Predictors of the development of takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage and outcomes in patients with intra-aortic balloon pumps

OBJECTIVETakotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs.METHODSThe authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2.RESULTSTC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040).CONCLUSIONSTC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.

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Impact of Hyperoxia and Hypocapnia on Neurological Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Retrospective Study

Critical Care Research and Practice ◽

10.1155/2019/7584573 ◽

2019 ◽

Vol 2019 ◽

pp. 1-8

Author(s):

Kin Chio Li ◽

Catherine Wing Yan Tam ◽

Hoi-Ping Shum ◽

Wing Wa Yan

Keyword(s):

Subarachnoid Hemorrhage ◽

Critically Ill ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Classification Tree ◽

Tertiary Hospital ◽

Classification Tree Analysis ◽

Radiological Findings ◽

Neurological Outcomes ◽

Poor Outcomes ◽

The Impact

In recent decades, there is increasing evidence suggesting that hyperoxia and hypocapnia are associated with poor outcomes in critically ill patients with cardiac arrest or traumatic brain injury. Yet, the impact of hyperoxia and hypocapnia on neurological outcome in patients with subarachnoid hemorrhage (SAH) has not been well studied. In the present study, we evaluated the impact of hyperoxia and hypocapnia on neurological outcomes in patients with aneurysmal SAH (aSAH). Patients with aSAH who were admitted to the intensive care unit (ICU) of a tertiary hospital in Hong Kong between January 2011 and December 2016 were retrospectively recruited. Patients’ demographics, comorbidities, radiological findings, clinical grades of SAH, PO2, and PCO2 within 24 hours of ICU admission, and Glasgow Outcome Scale (GOS) at 3 months after admission were recorded. Patients with a GOS score of 3 or less were considered having poor neurological outcomes. Among the 244 patients with aSAH, 122 of them (50%) had poor neurological outcomes at 3 months. Early hyperoxia (PO2 > 200 mmHg) and hypercapnia (PCO2 > 45 mmHg) were more common among patients with poor neurological outcomes. Logistic regression analysis indicated that hyperoxia independently predicted poor neurological outcomes (OR 3.788, 95% CI 1.131–12.690, P=0.031). Classification tree analysis revealed that hypocapnia was associated with poor neurological outcomes in patients who were less critically ill (APACHE < 50) and without concomitant intracranial hemorrhage (ICH) or intraventricular hemorrhage (IVH) (adjusted P=0.006, χ2 = 7.452). These findings suggested that hyperoxia and hypocapnia may be associated with poor neurological outcomes in patients with aSAH.

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Effect of stress-induced hyperglycemia after non-traumatic non-aneurysmal subarachnoid hemorrhage on clinical complications and functional outcomes

10.21203/rs.3.rs-944631/v1 ◽

2021 ◽

Author(s):

Zeyu Zhang ◽

Yue Zhao ◽

Yibo Liu ◽

Xiaoyu Wang ◽

Houshi Xu ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Cerebral Infarction ◽

Functional Outcomes ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Complication Rates ◽

Poor Outcome ◽

Clinical Complications ◽

Symptomatic Vasospasm ◽

Poor Outcomes

Abstract Background Despite having an overall benign course, non-traumatic non-aneurysmal subarachnoid hemorrhage (naSAH) is still accompanied by a risk of clinical complications and poor outcomes. Risk factors and mechanisms of complications and poor outcomes after naSAH remain unknown. Our aim was to explore the effect of stress-induced hyperglycemia (SIH) on complication rates and functional outcomes in naSAH patients. Methods We retrospectively reviewed patients with naSAH admitted to our institution between 2013 and 2018. SIH was identified according to previous criterion. Symptomatic vasospasm, delayed cerebral infarction, and hydrocephalus were identified as main complications. Outcomes were reviewed using a modified Rankin Scale (mRS) at discharge, 3 months, and 12 months. A statistical analysis of clinical, radiological, and laboratory risk factors of complications and outcomes was conducted. Results 244 naSAH patients were incorporated in the cohort with 74 (30.3%) SIH. After adjusting for age, gender, hypertension, Hunt and Hess (HH) grade, modified Fisher Scale (mFS), intraventricular hemorrhage (IVH), and subarachnoid blood distribution, SIH was significantly associated with symptomatic vasospasm (P < 0.001, 12.176 [4.904–30.231]), delayed cerebral infarction (P < 0.001, 12.434 [3.850-40.161]), hydrocephalus (P = 0.008, 5.771 [1.570-21.222]), and poor outcome at 12 months (P = 0.006, 5.506 [1.632–18.581]), whereas the correlation between SIH and poor outcome at discharge (P = 0.064, 2.409 [0.951-6.100]) or 3 months (P = 0.110, 2.029 [0.852–4.833]) was not significant. Incorporation of SIH increased the area under curve (AUC) of ROC in the combined model for predicting symptomatic vasospasm (P = 0.002), delayed cerebral infarction (P = 0.024), hydrocephalus (P = 0.037), and 12-month poor outcome (P = 0.087). Conclusions SIH is a significant and independent risk factor for symptomatic vasospasm, delayed cerebral infarction, hydrocephalus, and long-term poor outcome in naSAH patients. Identifying SIH early after naSAH is important for decision-making and treatment planning.

