Cocaine use as an independent predictor of seizures after 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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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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Costs of Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

Neurosurgery ◽

10.1227/01.neu.0000371980.08391.71 ◽

2010 ◽

Vol 67 (2) ◽

pp. 345-352 ◽

Cited By ~ 16

Author(s):

Chia-Hung Chou ◽

Shelby D. Reed ◽

Jennifer S. Allsbrook ◽

Janet L. Steele ◽

Kevin A. Schulman ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Length Of Stay ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Endovascular Coiling ◽

Billing Data ◽

Surgical Clipping ◽

Physician Billing ◽

Symptomatic Vasospasm ◽

Hospital Stays ◽

The Impact

Abstract OBJECTIVE To assess the impact of vasospasm on costs, length of stay, and mortality among inpatients with aneurysmal subarachnoid hemorrhage. METHODS We combined hospital accounting and physician billing data for a consecutive cohort of 198 patients who underwent surgical clipping or endovascular coiling for subarachnoid hemorrhage repair. We considered patients with transcranial Doppler (TCD) velocity of 120 cm/s or greater in the middle cerebral artery to have TCD-defined vasospasm and patients with delayed ischemic neurological deficit to have symptomatic vasospasm. We compared outcomes of patients with TCD-defined vasospasm (n = 116) and those without (n = 73) and patients with symptomatic vasospasm (n = 62) and those without (n = 127), adjusting for demographic and clinical characteristics. RESULTS In adjusted analyses, the incremental cost attributable to TCD-defined vasospasm was 1.20 times higher (95% confidence interval, 1.06–1.36; P = .004) than for patients without TCD-defined vasospasm. Length of stay was an estimated 1.22 times longer for patients with TCD-defined vasospasm (95% CI, 1.07–1.39; P < .01). For symptomatic vasospasm, adjusted costs were 1.27 times higher (95% CI, 1.12–1.43; P < .001) and length of stay was an estimated 1.24 times longer (95% CI, 1.09–1.40; P < .01) for patients with vasospasm than for those without. There was no significant relationship between either type of vasospasm and in-hospital mortality. CONCLUSION Patients with subarachnoid hemorrhage and TCD-defined or symptomatic vasospasm incur higher inpatient costs and longer hospital stays than those without vasospasm.

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In-hospital complication–related risk factors for discharge and 90-day outcomes in patients with aneurysmal subarachnoid hemorrhage after surgical clipping and endovascular coiling: a propensity score–matched analysis

Journal of Neurosurgery ◽

10.3171/2021.10.jns211484 ◽

2021 ◽

pp. 1-12

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Propensity Score ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Hospital Charges ◽

Treatment Modalities ◽

Endovascular Coiling ◽

Surgical Clipping ◽

Prediction Ability ◽

The Impact

OBJECTIVE More than 10 years have passed since the two best-known clinical trials of ruptured aneurysms (International Subarachnoid Aneurysm Trial [ISAT] and Barrow Ruptured Aneurysm Trial [BRAT]) indicated that endovascular coiling (EC) was superior to surgical clipping (SC). However, in recent years, the development of surgical techniques has greatly improved; thus, it is necessary to reanalyze the impact of the differences in treatment modalities on the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS The authors retrospectively reviewed all aSAH patients admitted to their institution between January 2015 and December 2020. The functional outcomes at discharge and 90 days after discharge were assessed using the modified Rankin Scale (mRS). In-hospital complications, hospital charges, and risk factors derived from multivariate logistic regression were analyzed in the SC and EC groups after 1:1 propensity score matching (PSM). The area under the receiver operating characteristic curve was used to calculate each independent predictor’s prediction ability between treatment groups. RESULTS A total of 844 aSAH patients were included. After PSM to control for sex, aneurysm location, Hunt and Hess grade, World Federation of Neurosurgical Societies (WFNS) grade, modified Fisher Scale grade, and current smoking and alcohol abuse status, 329 patients who underwent SC were compared with 329 patients who underwent EC. Patients who underwent SC had higher incidences of unfavorable discharge and 90-day outcomes (46.5% vs 33.1%, p < 0.001; and 19.6% vs 13.8%, p = 0.046, respectively), delayed cerebral ischemia (DCI) (31.3% vs 20.1%, p = 0.001), intracranial infection (20.1% vs 1.2%, p < 0.001), anemia (42.2% vs 17.6%, p < 0.001), hypoproteinemia (46.2% vs 21.6%, p < 0.001), and pneumonia (33.4% vs 24.9%, p = 0.016); but a lower incidence of urinary tract infection (1.2% vs 5.2%, p = 0.004) and lower median hospital charges ($12,285 [IQR $10,399–$15,569] vs $23,656 [IQR $18,816–$30,025], p < 0.001). A positive correlation between the number of in-hospital complications and total hospital charges was indicated in the SC (r = 0.498, p < 0.001) and EC (r = 0.411, p < 0.001) groups. The occurrence of pneumonia and DCI, WFNS grade IV or V, and age were common independent risk factors for unfavorable outcomes at discharge and 90 days after discharge in both treatment modalities. CONCLUSIONS EC shows advantages in discharge and 90-day outcomes, in-hospital complications, and the number of risk factors but increases the economic cost on patients during their hospital stay. Severe in-hospital complications such as pneumonia and DCI may have a long-lasting impact on the prognosis of patients.

