Cortisol dynamics and endothelin-1/nitric oxide ratio are associated with clinical vasospasme.

Background: Cortisol dynamics in serum might be related to clinical vasospasm, also known as delayed ischemic neurological deficits (DIND). Two vasoactive substances that play a role in pathophysiology of DIND are endothelin-1 (ET1) and nitric oxide (NO), both are proved associated with cortisol. This study aimed to know how cortisol plays a role on ET1/NO ratio and its relationship to DIND. Methods: This was a prospective cohort study for the first 14 days after aneurysmal subarachnoid hemorrhage (SAH). Patients with inclusion criteria will be enrolled for blood test before surgery, and post-operative day 2, 4, 7, and 10 (between 8:00-9:00 AM). The blood tests were performed for cortisol, ACTH, CBG, NO, and ET1. Free cortisol is calculated with Coolens equation. Logistic regression was used to see the interaction model and its scale. Bivariate analysis (corelation) was used to see the relationship between total cortisol, free cortisol, NO, ET1, and clinical vasospasm (DIND). Results: Forty-four patients were enrolled into this study (20 males; 24 females). Mean age was 52.02 ± 11.23 years. There were 29 patients (66%) within DIND group and 15 patients non-DIND as the control group. The mean of cortisol level shown was significantly higher in DIND group (35.99 ± 14.24) μg/dL compared to non-DIND group (19.57 ± 6.19) μg/dL, p < 0.001. The mean of free cortisol level was significantly higher in DIND group (2.06 ± 1.094) μg/dL compared to non-DIND group (0.838 ± 0.365 μg/dL; p < 0.001). The scatter plot graph showed that correlation of cortisol with ET1/NO ratio started increasing on day 4 and became stronger on day 10. Conclusion: Cortisol is associated with DIND following aneurysmal SAH, probably through its role in keeping the balance between ET1 and NO level.

Role of Acetazolamide Brain SPECT in the Evaluation of Delayed Ischemic Neurological Deficits Following Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE: The purpose of this study is to evaluate the role of acetazolamide brain SPECT in the assessment of delayed ischemic neurological deficits(DINDs) following aneurysmal subarachnoid hemorrhage. METHODS: Prospective analysis of consecutive patients with aneurysmal subarachnoid hemorrhage was made from July 1999 to December 2000. Regular neurological examination and Transcranial Doppler(TCD) monitoring were done for monitoring development of DINDs. Postoperative cerebral angiography and acetazolamide brain SPECT were performed according to our spasm-monitoring algorithm. Correlation of three diagnostic tools with development of DINDs was evaluated and concordance rates between each diagnostic tool were investigated. RESULTS: A total of 65 patients were included. DINDs were developed in 44.6% of patients. Spasm evidences on TCD monitoring, cerebral angiography and acetazolamide brain SPECT were observed in 38.5%, 40.0%, 41.5% of patients. Although there is no statistical significance, acetazolamide brain SPECT was more correlated with DINDs development than other two tools. Spasm evidence on TCD were not proceeded the development of DINDs in 58.6% of patients with DINDs. Concordance rate between acetazolamide brain SPECT and cerebral angiography was highest. However, there are significant numbers of discordance between two tools. CONCLUSION: Three diagnostic tools are complementary to each other in the assessment of DINDs. However, considering that DINDs is basically attributable to cerebral hemodynamic alteration rather than arterial morphologic change, acetazolamide brain SPECT seems to be the most useful tool in the evaluation of DINDs.