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Prediction of Cerebral Vasospasm in Patients Presenting with Aneurysmal Subarachnoid Hemorrhage: A Review

Neurosurgery ◽

10.1227/01.neu.0000156644.45384.92 ◽

2005 ◽

Vol 56 (4) ◽

pp. 633-654 ◽

Cited By ~ 139

Author(s):

Christopher G. Harrod ◽

Bernard R. Bendok ◽

H Hunt Batjer

Keyword(s):

Risk Factors ◽

Risk Factor ◽

Subarachnoid Hemorrhage ◽

Cerebral Vasospasm ◽

English Language ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Mortality Rates ◽

Medical Complication ◽

High Morbidity ◽

Language Literature

Abstract OBJECTIVE: Cerebral vasospasm is a devastating medical complication of aneurysmal subarachnoid hemorrhage (SAH). It is associated with high morbidity and mortality rates, even after the aneurysm has been treated. A substantial amount of experimental and clinical research has been conducted in an effort to predict and prevent its occurrence. This research has contributed to significant advances in the understanding of the mechanisms leading to cerebral vasospasm. The ability to accurately and consistently predict the onset of cerebral vasospasm, however, has been challenging. This topic review describes the various methodologies and approaches that have been studied in an effort to predict the occurrence of cerebral vasospasm in patients presenting with SAH. METHODS: The English-language literature on the prediction of cerebral vasospasm after aneurysmal SAH was reviewed using the MEDLINE PubMed (1966–present) database. RESULTS: The risk factors, diagnostic imaging, bedside monitoring approaches, and pathological markers that have been evaluated to predict the occurrence of cerebral vasospasm after SAH are presented. CONCLUSION: To date, a large blood burden is the only consistently demonstrated risk factor for the prediction of cerebral vasospasm after SAH. Because vasospasm is such a multifactorial problem, attempts to predict its occurrence will probably require several different approaches and methodologies, as is done at present. Future improvements in the prevention of cerebral vasospasm from aneurysmal SAH will most likely require advances in our understanding of its pathophysiology and our ability to predict its onset.

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Risk factors for ischemic lesions following aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/jns.2005.102.2.0194 ◽

2005 ◽

Vol 102 (2) ◽

pp. 194-201 ◽

Cited By ~ 38

Author(s):

