Carotid atherosclerotic disease in aneurysmal subarachnoid hemorrhage: an underrated risk for cerebral infarction

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OBJECTIVE Carotid atherosclerotic disease (CAD), which commonly results in internal carotid artery (ICA) stenosis, is a risk factor for ischemic stroke due to cerebral hypoperfusion. The aim of this study was to analyze the predictive value of CAD for the occurrence of infarction and an unfavorable outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS Consecutive patients with aSAH treated at a central European tertiary care center between December 2004 and June 2016 were analyzed retrospectively. To quantify CAD, the North American Symptomatic Carotid Endarterectomy Trial score was calculated based on CTA. The study endpoints were the occurrence of cerebral infarction, subgrouped according to timing (≤ 48 hours vs > 48 hours), location in the ICA territory and its subterritories, and occurrence of an unfavorable outcome (modified Rankin Scale score ≥ 4) at 6 months. Binary logistic regression was used to adjust for the following confounders: age, radiological and clinical hemorrhage severity, vasospasm in the ICA, smoking status, arterial hypertension, obesity, and acute hydrocephalus. RESULTS Of 799 consecutive patients treated for aSAH, 378 (256 female, mean age 55.82 years) had CTA available and were included in this analysis. CAD was shown to have independent predictive value for an unfavorable outcome (adjusted OR [aOR] 1.02, 95% CI 1.00–1.05; p = 0.031) and the occurrence of infarction in the ICA territory (aOR 1.04, 95% CI 1.02–1.06; p < 0.001). Regarding infarction timing, there was an independent association with delayed cerebral infarctions (aOR 1.03, 95% CI 1.01–1.05; p = 0.006) but not with early infarctions (aOR 1.01, 95% CI 0.99–1.03; p = 0.388). CONCLUSIONS These findings highlight the negative impact of CAD on the risk of cerebral ischemia and a poor outcome after aSAH. Further studies are needed to confirm the relevance of CAD during the clinical course of aSAH and to identify potential treatment strategies.

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