Acute focal neurological deficits in aneurysmal subarachnoid hemorrhage - Relation of clinical course, CT findings, and metabolite abnormalities monitored with bedside microdialysis

Background and Purpose - We sought ( 1) to identify early metabolic markers for the development of (ir) reversible neurological deficits and cerebral infarction in subarachnoid hemorrhage (SAH) patients by using the microdialysis technique and ( 2) to evaluate the influence of intracerebral hemorrhage (ICH) on microdialysis parameters. Methods - We performed a prospective study of 44 SAH patients with acute focal neurological deficits (AFND) occurring acutely with SAH ( due to ICH) or directly after surgery ( due to clip stenosis, thromboembolism, or early edema). Fifty-one nonischemic SAH patients served as a control group. A microdialysis catheter was inserted into the vascular territory of the aneurysm after clipping. The microdialysates were analyzed hourly for extracellular glucose, lactate, lactate/pyruvate ratio, glutamate, and glycerol with a bedside analyzer. Microdialysis-related CT findings were evaluated for the presence of ICH and cerebral infarction. Reversibility of neurological symptoms after 4 weeks and 6- and 12-month outcomes were assessed. Results - In patients with AFND, cerebral metabolism was severely disturbed when microdialysis started compared with controls ( P < 0.005). Infarction on CT was associated with pathological microdialysis parameters ( P < 0.002) and development of a fixed deficit ( P < 0.003), while the presence of ICH alone was not. A secondary neurological deterioration of AFND patients (n = 11) was reflected by preceding ( 0 to 20 hours) changes of microdialysate concentrations. Conclusions - In the presence of ICH, pathological microdialysis values may indicate reversible tissue damage. Extreme microdialysis values and pathological microdialysis concentrations that further deteriorate 2-fold are highly indicative of the development of cerebral infarction and permanent neurological deficits. Therefore, the analysis of relative changes of microdialysis parameters is crucial for the detection of ischemia in SAH patients.