Quantitative assessments of pupillary light reflexes in hospital-onset unresponsiveness

Abstract Background Patients who develop hospital-onset unresponsiveness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the gold standard method in the initial evaluation of unresponsive patients. However, the current method of shining light and subjective description often shows poor reliability. The objective of this study is to explore whether a quantitative measurement of pupillary light reflexes is useful in detecting brain herniation syndrome and predicting neurological outcomes in patients who developed hospital-onset unresponsiveness after admission for non-neurological reasons. Methods This was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unresponsiveness was defined as a newly developed unresponsive state as assessed by the ACDU (Alert, Confused, Drowsy, and Unresponsive) scale during the hospital stay. Demographics, comorbidities, pupillometry parameters including Neurological Pupil index, brain herniation syndrome, in-hospital mortality, and modified Rankin Scale at 3-months were analyzed. Results In 214 consecutive patients with hospital-onset unresponsiveness, 37 (17%) had brain herniation syndrome. The optimal cut-off value of Neurological Pupil index for detecting brain herniation syndrome was < 1.6 (specificity, 91% [95% confidence interval (CI) = 86–95]; sensitivity, 49% [95% CI = 32–66]). The in-hospital mortality rate was 28% (59/214); the Neurological Pupil index was negatively associated with in-hospital mortality after adjustments for the presence of brain herniation syndrome (adjusted odds ratio = 0.77, 95% CI = 0.62–0.96). Poor neurological outcomes (modified Rankin Scale ≥4) at 3 months was observed in 76% (152/201) of the patients; the Neurological Pupil index was negatively associated with poor neurological outcomes after adjustments for clinical variables (adjusted odds ratio = 0.67, 95% CI = 0.49–0.90). Conclusions Quantitative measurements of pupillary light reflexes may be useful for early detection of potentially life-threatening neurological conditions in patients with hospital-onset unresponsiveness.

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Quantitative Assessments of Pupillary Light Reflexes in Hospital-Onset Unconsciousness

10.21203/rs.3.rs-107836/v1 ◽

2020 ◽

Author(s):

Hyunjo Lee ◽

Soh Hyun Choi ◽

Bobin Park ◽

Yoon-Hee Hong ◽

Han-Bin Lee ◽

...

Keyword(s):

Hospital Mortality ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Medical Center ◽

Modified Rankin Scale ◽

Brain Herniation ◽

Negatively Associated ◽

Neurological Outcomes ◽

Pupillary Light ◽

Neurological Pupil Index

Abstract BackgroundPatients who develop hospital-onset unconsciousness should be promptly managed in order to avoid clinical deterioration. Pupillary examination through pupillary light reflex is the mainstay method in the initial evaluation of unconscious patients, but the current method of light shedding and subjective description often shows poor reliability. The objective of this study is to explore whether a quantitative measurement of pupillary light reflexes is useful in detecting brain herniation syndrome and predicting neurological outcomes in non-neurological patients who developed hospital-onset unconsciousness.MethodsThis was a registry-based observational study on patients who activated the neurological rapid response team at Asan Medical Center (Seoul, Korea). Hospital-onset unconsciousness was defined as a newly developed stupor or comatose state during admission. Demographics, comorbidities, pupillometry parameters including Neurological Pupil index, brain herniation syndrome, in-hospital mortality, and modified Rankin Scale at 3-months were analyzed.ResultsIn 214 consecutive patients with hospital-onset unconsciousness, 37 (17%) had brain herniation syndrome. The optimal cut-off value of Neurological Pupil index for detecting brain herniation syndrome was < 1.6 (specificity, 91% [95% confidence interval (CI) = 86−95]; sensitivity, 49% [95% CI = 32−66]). The in-hospital mortality rate was 28% (59/214); the Neurological Pupil index was negatively associated with in-hospital mortality after adjustments for the presence of brain herniation syndrome (adjusted odds ratio = 0.77, 95% CI = 0.62–0.96). Poor neurological outcomes (modified Rankin Scale ≥ 4) at 3 months was observed in 76% (152/201) of the patients; the Neurological Pupil index was negatively associated with poor neurological outcomes after adjustments for clinical variables (adjusted odds ratio = 0.67, 95% CI = 0.49–0.90). ConclusionsQuantitative measurements of pupillary light reflexes may be useful for early detection of potentially life-threatening neurological conditions in patients with hospital-onset unconsciousness.