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Endovascular coiling versus surgical clipping for aneurysmal subarachnoid hemorrhage: A meta-analysis of randomized controlled trials

Journal of Research in Medical Sciences ◽

10.4103/jrms.jrms_414_18 ◽

2019 ◽

Vol 24 (1) ◽

pp. 88

Author(s):

Qiuxiang Xiao ◽

Muyun Luo ◽

Shaochun Yang ◽

Guanfu Ding

Keyword(s):

Subarachnoid Hemorrhage ◽

Randomized Controlled Trials ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Endovascular Coiling ◽

Controlled Trials ◽

Surgical Clipping ◽

Randomized Controlled

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Abstract TP425: The Impact of Social Determinants of Health on 1-Month Outcomes Post Aneurysmal Subarachnoid Hemorrhage

Stroke ◽

10.1161/str.51.suppl_1.tp425 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Drew Prescott ◽

Xueyuan Cao ◽

Brandon Baughman ◽

Ansley Stanfill

Keyword(s):

Subarachnoid Hemorrhage ◽

Drug Abuse ◽

Marital Status ◽

Social Determinants ◽

Household Income ◽

Physical Disability ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Stroke Severity ◽

Depression And Anxiety ◽

The Impact

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) carries high disability rates. Depression and anxiety are also common for survivors, but little work has been done to investigate the role of social determinants of health (SDOH) on such outcomes. The purpose of this abstract is to examine the impact of SDOH on physical disability, depression, and anxiety at 1-month post-aSAH, in order to better identify factors that are amenable to intervention to improve quality of life for these patients. Methods: A retrospective chart review was conducted of aSAH patients (selected by ICD-9/10 code) seen at a high-volume neurology and neurosurgery clinic from 2002-2018. Standard patient demographic and clinical characteristics were collected. The outcomes of physical disability, depression, and anxiety were also collected at 1-month post-aSAH. The studied SDOH characteristics were: race, gender, marital status, employment, smoking, drug/alcohol use, and household income level category (defined as low or middle income per US Census Bureau standards). Results: These patients (N=970) were 52.9 (±14.5) years old, 59.5% Caucasian, and 67.4% female. In addition to stroke severity measures (i.e., Hunt/Hess Grade, Fisher, GCS at time of admission), physical disability at 1-month was also associated with female gender, drug abuse, and low household income ( p ≤0.05). Depression at 1-month was not associated with stroke severity measures but was associated with these same SDOH factors and also with unemployment prior to aSAH ( p <0.0001). Anxiety was not associated with drug abuse or income in this group. Race, marital status, and smoking history were not found to be associated with these 1-month outcomes. Conclusions: This work demonstrates that measures of SDOH should be included in addition to clinical variables in a comprehensive predictive model of outcomes post-aSAH.

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Secondary hemorrhagic complications in aneurysmal subarachnoid hemorrhage: when the impact hits hard

Journal of Neurosurgery ◽

10.3171/2018.9.jns182105 ◽

2020 ◽

Vol 132 (1) ◽

pp. 79-86 ◽

Cited By ~ 3

Author(s):

Marvin Darkwah Oppong ◽

Kathrin Buffen ◽

Daniela Pierscianek ◽

Annika Herten ◽

Yahya Ahmadipour ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Antiplatelet Therapy ◽

Clinical Data ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Final Analysis ◽