Seppo Juvela ◽

Jari Siironen ◽

Joona Varis ◽

Kristiina Poussa ◽

Matti Porras

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Univariate Analysis ◽

Delayed Cerebral Ischemia ◽

Artery Occlusion ◽

Ct Scans ◽

Content Type ◽

Fine Print

Object. The aim of this study was to test whether enoxaparin treatment (40 mg subcutaneously once daily) reduces the risk of cerebral infarction after subarachnoid hemorrhage (SAH) and to investigate predictive risk factors for permanent ischemic lesions visible on follow-up computerized tomography (CT) scans obtained 3 months after SAH. Methods. After undergoing surgery for a ruptured aneurysm, 170 patients were randomized in a prospective, double-blind, placebo-controlled trial to test the effect of enoxaparin on the occurrence of ischemic lesions, which were demonstrated on follow-up CT scans available for 156 patients. The presence of lesions correlated highly with an impaired outcome, as assessed using both the Glasgow Outcome and modified Rankin Scales (p < 0.01). Lesions occurred in 101 (65%) of the 156 patients. In half of the patients (51 patients) no lesion was visible on the CT scan obtained on the 1st postoperative day in 51 patients. On univariate analysis, the presence of lesions at 3 months post-SAH was not associated with enoxaparin treatment but did correlate with several clinical, radiological, and prehemorrhage variables. Significant independent risk factors for lesions consisted of an impaired initial clinical condition (odds ratio [OR] 2.63, 95% confidence interval [CI] 1.03–6.73), amount of subarachnoid blood (OR 6.51, 95% CI 2.27–18.65), nocturnal occurrence of SAH (that is, between 12:01 a.m. and 8:00 a.m.; OR 4.32, 95% CI 1.28–14.52), fixed symptoms of delayed ischemia (OR 5.21, 95% CI 1.02–26.49), duration of temporary artery occlusion during surgery (OR 1.66 per minute, 95% CI 1.20–2.31), and body mass index (OR 1.13/kg/m2, 95% CI 1.01–1.28). Conclusions The presence of ischemic lesions can be predicted by the severity of bleeding, delayed cerebral ischemia, excess weight, duration of temporary artery occlusion, and occurrence of nocturnal aneurysm rupture.

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Association of cystathionine beta-synthase polymorphisms and aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2017.2.jns162933 ◽

2018 ◽

Vol 128 (6) ◽

pp. 1771-1777 ◽

Cited By ~ 5

Author(s):

Philipp Hendrix ◽

Paul M. Foreman ◽

Mark R. Harrigan ◽

Winfield S. Fisher ◽

Nilesh A. Vyas ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Delayed Cerebral Ischemia ◽

Multivariate Logistic Regression Analysis ◽

The United States ◽

Insertion Polymorphism ◽

Neuroprotective Effects ◽

Insertion Allele ◽

The Impact

OBJECTIVECystathionine β-synthase (CBS) is involved in homocysteine and hydrogen sulfide (H2S) metabolism. Both products have been implicated in the pathophysiology of cerebrovascular diseases. The impact of CBS polymorphisms on aneurysmal subarachnoid hemorrhage (aSAH) and its clinical sequelae is poorly understood.METHODSBlood samples from all patients enrolled in the CARAS (Cerebral Aneurysm Renin Angiotensin System) study were used for genetic evaluation. The CARAS study prospectively enrolled aSAH patients at 2 academic institutions in the United States from 2012 to 2015. Common CBS polymorphisms were detected using 5′exonuclease genotyping assays. Analysis of associations between CBS polymorphisms and aSAH was performed.RESULTSSamples from 149 aSAH patients and 50 controls were available for analysis. In multivariate logistic regression analysis, the insertion allele of the 844ins68 CBS insertion polymorphism showed a dominant effect on aSAH. The GG genotype of the CBS G/A single nucleotide polymorphism (rs234706) was independently associated with unfavorable functional outcome (modified Rankin Scale Score 3–6) at discharge and last follow-up, but not clinical vasospasm or delayed cerebral ischemia (DCI).CONCLUSIONSThe insertion allele of the 844ins68 CBS insertion polymorphism was independently associated with aSAH while the GG genotype of rs234706 was associated with an unfavorable outcome both at discharge and last follow-up. Increased CBS activity may exert its neuroprotective effects through alteration of H2S levels, and independent of clinical vasospasm and DCI.

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Effect of Blood Pressure Variability During the Acute Period of Subarachnoid Hemorrhage on Functional Outcomes

Neurosurgery ◽

10.1093/neuros/nyaa019 ◽

2020 ◽

Vol 87 (4) ◽

pp. 779-787 ◽

Cited By ~ 1

Author(s):

Luis C Ascanio ◽

Alejandro Enriquez-Marulanda ◽

Georgios A Maragkos ◽

Mohamed M Salem ◽

Abdulrahman Y Alturki ◽

...

