Subject(s)
Feasibility Studies , Subarachnoid Hemorrhage , Vagus Nerve Stimulation , Humans , Subarachnoid Hemorrhage/therapy , Subarachnoid Hemorrhage/complications , Vagus Nerve Stimulation/methods , Vagus Nerve Stimulation/adverse effects , Male , Female , Middle Aged , Treatment Outcome , Adult , AgedABSTRACT
INTRODUCTION: The major mechanism of morbidity of delayed cerebral ischemia after subarachnoid hemorrhage (SAH) is considered to be severe vasospasm. Quantitative MRA (QMRA) provides direct measurements of vessel-specific volumetric blood flow and may permit a clinically relevant assessment of the risk of ischemia secondary to cerebral vasospasm. PURPOSE: To evaluate the utility of QMRA as an alternative imaging technique for the assessment of cerebral vasospasm after SAH. METHODS: QMRA volumetric flow rates of the anterior cerebral artery (ACA), middle cerebral artery (MCA), and posterior cerebral artery (PCA) were compared with vessel diameters on catheter-based angiography. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of QMRA for detecting cerebral vasospasm was determined by receiver-operating characteristic curves. Spearman correlation coefficients were calculated for QMRA flow versus angiographic vessel diameter. RESULTS: Sixty-six vessels (10 patients) were evaluated with QMRA and catheter-based angiography. The median percent QMRA flow of all vessels with angiographic vasospasm (55.0%, IQR 34.3-71.6%) was significantly lower than the median percent QMRA flow of vessels without vasospasm (91.4%, IQR 81.4-100.4%) (p < 0.001). Angiographic vasospasm reduced QMRA-assessed flow by 23 ± 5 (p = 0.018), 95 ± 12 (p = 0.042), and 16 ± 4 mL/min (p = 0.153) in the ACA, MCA, and PCA, respectively, compared to vessels without angiographic vasospasm. The sensitivity, specificity, PPV, and NPV of QMRA for the discrimination of cerebral vasospasm was 84%, 72%, 84%, and 72%, respectively, for angiographic vasospasm >25% and 91%, 60%, 87%, and 69%, respectively, for angiographic vasospasm >50%. The Spearman correlation indicated a significant association between QMRA flows and vessel diameters (rs = 0.71, p < 0.001). CONCLUSION: Reduction in QMRA flow correlates with angiographic vessel narrowing and may be useful as a non-invasive imaging modality for the detection of cerebral vasospasm after SAH.
ABSTRACT
OBJECTIVE: Angiographic treatment of asymptomatic cerebral vasospasm (CVS) in aneurysmal subarachnoid hemorrhage remains controversial. We sought to investigate its relationship with the development of delayed cerebral ischemia. METHODS: Consecutive patients admitted between July 2017 and June 2019, with a diagnosis of aneurysmal subarachnoid hemorrhage, were retrospectively analyzed. The rate of development of delayed cerebral ischemia was compared between a group of patients who underwent cerebral angiography for asymptomatic CVS and those who did not. The Mann-Whitney U test or χ2 test was used to compare the 2 groups. RESULTS: Thirty-seven of the 94 patients with aneurysmal subarachnoid hemorrhage were screened for CVS, of whom 16 (43%) had moderate-severe vasospasm. When patients who underwent therapeutic cerebral angiography were compared with those who did not and after adjusting for sex, age, and grade of subarachnoid hemorrhage, treatment was not found to be significantly associated with delayed cerebral ischemia (hazard ratio = 0.82, 95% confidence interval: 0.19-3.52, P = 0.79). We found that the median length of stay in the intensive care unit and hospital increased significantly with the severity of CVS (P < 0.001). CONCLUSIONS: Cerebral angiography has a low rate of detecting moderate-severe CVS in asymptomatic patients. Moreover, there was no statistically significant difference in the rate of delayed cerebral ischemia between asymptomatic patients treated versus those not treated for CVS. There was significant association between the severity of CVS and the intensive care unit and hospital length of stay. More studies are needed to evaluate the utility of treating asymptomatic CVS in high-grade aneurysmal subarachnoid hemorrhage.
