Decreasing delayed cerebral infarction after aneurysmal subarachnoid hemorrhage using active blood clearance and prevention of delayed cerebral ischemia: results of a 16-year patient registry

OBJECTIVE Active clearance of intracranial blood by intrathecal irrigation, fibrinolysis, and application of vasodilatory drugs may prevent delayed cerebral infarction (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Starting in 2015, the authors gradually implemented four methods for active blood clearance and prevention of delayed cerebral ischemia (ABCD) using urokinase and nimodipine in clinical management. In this paper, the impact of a patient-tailored use of these methods on DCI prevention is reported. METHODS Nine hundred sixty consecutive patients with aSAH admitted between 2008 and 2023 were included. Patients admitted before October 2015 were managed according to international guidelines (before-ABCD cohort, n = 543). ABCD became available in October 2015 and was gradually implemented by four different methods (after-ABCD cohort, n = 417) in patients at high risk for DCI. Nine patients in the after-ABCD cohort who were enrolled in a randomized trial on ABCD and allocated to standard of care were excluded. Cranial imaging was reviewed by an independent board and infarcts were classified as early, iatrogenic, or delayed. RESULTS After October 2015, 139 (33.3%) of 417 patients were selected for ABCD and the amount of extravasated blood (Hijdra sum score) was the key factor for ABCD use. Stereotactic catheter ventriculocisternostomy was developed in October 2015 and used in 88 patients. Intraoperative placement of a cisternoventricular catheter via the fenestrated lamina terminalis was introduced in 2018 and used in 30 patients. In 2021, ventriculolumbar irrigation and lumbo-lumbar irrigation were developed and used in 18 and 3 patients, respectively. DCI occurred in 115 (21.2%) of 543 patients before versus 32 (7.7%) of 417 patients after ABCD implementation (p < 0.0001). The per-patient DCI burden declined from 38.6 to 11.7 cm 3 . Neurological outcome was improved in patients with a high blood load (Hijdra score ≥ 30), and 26% after ABCD versus 9% of patients before ABCD achieved a modified Rankin Scale score of 0–3 (p = 0.006). CONCLUSIONS Implementation of ABCD was associated with a low complication rate and a decline of 70% in the per-patient DCI burden. Outcomes were significantly improved in patients with a high blood load.