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Outcomes of Neutropenic Patients with Clostridium difficile Infection

Infection Control and Hospital Epidemiology ◽

10.1017/ice.2020.950 ◽

2020 ◽

Vol 41 (S1) ◽

pp. s339-s340

Author(s):

Roopali Sharma ◽

Deepali Dixit ◽

Sherin Pathickal ◽

Jenny Park ◽

Bernice Lee ◽

...

Keyword(s):

Clostridium Difficile ◽

Length Of Stay ◽

Hospital Mortality ◽

Treatment Failure ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Hospital Length ◽

Hospital Length Of Stay ◽

End Point ◽

Neutropenic Patients

Background: Data from Clostridium difficile infection (CDI) in neutropenic patients are still scarce. Objective: To assess outcomes of CDI in patients with and without neutropenia. Methods: The study included a retrospective cohort of adult patients at 3 academic hospitals between January 2013 and December 2017. The 2 study arms were neutropenic patients (neutrophil count <500/mm3) and nonneutropenic patients with confirmed CDI episodes. The primary outcome evaluated the composite end point of all-cause in-hospital mortality, intensive care unit (ICU) admissions, and treatment failure at 7 days. The secondary outcome evaluated hospital length of stay. Results: Of 962 unique cases of CDI, 158 were neutropenic (59% men) and 804 were nonneutropenic (46% men). The median age was 57 years (IQR, 44–64) in the neutropenic group and 68 years (IQR, 56–79) in the nonneutropenic group. The median Charlson comorbidity score was 5 (IQR, 3–7.8) and 4 (IQR, 3–5) in the neutropenic and nonneutropenic groups, respectively. Regarding severity, 88.6% versus 48.9% were nonsevere, 8.2% versus 47% were severe, and 3.2% versus 4.1% were fulminant in the neutropenic and nonneutropenic groups, respectively. Also, 63% of patients (60.9% in nonneutropenic, 65.2% in neutropenic) were exposed to proton-pump inhibitors. A combination CDI treatment was required in 53.2% of neutropenic patients and 50.1% of nonneutropenic patients. The primary composite end point occurred in 27% of neutropenic patients versus 22% of nonneutropenic patients (P = .257), with an adjusted odds ratio of 1.30 (95% CI, 0.84–2.00). The median hospital length of stay after controlling for covariates was 21.3 days versus 14.2 days in the neutropenic and nonneutropenic groups, respectively (P < .001). Complications (defined as hypotension requiring vasopressors, ileus, or bowel perforation) were seen in 6.0% of the nonneutropenic group and 4.4% of the neutropenic group (P = .574), with an adjusted odds ratio of 0.61 (95% CI, 0.28–1.45). Conclusions: Neutropenic patients were younger and their cases were less severe; however, they had lower incidences of all-cause in-hospital mortality, ICU admissions, and treatment failure. Hospital length of stay was significantly shorter in the neutropenic group than in the nonneutropenic group.Funding: NoneDisclosures: None

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Comprehensive assessment of disability post-stroke using the newly developed miFUNCTION scale

International Journal of Stroke ◽

10.1177/1747493019840933 ◽

2019 ◽

Vol 15 (2) ◽

pp. 167-174 ◽

Cited By ~ 2

Author(s):

Charlotte Zerna ◽

Tyler Burley ◽

Theresa L Green ◽

Sean P Dukelow ◽

Andrew M Demchuk ◽

...

