Doppler ultrasonography screening of poor-grade subarachnoid hemorrhage patients increases the diagnosis of deep venous thrombosis.

BACKGROUND: Prophylactic anticoagulation greatly decreases the prevalence of deep venous thrombosis (DVT) in neurosurgical patients. Using Doppler ultrasonography (USG), recent studies demonstrate a 1% DVT detection rate following microsurgery or endovascular treatment for aneurysmal subarachnoid hemorrhage (aSAH). We hypothesize that reported statistics underestimate the DVT detection rate in this high risk cohort by accounting for only symptomatic thromboses. This study utilizes Doppler USG to examine the prevalence of DVT in a large population of aSAH patients and attempts to identify a high-risk subgroup within this cohort. METHODS: We retrospectively examined 178 aSAH patients who underwent screening lower extremity Dopplers (LEDs) and 57 who did not undergo screening LEDs. All received pharmacologic and mechanical DVT prophylaxis. We analysed DVT prevalence within these two groups and compared rates to the literature. We then segregated patients according to Hunt-Hess grade and determined DVT prevalence within subgroups. RESULTS: Patients who underwent LED screening demonstrated a 3.4% (6/178) DVT rate, compared to 0% (0/57) in the unscreened cohort. Our screening protocol yielded a thrombosis rate almost triple that reported in the literature (3.4% versus 1.2%). A significantly greater (p<0.05) percentage of screened Hunt-Hess III-V patients (6.5%, 6/93) had positive LEDs compared to Hunt-Hess I-II patients (0%, 0/85). CONCLUSION: These data suggest that while pharmacologic prophylaxis lowers the prevalence of symptomatic DVTs in aSAH patients, the number of asymptomatic DVTs remains significant, particularly in patients with formidable neurological deficits. While a formal cost-effective analysis is warranted, our data suggest that screening high-risk patients may increase the diagnosis of asymptomatic DVTs and potentially prevent serious medical complications.

Pupillary reactivity upon hospital admission predicts long-term outcome in poor grade aneurysmal subarachnoid hemorrhage patients.

BACKGROUND: Historically, the prognosis for poor grade subarachnoid hemorrhage patients has been considered dismal. As a result, many hospitals have chosen conservative management over aggressive therapy. This guarded approach, however, is based on studies that do not take into account newer, more effective, management protocols and more recent long-term evidence that significant neurological recovery occurs in the months to years following discharge. More accurate and predictive methods are needed to decide when aggressive therapy is warranted. METHODS: Two hundred and twenty-six grade aneurysmal subarachnoid hemorrhage (aSAH) patients of grades IV and V were admitted to Columbia University Medical Center and enrolled in our study. Demographics, clinical information (e.g. pupillary reactivity on admission), and treatment course (operative versus non-operative) were recorded. Rankin scores at 14 days, 3 months, and 1 year were also recorded. A favorable Rankin score was defined as 0-3. Unfavorable was defined as 4-6. RESULTS: Among all poor grade patients who received operative therapy, pupillary reactivity at admission was not predictive of a favorable Rankin score at day 14 (odds ratio = 3.3, P = 0.129). Pupillary reactivity, however, was predictive of Rankin score at 3 months (odds ratio = 4.57, P = 0.05) and 12 months (odds ratio = 6.44, P = 0.008). After constructing a Kaplan-Meiers survival curve, pupillary reactivity was a better predictor of survival at 12 months than H&H grade [Hazard ratio 3.342 (1.596-7.000) P = 0.001 versus 1.964 (1.016-3.798) P = 0.045]. CONCLUSIONS: This study demonstrates that significant recovery occurs in the weeks to months after poor grade aSAH. Pupillary reactivity on admission can be used as a predictor of survival and recovery at intermediate and long-term time points, more so than Hunt and Hess grade.