Minor Bleeding ◽

Thrombolytic Agents ◽

Poor Outcome ◽

Hemorrhagic Complications ◽

The Impact

OBJECTIVEClinical data on secondary hemorrhagic complications (SHCs) in patients with aneurysmal subarachnoid hemorrhage (SAH) are sparse and mostly limited to ventriculostomy-associated SHCs. This study aimed to elucidate the incidence, risk factors, and impact on outcome of SHCs in a large cohort of SAH patients.METHODSAll consecutive patients with ruptured aneurysms treated between January 2003 and June 2016 were eligible for this study. Patients’ charts were reviewed for clinical data, and imaging studies were reviewed for radiographic data. SHCs were divided into those associated with ventriculostomy and those not associated with ventriculostomy, as well as into major and minor bleeding forms, depending on clinical impact.RESULTSSixty-two (6.6%) of the 939 patients included in the final analysis developed SHCs. Ventriculostomy-associated bleedings (n = 16) were independently predicted by mono- or dual-antiplatelet therapy after aneurysm treatment (p = 0.028, adjusted odds ratio [aOR] = 10.28; and p = 0.026, aOR = 14.25, respectively) but showed no impact on functional outcome after SAH. Periinterventional use of thrombolytic agents for early effective anticoagulation was the only independent predictor (p = 0.010, aOR = 4.27) of major SHCs (n = 38, 61.3%) in endovascularly treated patients. In turn, a major SHC was independently associated with poor outcome at the 6-month follow-up (modified Rankin Scale score > 3). Blood thinning drug therapy prior to SAH was not associated with SHC risk.CONCLUSIONSSHCs present a rare sequela of SAH. Antiplatelet therapy during (but not before) SAH increases the risk of ventriculostomy-associated bleedings, but without further impact on the course and outcome of SAH. The use of thrombolytic agents for early effective anticoagulation carries relevant risk for major SHCs and poor outcome.

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THE IMPACT OF BALLOON ANGIOPLASTY ON THE EVOLUTION OF VASOSPASM-RELATED INFARCTION AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Neurosurgery ◽

10.1227/01.neu.0000311351.32904.8b ◽

2008 ◽

Vol 62 (3) ◽

pp. 610-617 ◽

Cited By ~ 47

Author(s):

Leonie Jestaedt ◽

Mirko Pham ◽

Andreas J. Bartsch ◽

Ekkehard Kunze ◽

Klaus Roosen ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Middle Cerebral Artery ◽

Cerebral Artery ◽

Balloon Angioplasty ◽

Anterior Cerebral Artery ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Fisher Exact Test ◽

Computed Tomographic ◽

Fisher Grade ◽

The Impact

Abstract OBJECTIVE Vasospasm of the cerebral vessels remains a major source for morbidity and mortality after aneurysmal subarachnoid hemorrhage. The purpose of this study was to evaluate the frequency of infarction after transluminal balloon angioplasty (TBA) in patients with severe subarachnoid hemorrhage-related vasospasm. METHODS We studied 38 patients (median Hunt and Hess Grade II and median Fisher Grade 4) with angiographically confirmed severe vasospasm (>70% vessel narrowing). A total of 118 vessels with severe vasospasm in the anterior circulation were analyzed. Only the middle cerebral artery, including the terminal internal carotid artery, was treated with TBA (n = 57 vessel segments), whereas the anterior cerebral artery was not treated (n = 61 vessel segments). For both the treated and the untreated vessel territories, infarction on unenhanced computed tomographic scan was assessed as a marker for adverse outcome. RESULTS Infarction after TBA occurred in four middle cerebral artery territories (four out of 57 [7%]), whereas the infarction rate was 23 out of 61 (38%) in the anterior cerebral artery territories not subjected to TBA (P < 0.001, Fisher exact test). Three procedure-related complications occurred during TBA (dissection, n = 1; temporary vessel occlusions, n = 2). One of these remained asymptomatic, whereas this may have contributed to the development of infarction on follow-up computed tomographic scans in two cases. CONCLUSION In a population of patients with a high risk of infarction resulting from vasospasm after subarachnoid hemorrhage, the frequency of infarction in the distribution of vessels undergoing TBA amounts to 7% and is significantly lower than in vessels not undergoing TBA despite some risk inherent to the procedure.

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Cigarette smoking and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide analysis

Journal of Neurosurgery ◽

10.3171/2016.10.jns16748 ◽

2017 ◽

Vol 129 (2) ◽

pp. 446-457 ◽

Cited By ~ 10

Author(s):

Hormuzdiyar H. Dasenbrock ◽

Robert F. Rudy ◽

Pui Man Rosalind Lai ◽

Timothy R. Smith ◽

Kai U. Frerichs ◽

...