Keyword(s):

Pilot Study ◽

Confidence Interval ◽

Endovascular Treatment ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Outcome Measure ◽

Observer Agreement ◽

International Classification Of Functioning ◽

Modified Rankin Scale ◽

Escape Trial

Background and Purpose The modified Rankin Scale (mRS) is the most widely used primary outcome measure in acute stroke trials. However, substantial interobserver variability impairs outcome assessment as well as reduces power of clinical trials. Guided by the International Classification of Functioning, Disability and Health, we developed a comprehensive, hierarchical assessment tool (miFUNCTION) to address the shortcomings of the modified Rankin Scale and deliver a more thorough understanding of disability following stroke. Methods The initial construct validity of miFUNCTION was established in a pilot study of patients at an outpatient stroke prevention clinic that had been diagnosed with stroke within 60 days. To further assess criterion validity, miFUNCTION was compared against the modified Rankin Scale and other outcome measures within the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial. Logistic regression analysis with miFUNCTION as an outcome was used to demonstrate the beneficial effect of endovascular treatment. Results The pilot study showed moderate inter-observer agreement (k = 0.585, p < 0.005) but near perfect correlation between miFUNCTION and modified Rankin Scale (ρ = 0.821, p < 0.05). The correlation of miFUNCTION and modified Rankin Scale was near perfect again in the ESCAPE trial (ρ = 0.944). Effect size of the multivariable models using modified Rankin Scale (adjusted odds ratio: 3.45, 95% confidence interval: 2.05–5.78) and miFUNCTION (adjusted odds ratio: 3.32, 95% confidence interval: 1.99–5.55) as an outcome measure for the ESCAPE trial patients was similar. Conclusions miFUNCTION is strongly associated with the degree of disability following stroke both in an outpatient setting and a clinical trial. Further work remains to assess sensitivity to change and to improve the inter-observer reliability of the scale.

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Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Stroke ◽

10.1161/strokeaha.120.031672 ◽

2021 ◽

Author(s):

Tomas Dobrocky ◽

Eike I. Piechowiak ◽

Bastian Volbers ◽

Nedelina Slavova ◽

Johannes Kaesmacher ◽

...

Keyword(s):

Middle Cerebral Artery ◽

Scale Score ◽

Cerebral Artery ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

National Institutes Of Health ◽

Neurological Deficits ◽

Minor Stroke ◽

Modified Rankin Scale ◽

Stroke Patients

Background and Purpose: Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion. Methods: Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only. Results: Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0−2) for EVT (adjusted odds ratio, 0.96; adjusted P =0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P =0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P =0.032) in the EVT compared with the IVT only group. Conclusions: Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

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The Burden of Hyperbilirubinemia in Critically Ill Patients with Hematological Malignancies: Post-hoc Analysis of a Prospective Multicenter Multinational Study

10.21203/rs.3.rs-15794/v1 ◽

2020 ◽

Author(s):

Magali Bisbal ◽

Michael Darmon ◽

Colombe Saillard ◽

Vincent Mallet ◽

Charlotte Mouliade ◽

...

Keyword(s):

Hospital Mortality ◽

Critically Ill ◽

Cancer Progression ◽

Critically Ill Patients ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Hematological Malignancies ◽

Severity Of Illness ◽

Rank Test ◽

Total Serum

Abstract BackgroundThe evidence on the clinical significance of hyperbilirubinemia (HB) in critically ill patients with hematological malignancies is scarce. We therefore studied its burden in a 2010-2011 Franco-Belgian multicenter prospective study designed to evaluate the prognosis of these patients.Patients and methodsThe cohort comprised 893 patients from 17 centers, 61% men, with a median (interquartile range) age of 60 (49 – 70) years, and preferentially with underlying non-Hodgkin lymphoma (32%) or acute myeloid leukemia (27%). HB was defined as a total serum bilirubin ≥ 33 µmol/L at intensive care unit (ICU) admission. Our main goal was to evaluate the relationship between HB and outcome of critically ill hematological patients. Causes and management of HB in the ICU were analyzed as secondary end points.ResultsHB concerned 185 (21%) patients. Cyclosporine and antimicrobial treatments, ascites and cirrhosis, acute kidney injury, neutropenia, and myeloma (adjusted odd ratio [aOR] 0.38, p=0.006) were risk factors. Hospital mortality was 56.3% and 36.3% in patients with and without HB, respectively (p<0.0001 with the log-rank test). Adjusted for severity of illness, the adjusted odds ratio (95% confidence interval) of HB for in-hospital mortality was 1.86 (1.28, 2.72). HB was overlooked by the ICU team for 92 (53%) patients. Overwise, liver workups for HB led to treatment modifications in 32 (40%) patients, including chemotherapy for cancer progression that was associated with reduced mortality with an adjusted odds ratio of 0.23, (p=0.02).ConclusionHB is associated with outcome of critically ill hematological adult patients and should be systematically explored and treated.

