Effect of Acute Cocaine Use on Vasospasm and Outcome in Aneurysmal Subarachnoid Hemorrhage

OBJECT Seizures are relatively common after aneurysmal subarachnoid hemorrhage (aSAH). Seizure prophylaxis is controversial and is often based on risk stratification; middle cerebral artery (MCA) aneurysms, associated intracerebral hemorrhage (ICH), poor neurological grade, increased clot thickness, and cerebral infarction are considered highest risk for seizures. The purpose of this study was to evaluate the impact of recent cocaine use on seizure incidence following aSAH. METHODS Prospectively collected data from aSAH patients admitted to 2 institutional neuroscience critical care units between 1991 and 2009 were reviewed. The authors analyzed factors that potentially affected the incidence of seizures, including patient demographic characteristics, poor clinical grade (Hunt and Hess Grade IV or V), medical comorbidities, associated ICH, intraventricular hemorrhage (IVH), hydrocephalus, aneurysm location, surgical clipping and cocaine use. They further studied the impact of these factors on “early” and “late” seizures (defined, respectively, as occurring before and after clipping/coiling). RESULTS Of 1134 aSAH patients studied, 182 (16%) had seizures; 81 patients (7.1%) had early and 127 (11.2%) late seizures, with 26 having both. The seizure rate was significantly higher in cocaine users (37 [26%] of 142 patients) than in non-cocaine users (151 [15.2%] of 992 patients, p = 0.001). Eighteen cocaine-positive patients (12.7%) had early seizures compared with 6.6% of cocaine-negative patients (p = 0.003); 27 cocaine users (19%) had late seizures compared with 10.5% non-cocaine users (p = 0.001). Factors that showed a significant association with increased risk for seizure (early or late) on univariate analysis included younger age (< 40 years) (p = 0.009), poor clinical grade (p = 0.029), associated ICH (p = 0.007), and MCA aneurysm location (p < 0.001); surgical clipping was associated with late seizures (p = 0.004). Following multivariate analysis, age < 40 years (OR 2.04, 95% CI 1.355–3.058, p = 0.001), poor clinical grade (OR 1.62, 95% CI 1.124–2.336, p = 0.01), ICH (OR 1.95, 95% CI 1.164–3.273, p = 0.011), MCA aneurysm location (OR 3.3, 95% CI 2.237–4.854, p < 0.001), and cocaine use (OR 2.06, 95% CI 1.330–3.175, p = 0.001) independently predicted seizures. CONCLUSIONS Cocaine use confers a higher seizure risk following aSAH and should be considered during risk stratification for seizure prophylaxis and close neuromonitoring.

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Cocaine use as a predictor of outcome in aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2003.99.2.0271 ◽

2003 ◽

Vol 99 (2) ◽

pp. 271-275 ◽

Cited By ~ 55

Author(s):

Jay U. Howington ◽

Scott C. Kutz ◽

Gregory E. Wilding ◽

Deepak Awasthi

Keyword(s):

Statistical Analysis ◽

Subarachnoid Hemorrhage ◽

Retrospective Review ◽

Aneurysmal Subarachnoid Hemorrhage ◽

User Group ◽

Cocaine User ◽

Content Type ◽

Cocaine Use ◽

Poor Outcome ◽

Fine Print

Object. The goal of this study was to analyze the relationship between cocaine use and outcomes of aneurysmal subarachnoid hemorrhage (SAH). Methods. A retrospective review was performed of the medical records of patients with intracranial aneurysms treated at a single institution between January 1996 and December 2001. Only patients who presented with SAH were included in the study. The covariates chosen for the statistical analysis included the following: patient age, sex, and race; systolic and mean arterial blood pressure measurements on hospital admission; Hunt and Hess and Fisher grades; preexistent major systemic disease; and history of alcohol, tobacco, or cocaine use. The Glasgow Outcome Scale (GOS) was used to standardize outcome and was dichotomized such that a score between 1 and 3 was considered a poor outcome and a score of 4 or 5 was considered a favorable outcome. The records of 151 patients were reviewed and 108 of these presented with aneurysmal SAH. Of these 108 patients, 36 (33.3%) had used cocaine within 24 hours before presentation. A Hunt and Hess grade of IV or V was assigned to 20 (55.6%) of 36 patients who used cocaine, compared with eight (11.1%) of 72 patients who did not; this difference was found to be statistically significant (p < 0.0001). Twenty-eight patients (77.8%) in the cocaine user group and 20 patients (27.8%) in the non—cocaine user group experienced clinically significant, angiographically confirmed vasospasm during their hospital course (p < 0.0001). Cocaine use was associated with a 2.8-fold greater risk of developing vasospasm (95% confidence interval [CI] 1.86–4.22). A GOS score of 1, 2, or 3 was assigned to 33 patients (91.7%) in the cocaine user group and to 20 patients (27.8%) in the non—cocaine user group (p < 0.0001). Cocaine use was associated with a 3.3-fold greater risk of poor outcome (95% CI 2.24–4.85). This association was found to be independent of Hunt and Hess grade as well as of vasospasm. Conclusions. Cocaine adversely affects both the presentation of and outcome in patients with aneurysmal SAH who are undergoing treatment for this disease. The vasoactive properties of the drug appear to aggravate the already tenuous situation of SAH and increase both the occurrence and influence of cerebral vasospasm. Statistical analysis demonstrates that cocaine directly affects both presentation and outcome in a significant manner. It is the authors' interpretation of the results of this retrospective review that cocaine use negatively affects outcome to such an extent that it should be considered equal to the presence of a major systemic illness when determining Hunt and Hess grade.