Subject(s)
Brain Ischemia , Subarachnoid Hemorrhage , Vasospasm, Intracranial , Brain Ischemia/diagnostic imaging , Brain Ischemia/etiology , Brain Ischemia/prevention & control , Cerebral Angiography , Cerebral Infarction/complications , Humans , Retrospective Studies , Subarachnoid Hemorrhage/complications , Subarachnoid Hemorrhage/diagnostic imaging , Vasospasm, Intracranial/diagnostic imaging , Vasospasm, Intracranial/etiology , Vasospasm, Intracranial/prevention & controlABSTRACT
Despite multiple investigational drugs, headache due to subarachnoid hemorrhage (SAH) remains inadequately controlled and requires high opiate utilization. This study investigates the factors associated with increased opiate usage for the management of headache in SAH in the first 14 days of admission, the association between opiate usage and hospital length of stay, and the incidence of opiate consumption during the outpatient follow up. This is a single-center cross-sectional study. A total of 138 patients admitted between January 1, 2017, and May 31, 2019, with a diagnosis of SAH, were identified through a neurocritical care dashboard. Outpatient electronic medical records were evaluated at three months. Statistical analysis included descriptive statistics, Mann-Whitney U test, stepwise regression, and multiple regression analysis. We found that of 138 patients, the majority (90%) were prescribed opiates during their hospitalization, and the mean daily morphine equivalent dosage was 18.74 mg. Steroid usage was associated with an increase in 14-day opiate usage (r = 0.4, p = 0.0001); however, the cerebral spinal fluid profile did not show a statistically significant correlation. Over 14 days, smokers significantly used more opiates compared to nonsmokers (353 mg vs. 184 mg, p = 0.01). In addition, peri-mesencephalic SAH required less morphine compared to aneurysmal SAH (195 mg vs. 283 mg, p = 0.004). Aneurysm clipping was associated with less opiate usage compared to aneurysm coiling (186 vs. 320, p = 0.08). Only the high Hunt and Hess scale score predicted opiate usage, and the high modified Fisher scale score, aneurysmal SAH, and more opiate usage predicted hospital length of stay. A total of 48 patients (42%) suffered from headaches during their outpatient follow-up within three months of discharge; however, only six (5%) were still on opiates. There was a significant association between the amount of opiate used in the first 14 days of admission and the rate of post-discharge headache. In summary, even though patients admitted with SAH require a large amount of opiate for headache management, this did not lead to more opiate consumption in the outpatient setting. However, patients continued to suffer from headaches at three months follow-up. This high opiate consumption is associated with increased hospital length of stay. Studies are needed to identify opiate sparing analgesics that target the pathogenesis of headaches in this patient population.
Subject(s)
Hospital Mortality , Severity of Illness Index , Subarachnoid Hemorrhage/mortality , Female , Humans , MaleABSTRACT
BACKGROUND: Although subdural hematoma (SDH) is common in neurocritical practice, little is known about SDH patients requiring prolonged mechanical ventilation (PMV). We aimed to determine predictors of PMV and its relationship with outcome in patients with SDH. METHODS: SDH patients admitted to Rush University neurointensive care unit from January 2009 to March 2012 were reviewed. Duration of intubation, pulmonary complications, demographics, treatment, discharge disposition, and length of stay (LOS) were reviewed. PMV was defined as duration of intubation >4 days. Univariate and multivariate analyses were performed to identify predictors of PMV and association with outcome among survivors with SDH. RESULTS: Of the 288 survivors with SDH, the mean age was 68, and of them 179 were male. A total of 137 required surgical SDH evacuation. Pneumonia occurred in 26 patients. Forty-eight patients (17%) required intubation, with duration of intubation being 1 to 20 days (median 3.0). Factors independently associated with PMV included alcohol abuse (OR, 4.31; 95% CI, 1.36-13.67), admission GCS<15 (OR, 11; 95% CI, 2.36-51.52), and surgical evacuation (OR, 9.27; 95% CI, 1.93-44.54). PMV predicted pneumonia (OR, 5.85; 95% CI, 1.52-22.57), tracheostomy (OR, 26.67; 95% CI, 2.93-242.67), increased LOS, and unfavorable discharge destination (OR, 73.1; 95% CI, 14.03-380.69). CONCLUSIONS: PMV is associated with pulmonary complications, increased LOS, and unfavorable discharge destination in patients with SDH. Alcohol abuse, admission GCS, and surgical evacuation are associated with PMV among patients with SDH. Future studies should investigate the role of early tracheostomy in high-risk patients and impact on outcomes.