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Clinical Relevance of Impaired Consciousness in Accidental Hypothermia: A Japanese Multicenter Retrospective Study

10.21203/rs.3.rs-102317/v1 ◽

2020 ◽

Author(s):

Masahiro Fukuda ◽

Masahiro NOZAWA ◽

Yohei OKADA ◽

Sachiko MORITA ◽

Naoki EHARA ◽

...

Keyword(s):

Hospital Mortality ◽

Likelihood Ratio ◽

Clinical Relevance ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Accidental Hypothermia ◽

Impaired Consciousness ◽

Severe Hypothermia ◽

Level Of Consciousness ◽

The Relationship

Abstract Background: Severe accidental hypothermia (AH) is a life-threatening condition, and early identification can enable transport to an appropriate medical facility. The Swiss staging model has been used to classify patients with AH, but little is known regarding the relationship between the degree of impaired consciousness and core body temperature (BT) in AH. This study aimed to clarify the relationship between the level of consciousness and core BT and determine whether the level of consciousness could be used to predict severe hypothermia and in-hospital mortality among patients with AH.Methods: We retrospectively investigated the clinical relevance of impaired consciousness in AH. We included adult patients with AH and excluded patients with out-of-hospital cardiac arrest. The patients were identified from the J-point registry, which contains information regarding patients treated for AH between April 1, 2011 and March 31, 2016 in any of the 12 participating institutions in Japan. The primary exposure of interest was the level of consciousness at hospital arrival. Odds ratios were calculated for severe hypothermia and in-hospital mortality.Results: Overall, 505 of the 572 patients in the registry were included. Compared to mildly impaired consciousness, the adjusted odds ratio for severe hypothermia was 3.3 (95% confidence interval [CI]: 1.7–6.3) for moderately impaired consciousness and 4.7 (95% CI: 2.4–9.1) for severely impaired consciousness. Severely impaired consciousness as a predictor severe hypothermia had a sensitivity of 0.44 (95% CI: 0.34–0.54), specificity of 0.78 (95% CI: 0.74–0.82), positive likelihood ratio of 2.04, and negative likelihood ratio of 0.71. Compared to mildly impaired consciousness, the adjusted odds ratio for in-hospital mortality was 1.7 (95% CI: 0.95–2.9) for moderately impaired consciousness and 2.1 (95% CI: 1.2–3.8) for severely impaired consciousness.Conclusions: Severely impaired consciousness was a reliable predictor of severe hypothermia and in-hospital mortality in patients with AH. Thus, in an urban out-of-hospital emergency setting, the level of impaired consciousness may be helpful for triaging patients to the appropriate hospital.

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National trends in coronary intensive care unit admissions, resource utilization, and outcomes

European Heart Journal Acute Cardiovascular Care ◽

10.1177/2048872619883400 ◽

2019 ◽

Vol 9 (8) ◽

pp. 923-930

Author(s):

Sarah Woolridge ◽

Wendimagegn Alemayehu ◽

Padma Kaul ◽

Christopher B Fordyce ◽

Patrick R Lawler ◽

...

Keyword(s):