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Impact of Acute Cocaine Use on Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/strokeaha.111.000749 ◽

2013 ◽

Vol 44 (7) ◽

pp. 1825-1829 ◽

Cited By ~ 23

Author(s):

Tiffany R. Chang ◽

Robert G. Kowalski ◽

Filissa Caserta ◽

Juan Ricardo Carhuapoma ◽

Rafael J. Tamargo ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Cocaine Use

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Delayed cerebral ischemia causing cortical blindness due to repeat cocaine use weeks subsequent to aneurysmal subarachnoid hemorrhage

Radiology Case Reports ◽

10.1016/j.radcr.2020.05.050 ◽

2020 ◽

Vol 15 (9) ◽

pp. 1455-1459 ◽

Cited By ~ 2

Author(s):

Brendan J. Klein ◽

Joshua A. Cuoco ◽

Cara M. Rogers ◽

John J. Entwistle ◽

Eric A. Marvin ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Cerebral Ischemia ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Cortical Blindness ◽

Cocaine Use

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In-hospital outcomes of aneurysmal subarachnoid hemorrhage associated with cocaine use in the USA

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2014.05.012 ◽

2014 ◽

Vol 21 (12) ◽

pp. 2088-2091 ◽

Cited By ~ 7

Author(s):

Santosh B. Murthy ◽

Yogesh Moradiya ◽

Shreyansh Shah ◽

Neeraj S. Naval

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Hospital Outcomes ◽

Cocaine Use ◽

The Usa

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Abstract 50: Impact of Acute Cocaine use on Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.44.suppl_1.a50 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Neeraj S Naval ◽

Tiffany Chang ◽

Robert Kowalski ◽

Filissa Caserta ◽

Juan R Carhuapoma ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Hospital Mortality ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Cocaine Exposure ◽

Cocaine Use ◽

History Of ◽

Cocaine Users ◽

The Impact ◽

Patient Presentation

Objective: To analyze the impact of acute cocaine use on presentation and outcomes following aneurysmal subarachnoid hemorrhage (aSAH). Background: Acute cocaine use has been temporally associated with aSAH but there are varying reports describing how it affects patient presentation, complications and outcomes. Design/Methods: Data of aSAH patients admitted to our institution between 1991-2009 were reviewed to determine which patients had used cocaine within 72 hours of aSAH based on positive urine toxicology or a history of cocaine use within 72 hours (C). These patients were then compared with aSAH patients without recent cocaine exposure (NC) in relation to their clinical and radiological presentations, complications such as DIND (delayed ischemic neurological deficit defined by vasospasm mediated cerebral infarcts) and outcomes defined by hospital mortality. Results: Data of 1134 patients were reviewed; aSAH in142 patients (12.5%) was associated with cocaine use. Cocaine users were more likely to be younger (mean age: C:49, NC:53, p0.05), admission GCS 0.05), associated IVH (C:56%, NC:51%, p>0.05) or hydrocephalus on admission CT (C:49%; NC:52%, p> 0.05). Cocaine users were more likely to have vasospasm related infarcts when compared to non-cocaine users (C:22%; NC:16%, p<0.05) but after correcting for other factors impacting vasospasm, cocaine use was not independently associated with DIND. Cocaine users had higher rates of aneurysm re-rupture (C:7.7%, NC:2.7%, p0.004). Cocaine users were less likely to survive hospitalization compared to non-users following univariate analysis (Mortality: C:26%, NC:17%, p< 0.05); the adjusted odds of hospital mortality were 2.9 times higher among cocaine users following multivariate analysis (p<0.001). Conclusions: Acute cocaine use was associated with a higher risk of aneurysm re-rupture and hospital mortality following aSAH. The various mechanisms for the nearly threefold increased odds of death associated with cocaine use warrants further investigation.

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