Subject(s)
Hematoma, Subdural/surgery , Lung Diseases/etiology , Postoperative Complications/etiology , Respiration, Artificial/adverse effects , Adolescent , Adult , Aged , Aged, 80 and over , Female , Humans , Intubation, Intratracheal , Length of Stay , Lung Diseases/diagnostic imaging , Lung Diseases/epidemiology , Male , Middle Aged , Neurosurgical Procedures , Patient Discharge , Postoperative Complications/diagnostic imaging , Postoperative Complications/epidemiology , Radiography , Retrospective Studies , Survivors , Treatment Outcome , Ventilator Weaning , Young AdultSubject(s)
Aneurysm, Ruptured/diagnostic imaging , Intracranial Aneurysm/diagnostic imaging , Middle Cerebral Artery/diagnostic imaging , Subarachnoid Hemorrhage/diagnostic imaging , Tomography, X-Ray Computed , Aneurysm, Ruptured/complications , Female , Humans , Intracranial Aneurysm/complications , Middle Aged , Rupture, Spontaneous , Subarachnoid Hemorrhage/etiologyABSTRACT
BACKGROUND: The intracerebral hemorrhage (ICH) score is a simple grading scale that can be used to stratify risk of 30 day mortality in ICH patients. A similar risk stratification scale for subarachnoid hemorrhage (SAH) is lacking. We sought to develop a risk stratification mortality score for SAH. METHODS: With approval from the Institutional Review Board, we retrospectively reviewed 400 consecutive SAH patients admitted to our institution from August 1, 2006 to March 1, 2011. The SAH score was developed from a multivariable logistic regression model which was validated with bootstrap method. A separate cohort of 302 SAH patients was used for evaluation of the score. RESULTS: Among 400 patients with SAH, the mean age was 56.9 ± 13.9 years (range, 21.5-96.2). Among the 366 patients with known causes of SAH, 292 (79.8%) of patients had aneurysmal SAH, 65 (17.8%) were angiogram negative, and 9 (2%) were other vascular causes. The overall in-hospital mortality rate was 20%. In multivariable analysis, the variables independently associated with the in-hospital mortality were Hunt and Hess score (HH) (p < 0.0001), age (p < 0.0001), intraventricular hemorrhage (IVH) (p = 0.049), and re-bleed (p = 0.01). The SAH score (0-8) was made by adding the following points: HH (HH1-3 = 0, HH4 = 1, HH5 = 4), age (<60 = 0, 60-80 = 1, ≥80 = 2), IVH (no = 0, yes = 1), and re-bleed within 24 h (no = 0, yes = 1). Using our model, the in-hospital mortality rates for patients with score of 0, 1, 2, 3, 4, 5, 6, and 7 were 0.9, 4.5, 9.1, 34.5, 52.9, 60, 82.1, and 83.3% respectively. Validation analysis indicates good predictive performance of this model. CONCLUSION: The SAH score allows a practical method of risk stratification of the in-hospital mortality. The in-hospital mortality increases with increasing SAH mortality score. Further investigation is warranted to validate these findings.