Intensive Care Unit ◽

Critical Care ◽

Intensive Care ◽

Hospital Mortality ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Mortality Rates ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Background: Emerging evidence suggests that coronary intensive care units are evolving into intensive care environments with an increasing burden of non-cardiovascular illness, but previous studies have been limited to older populations or single center experiences. Methods: Canadian national health-care data was used to identify all patients ≥18 years admitted to dedicated coronary intensive care units (2005–2015) and admissions were categorized as primary cardiac or non-cardiac. The outcomes of interest included longitudinal trends in admission diagnoses, critical care therapies, and all-cause in-hospital mortality. Results: Among the 373,992 patients admitted to a coronary intensive care unit, minimal changes in the proportion of patients admitted with a primary cardiac (88.2% to 86.9%; p<0.001) and non-cardiac diagnoses (11.8% to 13.1%; p<0.001) were observed. Among cardiac admissions, a temporal increase in the proportion of ST-segment elevation myocardial infarction (19.4% to 24.1%, p<0.001), non-ST-segment elevation myocardial infarction (14.6% to 16.2%, p<0.001), heart failure (7.3% to 8.4%, p<0.001), shock (4.9% to 5.7%, p<0.001), and decline in unstable angina (4.9% to 4.0%, p<0.001) and stable coronary diseases (21.3% to 12.4%, p<0.001) was observed. The proportion of patients requiring critical care therapies (57.8% to 63.5%, p<0.001) including mechanical ventilation (9.6% to 13.1%, p<0.001) increased. In-hospital mortality rates for patients with primary cardiac (4.9% to 4.4%; adjusted odds ratio 0.71, 95% confidence interval 0.63–0.79) and non-cardiac (17.8% to 16.1%; adjusted odds ratio 0.84, 0.73–0.97) declined; results were consistent when stratified by academic vs community hospital, and by the presence of on-site percutaneous coronary intervention. Conclusion: In a national dataset we observed a changing case-mix among patients admitted to a coronary intensive care unit, though the proportion of patients with a primary cardiac diagnosis remained stable. There was an increase in clinical acuity highlighted by critical care therapies, but in-hospital mortality rates for both primary cardiac and non-cardiac conditions declined across all hospitals. Our findings confirm the changing coronary intensive care unit case-mix and have implications for future coronary intensive care unit training and staffing.

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Admission Blood Pressure in Relation to Clinical Outcomes and Successful Reperfusion After Endovascular Stroke Treatment

Stroke ◽

10.1161/strokeaha.120.029907 ◽

2020 ◽

Vol 51 (11) ◽

pp. 3205-3214

Author(s):

Sophie A. van den Berg ◽

Simone M. Uniken Venema ◽

Maxim J.H.L. Mulder ◽

Kilian M. Treurniet ◽

Noor Samuels ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Lower Probability ◽

Modified Rankin Scale ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: Optimal blood pressure (BP) targets before endovascular treatment (EVT) for acute ischemic stroke are unknown. We aimed to assess the relation between admission BP and clinical outcomes and successful reperfusion after EVT. Methods: We used data from the MR CLEAN (Multicenter Randomized Controlled Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry, an observational, prospective, nationwide cohort study of patients with ischemic stroke treated with EVT in routine clinical practice in the Netherlands. Baseline systolic BP (SBP) and diastolic BP (DBP) were recorded on admission. The primary outcome was the score on the modified Rankin Scale at 90 days. Secondary outcomes included successful reperfusion (extended Thrombolysis in Cerebral Infarction score 2B-3), symptomatic intracranial hemorrhage, and 90-day mortality. Multivariable logistic and linear regression were used to assess the associations of SBP and DBP with outcomes. The relations between BPs and outcomes were tested for nonlinearity. Parameter estimates were calculated per 10 mm Hg increase or decrease in BP. Results: We included 3180 patients treated with EVT between March 2014 and November 2017. The relations between admission SBP and DBP with 90-day modified Rankin Scale scores and mortality were J-shaped, with inflection points around 150 and 81 mm Hg, respectively. An increase in SBP above 150 mm Hg was associated with poor functional outcome (adjusted common odds ratio, 1.09 [95% CI, 1.04–1.15]) and mortality at 90 days (adjusted odds ratio, 1.09 [95% CI, 1.03–1.16]). Following linear relationships, higher SBP was associated with a lower probability of successful reperfusion (adjusted odds ratio, 0.97 [95% CI, 0.94–0.99]) and with the occurrence of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.06 [95% CI, 0.99–1.13]). Results for DBP were largely similar. Conclusions: In patients with acute ischemic stroke treated with EVT, higher admission BP is associated with lower probability of successful reperfusion and with poor clinical outcomes. Further research is needed to investigate whether these patients benefit from BP reduction before EVT.