Keyword(s):

Blood Pressure ◽

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Standard Deviation ◽

Coefficient Of Variation ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Retrospective Chart Review ◽

Logistic Regression Models ◽

Poor Outcomes

Abstract BACKGROUND The association of blood pressure variation with poor outcomes in aneurysmal subarachnoid hemorrhage (aSAH) is unknown. OBJECTIVE To evaluate the association of systolic blood pressure (SBP) variation and clinical outcomes in aSAH. METHODS We conducted a retrospective chart review of all aSAH patients treated at an academic institution between 2007 and 2016. Patient demographics, aSAH characteristics, and blood pressure observations for the first 24 h of admission in 4-h intervals were obtained. SBP variability metrics assessed were mean, standard deviation, maximum, minimum, peak, trough, coefficient of variation, and successive variation. The primary outcome was a composite of the modified Rankin scale as good (0-2) or poor (3-6) at last follow-up. Comparisons between outcome groups were performed. Logistic regression models for each significant SBP metric controlling for potential confounders were constructed. RESULTS The study population was 202 patients. The mean age was 57 yr; 66% were female. The median follow-up time was 18 mo; 57 (29%) patients had a poor outcome. Patients with poor outcomes had higher standard deviation (17.1 vs 14.7 mmHg, P = .01), peak (23.5 vs 20.0 mmHg, P = .02), trough (22.6 vs 19.2 mmHg, P < .01), coefficient of variation (13.9 vs 11.8 mmHg, P < .01), and lower minimum SBP (101.4 vs 108.4, P < .01). The logistic regression showed that every 1-mmHg increase in the minimum SBP increased the odds of good outcomes (odds ratio = 1.03; 95% CI = 1.001-1.064; P = .04). Models including other SBP metrics were not significant. CONCLUSION Hypotension was found to be independently associated with poor outcomes in patients with aSAH.

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Risk factors for aneurysmal subarachnoid hemorrhage - BMI and serum lipids: 11-year follow-up of the HUNT and the Tromsø Study in Norway

Acta Neurologica Scandinavica ◽

10.1111/j.1600-0404.2011.01578.x ◽

2011 ◽

Vol 125 (6) ◽

pp. 382-388 ◽

Cited By ~ 23

Author(s):

M. S. Sandvei ◽

H. Lindekleiv ◽

P. R. Romundstad ◽

T. B. Müller ◽

L. J. Vatten ◽

...

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Serum Lipids ◽

Aneurysmal Subarachnoid Hemorrhage

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Flow diversion with Pipeline Embolic Device as treatment of subarachnoid hemorrhage secondary to blister aneurysms: dual-center experience and review of the literature

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012287 ◽

2016 ◽

Vol 9 (1) ◽

pp. 29-33 ◽

Cited By ~ 55

Author(s):

Italo Linfante ◽

Michael Mayich ◽

Ashish Sonig ◽

Jena Fujimoto ◽

Adnan Siddiqui ◽

...

Keyword(s):

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Flow Diversion ◽

Left Middle Cerebral Artery ◽

High Morbidity ◽

Imaging Data ◽

Microsurgical Clipping ◽

Long Term Follow Up ◽

Near Occlusion

BackgroundAneurysmal subarachnoid hemorrhage (aSAH) secondary to blister-type aneurysms (BAs) is associated with high morbidity and mortality. Microsurgical clipping or wrapping and/or use of traditional endovascular techniques to repair the lesion result in frequent regrowth and rebleeds and ultimately high fatality rates. Because of the purely endoluminal nature of arterial reconstruction, flow diversion may represent an ideal option to repair ruptured BAs.MethodsWe performed a retrospective analysis of our database including all consecutive patients with aSAH secondary to BAs treated with the Pipeline Embolic Device (PED) between November 2013 and November 2015 in two institutions. We collected basic patient demographics, aneurysm size, location, number and sizes of PEDs used, use of coiling, 30-day modified Rankin Scale (mRS) score, and follow-up imaging data.ResultsTen cases of aSAH were found as a result of a ruptured BA. Patients had a mean age of 47.2 years (range 27–68). Mean Hunt and Hess score was 1.6 (range 1–4). Lesions were predominantly left-sided, mostly along the dorsal aspect of the internal carotid artery, either paraclinoid or paraophthalmic (8/10). In two patients the BA was located in the left middle cerebral artery. All lesions were very small (mean 1.4×1.5 mm; range 0.75–2.1 mm). Placement of a single PED resulted in immediate occlusion or near-occlusion of the BA in 9 out of 10 patients. Nine patients did very well; eight had a 90-day mRS score of 0 and one had a 90-day mRS score of 1. Follow-up digital subtraction angiography was performed in all patients (mean 15 months; range 7–24). In the surviving nine patients there was complete occlusion of the BA on long-term follow-up angiography.ConclusionsRepair of ruptured BA with PED may be a safe and durable option.

