conclusions: The combined NIRS-ICP probe may be useful for early detection of cerebral perfusion deficits and impending DCI. Validation in larger patient collectives is needed.

Keywords: Delayed cerebral Ischemia; Near-infrared Spectroscopy; Subarachnoid hemorrhage.