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Acute myocardial infarction versus other cardiovascular events in community-acquired pneumonia

ERJ Open Research ◽

10.1183/23120541.00020-2015 ◽

2015 ◽

Vol 1 (1) ◽

pp. 00020-2015 ◽

Cited By ~ 13

Author(s):

Stefano Aliberti ◽

Julio Ramirez ◽

Roberto Cosentini ◽

Vincenzo Valenti ◽

Antonio Voza ◽

...

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Hospital Mortality ◽

Neurological Disease ◽

Odds Ratio ◽

Cardiovascular Events ◽

Adjusted Odds Ratio ◽

Community Acquired Pneumonia ◽

Female Sex ◽

Severity Of The Disease

The aim of the present study was to define the prevalence, characteristics, risk factors and impact on clinical outcomes of acute myocardial infarction (AMI) versus other cardiovascular events (CVEs) in patients with community-acquired pneumonia (CAP).This was an international, multicentre, observational, prospective study of CAP patients hospitalised in eight hospitals in Italy and Switzerland. Three groups were identified: those without CVEs, those with AMI and those with other CVEs.Among 905 patients, 21 (2.3%) patients experienced at least one AMI, while 107 (11.7%) patients experienced at least one other CVE. Patients with CAP and either AMI or other CVEs showed a higher severity of the disease than patients with CAP alone. Female sex, liver disease and the presence of severe sepsis were independent predictors for the occurrence of AMI, while female sex, age >65 years, neurological disease and the presence of pleural effusion predicted other CVEs. In-hospital mortality was significantly higher among those who experienced AMI in comparison to those experiencing other CVEs (43% versus 21%, p=0.039). The presence of AMI showed an adjusted odds ratio for in-hospital mortality of 3.57 (p=0.012) and for other CVEs of 2.63 (p=0.002).These findings on AMI versus other CVEs as complications of CAP may be important when planning interventional studies on cardioprotective medications.

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Clinical Response to Hypertensive Hypervolemic Therapy and Outcome After Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/01.neu.0000359530.04529.07 ◽

2010 ◽

Vol 66 (1) ◽

pp. 35-41 ◽

Cited By ~ 26

Author(s):

Jennifer A. Frontera ◽

Andres Fernandez ◽

J. Michael Schmidt ◽

Jan Claassen ◽

Katja E. Wartenberg ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

High Risk ◽

Clinical Response ◽

Clinical Improvement ◽

Odds Ratio ◽

Volume Expansion ◽

Adjusted Odds Ratio ◽

High Risk Patient ◽

Modified Rankin Scale ◽

Symptomatic Vasospasm

Abstract OBJECTIVE Hypertensive hypervolemic therapy is widely used to treat symptomatic vasospasm after subarachnoid hemorrhage. Few data exist to support a relationship between early clinical response and mortality or functional outcome. METHODS In a prospective cohort of 580 subarachnoid hemorrhage patients, we studied 95 patients with acute symptomatic vasospasm who received stepwise volume expansion with crystalloid and/or 5% albumin solution followed by intravenous pressors to maintain systolic blood pressure between 180 and 220 mm Hg. We separately assessed the effects of volume expansion and induced hypertension on the neurological examination during the first 2 hours of each intervention. We used multivariate logistic regression analysis to calculate adjusted odds ratios assessing the relationship between clinical response to hypertensive hypervolemic therapy and 3-month outcome, as measured by the modified Rankin Scale. RESULTS Of 95 patients with symptomatic vasospasm, volume expansion was used in 94% (n = 89), of whom 43% had a clinical response; 85% of the patients (n = 81) received pressors, of whom 68% responded. Early clinical improvement attributable to either volume expansion or pressors was not related to the development of infarction on computed tomography, but response to either modality within 2 hours was independently protective against death (adjusted odds ratio, 0.03; P < 0.05) and death-or-severe-disability (modified Rankin Scale score, 4–6; adjusted odds ratio, 0.1; P < 0.05) after adjusting for age, Hunt-Hess grade, angioplasty, and aneurysm size. CONCLUSION Subarachnoid hemorrhage patients with symptomatic vasospasm who fail to demonstrate early clinical improvement in response to volume or pressor therapy are at high risk for death or disability. Urgent endovascular intervention in this high-risk patient cohort may be justified.

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