Vasospasm and Delayed Cerebral Ischemia in Aneurysmal Rupture with Intracerebral Hemorrhage With and Without Subarachnoid Hemorrhage

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Abstract
Background: The risk of vasospasm and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is well characterized. However, the risk of these complications in cases of aneurysmal rupture causing intracerebral hemorrhage is less clear. Here, we characterized the incidence and radiographic features of aneurysmal ICH (aICH) and the associated risk of vasospasm and DCI. Methods: This is a retrospective single-center cohort study of 442 patients with aneurysmal hemorrhage from 2014 to 2021. Clinical and radiographic features were compared in those with versus without ICH and presence of ICH was analyzed as an independent risk factor for vasospasm and DCI. Further, the incidence of vasospasm/DCI in those with aneurysmal ICH without SAH was compared to those with ICH and cisternal SAH. Vasospasm and DCI were evaluated only in those surviving at least four days. Results: Overall, 83 of 442 patients (19%) had ICH, of whom only 8 (2%) had ICH without SAH. Among those surviving for 4 days, patients with ICH experienced higher rates of vasospasm (59% vs. 34%) and DCI (42% vs. 21%, both p = 0.0005) than those patients with SAH without ICH. Those with ICH without SAH experienced numerically lower rates of vasospasm than those with concomitant ICH and SAH (43% vs 62%) and DCI (14% vs. 46%). After adjustment for age, aneurysm size, WFNS grade, modified Fisher and IVH scores, ICH was an independent risk factor for vasospasm (OR 2.26, 95% CI 1.13–4.52) with a trend to higher risk of DCI (OR 1.83, 95% CI 0.90–3.68). Conclusion: Presence of ICH following aneurysmal rupture carries significantly higher risk of vasospasm with a trend to higher risk of DCI in survivors. In comparison, aneurysmal ICH without SAH is relatively rare but is still associated with vasospasm and DCI, though this estimate requires confirmation in larger cohorts.

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