Keyword(s):

Sensitivity Analysis ◽

Subarachnoid Hemorrhage ◽

Cigarette Smoking ◽

Cerebral Aneurysm ◽

Scale Score ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Institutional Care ◽

Care Facility ◽

Severity Scale ◽

The Impact

OBJECTIVEAlthough cigarette smoking is one of the strongest risk factors for cerebral aneurysm development and rupture, there are limited data evaluating the impact of smoking on outcomes after aneurysmal subarachnoid hemorrhage (SAH). Additionally, two recent studies suggested that nicotine replacement therapy was associated with improved neurological outcomes among smokers who had sustained an SAH compared with smokers who did not receive nicotine.METHODSPatients who underwent endovascular or microsurgical repair of a ruptured cerebral aneurysm were extracted from the Nationwide Inpatient Sample (NIS, 2009–2011) and stratified by cigarette smoking. Multivariable logistic regression analyzed in-hospital mortality, complications, tracheostomy or gastrostomy placement, and discharge to institutional care (a nursing or an extended care facility). Additionally, the composite NIS-SAH outcome measure (based on mortality, tracheostomy or gastrostomy, and discharge disposition) was evaluated, which has been shown to have excellent agreement with a modified Rankin Scale score greater than 3. Covariates included in regression constructs were patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities (including hypertension, drug and alcohol abuse), the NIS-SAH severity scale (previously validated against the Hunt and Hess grade), treatment modality used for aneurysm repair, and hospital characteristics. A sensitivity analysis was performed matching smokers to nonsmokers on age, sex, number of comorbidities, and NIS-SAH severity scale score.RESULTSAmong the 5784 admissions evaluated, 37.1% (n = 2148) had a diagnosis of tobacco use, of which 31.1% (n = 1800) were current and 6.0% (n = 348) prior tobacco users. Smokers were significantly younger (mean age 51.4 vs 56.2 years) and had more comorbidities compared with nonsmokers (p < 0.001). There were no significant differences in mortality, total complications, or neurological complications by smoking status. However, compared with nonsmokers, smokers had significantly decreased adjusted odds of tracheostomy or gastrostomy placement (11.9% vs 22.7%, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51–0.78, p < 0.001), discharge to institutional care (OR 0.71, 95% CI 0.57–0.89, p = 0.002), and a poor outcome (OR 0.65, 95% CI 0.55–0.77, p < 0.001). Similar statistical associations were noted in the matched-pairs sensitivity analysis and in a subgroup of poor-grade patients (the upper quartile of the NIS-SAH severity scale).CONCLUSIONSIn this nationwide study, smokers experienced SAH at a younger age and had a greater number of comorbidities compared with nonsmokers, highlighting the negative ramifications of cigarette smoking among patients with cerebral aneurysms. However, smoking was also associated with paradoxical superior outcomes on some measures, and future research to confirm and further understand the basis of this relationship is needed.

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Proximity to the Treating Centre and Outcomes Following Subarachnoid Hemorrhage

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/s0317167100011069 ◽

2011 ◽

Vol 38 (1) ◽

pp. 36-40 ◽

Cited By ~ 3

Author(s):

Cian J. O'Kelly ◽

Julian Spears ◽

David Urbach ◽

M. Christopher Wallace

Keyword(s):

Subarachnoid Hemorrhage ◽

Critically Ill ◽

Critically Ill Patients ◽

Survival Benefit ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mortality Rates ◽

Limited Resources ◽

Early Complications ◽

The Impact ◽

The Relationship

Abstract:Background:In the management of subarachnoid hemorrhage (SAH), the potential for early complications and the centralization of limited resources often challenge the delivery of timely neurosurgical care. We sought to determine the impact of proximity to the accepting neurosurgical centre on outcomes following aneurysmal SAH.Methods:Using administrative data, we analyzed patients undergoing treatment for aneurysmal subarachnoid hemorrhage at neurosurgical centres in Ontario between 1995 and 2004. We compared mortality for patients receiving treatment at a centre in their county (in-county) versus those treated from outside counties (out-of-county). We also examined the impact of distance from the patient's residence to the treating centre.Results:The mortality rates were significantly lower for in-county versus out-of-county patients (23.5% vs. 27.6%, p=0.009). This advantage remained significant after adjusting for potential confounders (HR=0.84, p=0.01). The relationship between distance from the treating centre and mortality was biphasic. Under 300km, mortality increased with increasing distance. Over 300km, a survival benefit was observed.Conclusions:Proximity to the treating neurosurgical centre impacts survival after aneurysmal SAH. These results have significant implications for the triage of these critically ill patients.

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