Subject(s)
Hospital Mortality , Severity of Illness Index , Subarachnoid Hemorrhage/mortality , Adult , Aged , Aged, 80 and over , Female , Humans , Male , Middle Aged , Risk Assessment , Young AdultABSTRACT
BACKGROUND: Although cardiac abnormalities are well described among patients with acute brain injury, they have not been investigated systematically for acute subdural hemorrhage (SDH). We sought to investigate the prevalence and characteristics of cardiac abnormalities in patients with SDH. METHODS: Consecutive adult patients admitted to Rush University Neurosciences Intensive Care Unit with a diagnosis of SDH were analyzed. Electrocardiograms (ECGs), obtained within 48 h of admission were reviewed. Myocardial injury, defined as troponin I elevation (>0.09 ng/ml) on admission was identified. RESULTS: One hundred and fourteen patients admitted with SDH between 1 January 2010 and 31 December 2011 were included. Mean age was 67.9 years (SD 16.6 years), 60% were male. Comorbidities included hypertension (74%), diabetes mellitus (31%), cardiovascular disease (35%), and cerebrovascular disease (25%). The SDH was right-sided in 47%, and the most common location was frontoparietal (43%). SDH size was 14.4 ± 7.9 mm, with 4.6 ± 5.5 mm midline shift. One or more ECG abnormalities were found in 75% of patients. Troponin was elevated in nine patients. Cardiac abnormalities were not associated with SDH characteristics. Classic neurogenic ECG findings were not encountered. CONCLUSIONS: Although we found ECG abnormalities to be common in patients with SDH, they were not associated with SDH characteristics, and classic neurogenic findings were not observed. Myocardial injury was infrequent and not associated with SDH characteristics. While cardiac abnormalities in acute intracerebral injury often are attributed to neurocardiogenic causes, these are unlikely prominent mechanisms in SDH. Other medical causes need to be considered, as this will have important implications for management.
Subject(s)
Arrhythmias, Cardiac/epidemiology , Hematoma, Subdural, Acute/epidemiology , Hematoma, Subdural/epidemiology , Adult , Aged , Aged, 80 and over , Arrhythmias, Cardiac/diagnosis , Comorbidity , Electrocardiography , Female , Hematoma, Subdural/diagnostic imaging , Hematoma, Subdural, Acute/diagnostic imaging , Humans , Male , Middle Aged , Prevalence , Radiography , Retrospective Studies , Troponin I/bloodABSTRACT
BACKGROUND: We report a case of global cerebral edema and herniation due to Posterior Reversible Leukoencephalopathy Syndrome (PRES). METHODS: Case report. RESULTS: A 37-year-old healthy female developed persistent severe occipital headache, and after 1 month of persistent headache, developed an episode of loss of consciousness. CT brain showed diffuse cerebral edema and effacement of the sulci and basal cisterns. Her initial neurological examination was nonfocal but with severe headache. Overnight, she acutely became unresponsive with fixed dilated pupils, tachycardia, and hypertension. She was intubated and treated with hypertonic saline and mannitol with improvement in her clinical status. Intracranial Pressure (ICP) monitor showed elevated ICPs to 37 mmHg which responded to mannitol. MRI brain showed diffuse vasogenic edema predominantly in the white matter without enhancement. Cerebral angiogram was unremarkable. Cerebrospinal fluid including infectious work-up was negative. With supportive care, her mental status improved. On her 3 month follow-up visit, she was asymptomatic and had returned to work. Repeat MRI brain at 3 months showed persistent white matter changes that subsequently resolved at 9 months. CONCLUSIONS: Although PRES is typically considered to have a benign clinical course, clinician should be aware that severe cases can present with global cerebral edema and associated complications including intracranial hypertension and herniation.
Subject(s)
Brain Edema/etiology , Encephalocele/etiology , Intracranial Hypertension/etiology , Posterior Leukoencephalopathy Syndrome/complications , Adult , Brain Edema/therapy , Encephalocele/therapy , Female , Humans , Intracranial Hypertension/therapy , Posterior Leukoencephalopathy Syndrome/therapyABSTRACT
BACKGROUND AND PURPOSE: The purpose of this study was to investigate time delays, adherence to guidelines, and their impact on outcomes in patients with warfarin-associated intracerebral hemorrhage transferred from community emergency departments to a comprehensive stroke center. METHODS: We collected demographic, clinical, transfer time, treatment, and outcome data for patients transferred to our institution with warfarin-associated intracerebral hemorrhage from community emergency departments. RESULTS: Among 928 patients with intracerebral hemorrhage, 56 (6%) with warfarin-associated intracerebral hemorrhage (median international normalized ratio, 2.55) were transferred to the comprehensive stroke center. Twenty patients received no acute reversal therapy before transfer, only 4 of whom had international normalized ratios ≤1.4 in the community emergency department. Median time of emergency department stay was 3.66 hours and median time to initiation of acute reversal therapy was 4.48 hours. Those who received ≥3 U of fresh-frozen plasma or recombinant activated Factor VIIa (11 patients) before transfer had lower repeat international normalized ratios and better discharge dispositions than those treated less aggressively. CONCLUSIONS: Treatment of warfarin-associated intracerebral hemorrhage in community emergency departments is often suboptimal and does not adhere to published guidelines. Treating coagulopathy aggressively before interhospital transfer may improve outcomes and warrants further investigation.