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Risk Factors for Shunt Dependency after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis including 25 Years of Data

Journal of Neurological Surgery Part B Skull Base ◽

10.1055/s-0036-1580084 ◽

2016 ◽

Vol 77 (S 01) ◽

Author(s):

Sam Safavi-Abbasi ◽

Christopher Wilson ◽

Robert Spetzler

Keyword(s):

Risk Factors ◽

Subarachnoid Hemorrhage ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Meta Analysis ◽

Shunt Dependency

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Evidence for a conditioning effect of inhalational anesthetics on angiographic vasospasm after aneurysmal subarachnoid hemorrhage

Journal of Neurosurgery ◽

10.3171/2019.3.jns183512 ◽

2020 ◽

Vol 133 (1) ◽

pp. 152-158 ◽

Cited By ~ 1

Author(s):

Umeshkumar Athiraman ◽

Diane Aum ◽

Ananth K. Vellimana ◽

Joshua W. Osbun ◽

Rajat Dhar ◽

...

Keyword(s):

Logistic Regression ◽

Subarachnoid Hemorrhage ◽

Brain Injury ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Multivariate Logistic Regression Analysis ◽

Secondary Brain Injury ◽

Large Artery ◽

Inhalational Anesthetics ◽

Angiographic Vasospasm ◽

Inhalational Anesthetic

OBJECTIVEDelayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH) is characterized by large-artery vasospasm, distal autoregulatory dysfunction, cortical spreading depression, and microvessel thrombi. Large-artery vasospasm has been identified as an independent predictor of poor outcome in numerous studies. Recently, several animal studies have identified a strong protective role for inhalational anesthetics against secondary brain injury after SAH including DCI—a phenomenon referred to as anesthetic conditioning. The aim of the present study was to assess the potential role of inhalational anesthetics against cerebral vasospasm and DCI in patients suffering from an SAH.METHODSAfter IRB approval, data were collected retrospectively for all SAH patients admitted to the authors’ hospital between January 1, 2010, and December 31, 2013, who received general anesthesia with either inhalational anesthetics only (sevoflurane or desflurane) or combined inhalational (sevoflurane or desflurane) and intravenous (propofol) anesthetics during aneurysm treatment. The primary outcomes were development of angiographic vasospasm and development of DCI during hospitalization. Univariate and logistic regression analyses were performed to identify independent predictors of these endpoints.RESULTSThe cohort included 157 SAH patients whose mean age was 56 ± 14 (± SD). An inhalational anesthetic–only technique was employed in 119 patients (76%), while a combination of inhalational and intravenous anesthetics was employed in 34 patients (22%). As expected, patients in the inhalational anesthetic–only group were exposed to significantly more inhalational agent than patients in the combination anesthetic group (p < 0.05). Multivariate logistic regression analysis identified inhalational anesthetic–only technique (OR 0.35, 95% CI 0.14–0.89), Hunt and Hess grade (OR 1.51, 95% CI 1.03–2.22), and diabetes (OR 0.19, 95% CI 0.06–0.55) as significant predictors of angiographic vasospasm. In contradistinction, the inhalational anesthetic–only technique had no significant impact on the incidence of DCI or functional outcome at discharge, though greater exposure to desflurane (as measured by end-tidal concentration) was associated with a lower incidence of DCI.CONCLUSIONSThese data represent the first evidence in humans that inhalational anesthetics may exert a conditioning protective effect against angiographic vasospasm in SAH patients. Future studies will be needed to determine whether optimized inhalational anesthetic paradigms produce definitive protection against angiographic vasospasm; whether they protect against other events leading to secondary brain injury after SAH, including microvascular thrombi, autoregulatory dysfunction, blood-brain barrier breakdown, neuroinflammation, and neuronal cell death; and, if so, whether this protection ultimately improves patient outcome.

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