Delayed cerebral infarction in poor grade subarachnoid hemorrhage. Features, predictors, and clinical impact

Objectives: To investigate predictors and clinical impact of delayed cerebral infarction (CI) in a national multicentric poor grade aneurysmal subarachnoid hemorrhage (aSAH) population. Methods: Retrospective analysis of prospectively collected data from the multi-centric POGASH (Poor Grade aSAH) registry of consecutive patients treated from January 1st, 2015, to June 30th, 2023. Poor grade was defined according to the worst-pretreatment WFNS scale. CI was defined as a new ischemic lesion/s within 6 weeks of aSAH onset, not present on CT acquired within 48hrs and not related to treatment or hematoma. Clinical outcome was assessed by the modified Rankin Scale. Results: Among 532 consecutive WFNS grades IV-V aSAH patients, CI occurred in 106 (19.9%). CI (adjusted OR 0.59 0.35-0.98; p 0.045) independently predicted increased disability. Volume of SAH (aOR 1.02, 95% C.I. 1.00-1.04; p 0.015), anterior communicating aneurysm, ACoA, (aOR 6.2, 95% C.I. 1.4-27.3; p 0.015) and need of angiographic treatment (aOR 2.2, 95% C.I. 1.3-3.8; p 0.002) resulted independently predictive of CI occurrence. CI volume emerged as the strongest predictor of increased disability (aOR 1.03 95% C.I. 1.01-1.05; p < .001) and mortality (aOR 1.009 95% CI 1.002-1.02; P 0.018) in the CI affected population. Conclusions: ACoA, SAH volume and need for DSA treatment predicted CI, whose detrimental role on outcome is mainly driven by its volumetric extension. CI volume resulted independently predictive of mortality and increased disability in early brain injury survivors.