Subject(s)
Anticoagulants/adverse effects , Cerebral Hemorrhage/chemically induced , Cerebral Hemorrhage/therapy , Community Health Centers , Emergency Medical Services , Emergency Service, Hospital , Warfarin/adverse effects , Aged , Anticoagulants/antagonists & inhibitors , Cerebral Hemorrhage/mortality , Factor VIIa/therapeutic use , Female , Hospital Mortality , Humans , International Normalized Ratio , Male , Plasma , Registries , Time Factors , Warfarin/antagonists & inhibitorsABSTRACT
BACKGROUND: Temporal patterns in aneurysmal subarachnoid hemorrhage (aSAH) may provide insight into modulation, and therefore, prevention of hemorrhage. We investigated the time of hemorrhage and its relationship to traditional risk factors among patients admitted with aSAH. METHODS: Admitted patients with aSAH were prospectively followed through outcomes and baseline demographics were abstracted through chart review. The group temporal distribution by hour of onset was summarized with cosinor nonlinear least squares. aSAH onset was gathered into night (2300-0500), morning (0500-1100), afternoon (1100-1700), and evening (0500-2300) daily phases. The odds ratio (OR) with 95% CI was calculated for having an aSAH during the morning, afternoon, and evening hours using night as a reference. Multinomial logit models were fitted using aSAH cases across time blocks to determine their associations with different risk factors. RESULTS: 202 patients had the hour of hemorrhage available, and 49 had phase identifiable [total 251: 38 (15%) night, 98 (39%) morning, 58 (23%) afternoon, 57 (23%) evening]. The peak hours of aSAH were between 0700 and 0800 representing 13% of the sample, with a significant cosinor-fitted phase of 7.33(95% CI 5.30, 9.36). For all aSAH cases, morning onset was significantly more common than night onset (OR = 2.58, 95% CI = 1.77-3.75). Nonsmokers were more likely to have aSAH in the morning than smokers (P = 0.043, OR = 3.10, 95% CI = 1.33-7.23). CONCLUSIONS: aSAH occur in a diurnal, morning prevalent pattern regardless of traditional aSAH risk factors. The association of these risk factors with existing onset patterns should be investigated in future studies.
Subject(s)
Circadian Rhythm/physiology , Subarachnoid Hemorrhage/physiopathology , Adult , Aged , Female , Humans , Hypertension/complications , Logistic Models , Male , Middle Aged , Prevalence , Risk Factors , Smoking/adverse effects , Subarachnoid Hemorrhage/epidemiology , Subarachnoid Hemorrhage/etiologyABSTRACT
BACKGROUND AND PURPOSE: The development of comprehensive stroke centers within hub-and-spoke stroke networks offers the opportunity to increase the proportion of acute ischemic stroke patients treated with intra-arterial therapies (IAT). Interhospital transfer delays will be critical in evaluating the success of this strategy. METHODS: We collected data on consecutive patients who were transferred to our institution for possible IAT. We defined transfer time as time elapsed from initial transfer call to arrival at our hospital and assessed whether transfer time was a predictor of emergent angiography using multivariable logistic regression. RESULTS: Among 132 patients referred for IAT, 53 (40.2%) were excluded on clinical grounds. The remaining 79 (59.8%) patients (mean age, 61 years; median National Institutes of Health Stroke Scale score, 18; 49.4% male) were analyzed. Sixty-one of 79 (77%) patients underwent emergent angiography for IAT. The median hospital-to-hospital distance was 14.7 (interquartile range, 8.5-21.9) miles and median transfer time was 104 (interquartile range, 80-135) minutes. Transfer time was 33% lower among those who underwent emergent angiography (100.6 versus 149.0 minutes; P<0.001). Adjusting for relevant covariates, transfer time remained an independent predictor of emergent angiography (OR, 0.975; 95% CI, 0.956-0.995; P=0.014). The odds of treatment decrease by 2.5% for every minute of transfer time. CONCLUSIONS: Delay in hospital-to-hospital transfer is a common reason that acute ischemic stroke patients are excluded from interventional therapy. The likelihood of receiving IAT decreases rapidly by increasing transfer time. Specific goals for transfer time should be considered in future quality standards for hub-and-spoke-organized stroke networks.
Subject(s)
Fibrinolytic Agents/therapeutic use , Injections, Intra-Arterial , Stroke/drug therapy , Thrombolytic Therapy , Transportation of Patients , Fibrinolytic Agents/administration & dosage , Humans , Male , Middle Aged , Registries , Time Factors , Treatment OutcomeABSTRACT
Little is known about the frequency of therapeutic hypothermia use after cardiac arrest in the United States. We, therefore, analyzed the Nationwide Inpatient Sample (NIS) to determine the prevalence of hypothermia use after cardiac arrest and patient and hospital factors associated with its use. Using 2007 NIS data, we identified adult patients with cardiac arrest using the ICD-9 diagnosis code, 427.5, while the use of therapeutic hypothermia was based on the ICD-9 procedure code, 99.81. Among 26,519 adult patients with cardiac arrest, only 92 (0.35%) were coded as having received therapeutic hypothermia. In a multivariable logistic regression model, independent factors associated with the use of therapeutic hypothermia included age as a continuous variable ([odds ratios] OR 0.97, 95% CI 0.963-0.989, p<0.001), comorbidity adjusted mortality score (OR 1.06, 95% CI 1.04-1.08, p<0.001), admission from the emergency room (OR 2.17, 95% CI 1.191-3.949, p=0.011), teaching hospital status (OR 2.68, 95% CI 1.36-5.29, p=0.005), acute myocardial infarction (OR 1.96, 95% CI 1.14-3.36, p=0.015), hospital location in the western United States (OR 2.21, 95% CI 1.16-3.14, p=0.011), and >97% registered nurse hospital staffing (OR 2.64, 95% CI 1.62-4.30, p<0.001). Therapeutic hypothermia may be utilized in <1% of cardiac arrest patients in U.S. hospitals. We identified important patient and hospital factors associated with therapeutic hypothermia utilization. Efforts to increase generalized utilization of this effective resuscitation strategy are warranted.
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BACKGROUND: Although neurogenic stunned myocardium (NSM) after aneurysmal subarachnoid hemorrhage (SAH) is well described, its clinical significance remains poorly defined. We investigated the influence of left ventricular (LV) dysfunction and cerebral vasospasm on cerebral infarction, serious cardiovascular events, and functional outcome after SAH. METHODS: Of the 481 patients enrolled in the University Columbia SAH Outcomes Project between 10/96 and 05/02, we analyzed a subset of 119 patients with at least one echocardiogram, serial transcranial Doppler (TCD) data, and with no prior history of cardiac disease. LV dysfunction was defined as an ejection fraction <40% on echocardiography. Infarction from vasospasm was adjudicated by the study team after comprehensive review of all clinical and imaging data. Functional outcome was assessed at 15 and 90 days with the modified Rankin Scale (mRS). RESULTS: Eleven percent of patients had LV dysfunction (N = 13). Younger age, hydrocephalus, and complete filling of the quadrigeminal and fourth ventricles were associated with LV dysfunction (all P < 0.05). Despite a similar frequency of pre-existing hypertension, 0% of patients with LV dysfunction reported taking antihypertensive medication, compared to 35% of those without (P = 0.009). There was a significant association between LV dysfunction and infarction from vasospasm after adjusting for clinical grade, age, and peak TCD flow velocity (P = 0.03). Patients with LV dysfunction also had higher rates of hypotension requiring vasopressors (P = 0.001) and pulmonary edema (P = 0.002). However, there was no association between LV dysfunction and outcome at 14 days after adjustment for established prognostic variables. CONCLUSIONS: LV dysfunction after SAH increases the risk of cerebral infarction from vasospasm, hypotension, and pulmonary edema, but with aggressive ICU support does not affect short-term survival or functional outcome. Antihypertensive medication may confer cardioprotection and reduce the risk of catecholamine-mediated injury after SAH.
Subject(s)
Cerebral Infarction/mortality , Subarachnoid Hemorrhage/mortality , Vasospasm, Intracranial/mortality , Ventricular Dysfunction, Left/mortality , Critical Care , Female , Hospital Mortality , Humans , Male , Middle Aged , Multivariate Analysis , Myocardial Stunning/epidemiology , Outcome Assessment, Health Care , Predictive Value of Tests , Prognosis , Recovery of Function , Risk Factors , Stroke VolumeABSTRACT
BACKGROUND AND PURPOSE: We aimed to determine the prevalence of acute brain infarcts using diffusion-weighted imaging (DWI) in patients with spontaneous intracerebral hemorrhage (ICH). METHODS: We collected data on consecutive patients with spontaneous ICH admitted to our institution between August 1, 2006 and December 31, 2008 and in whom DWI was performed within 28 days of admission. Patients with hemorrhage attributable to trauma, tumor, aneurysm, vascular malformation, and hemorrhagic conversion of arterial or venous infarction were excluded. Restricted diffusion within, contiguous with, or immediately neighboring the hematoma or chronic infarcts was not considered abnormal. Using multivariable logistic regression, we evaluated potential predictors of DWI abnormality including clinical and radiographic characteristics and treatments. A probability value <0.05 was considered significant in the final model. RESULTS: Among 118 spontaneous ICH patients (mean 59.6 years, 47.5% male, and 31.4% white) who also underwent MRI, DWI abnormality was observed in 22.9%. The majority of infarcts were small (median volume 0.25 mL), subcortical (70.4%), and subclinical (88.9%). Factors independently associated with DWI abnormality were prior ischemic stroke (P=0.002), MAP lowering by > or =40% (P=0.004), and craniotomy for ICH evacuation (P=0.001). CONCLUSIONS: We found that acute brain infarction is relatively common after acute spontaneous ICH. Several factors, including aggressive blood pressure lowering, may be associated with acute ischemic infarcts after ICH. These preliminary findings require further prospective study.
Subject(s)
Brain Infarction/diagnosis , Brain Infarction/etiology , Cerebral Hemorrhage/complications , Cerebral Hemorrhage/diagnosis , Diffusion Magnetic Resonance Imaging , Aged , Black People , Female , Humans , Male , Middle Aged , Prospective Studies , White PeopleABSTRACT
OBJECTIVE: Medical complications occur frequently after subarachnoid hemorrhage (SAH). Their impact on outcome remains poorly defined. DESIGN: Inception cohort study. PATIENTS: Five-hundred eighty patients enrolled in the Columbia University SAH Outcomes Project between July 1996 and May 2002. SETTING: Neurologic intensive care unit. INTERVENTIONS: Patients were treated according to standard management protocols. MEASUREMENTS AND MAIN RESULTS: Poor outcome was defined as death or severe disability (modified Rankin score, 4-6) at 3 months. We calculated the frequency of medical complications according to prespecified criteria and evaluated their impact on outcome, using forward stepwise multiple logistic regression after adjusting for known predictors of poor outcome. Thirty-eight% had a poor outcome; mortality was 21%. The most frequent complications were temperature>38.3 degreesC (54%), followed by anemia treated with transfusion (36%), hyperglycemia>11.1 mmol/L (30%), treated hypertension (>160 mm Hg systolic; 27%), hypernatremia>150 mmol/L (22%), pneumonia (20%), hypotension (<90 mm Hg systolic) treated with vasopressors (18%), pulmonary edema (14%), and hyponatremia<130 mmol/L (14%). Fever (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.1-3.4; p=.02), anemia (OR, 1.8; 95% CI, 1.1-2.9; p=.02), and hyperglycemia (OR, 1.8; 95% CI, 1.1-3.0; p=.02) significantly predicted poor outcome after adjustment for age, Hunt-Hess grade, aneurysm size, rebleeding, and cerebral infarction due to vasospasm. CONCLUSIONS: Fever, anemia, and hyperglycemia affect 30% to 54% of patients with SAH and are significantly associated with mortality and poor functional outcome. Critical care strategies directed at maintaining normothermia, normoglycemia, and prevention of anemia may improve outcome after SAH.