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Mei Q, Shen H, Liu J. A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis. Front Neurol 2024; 14:1280047. [PMID: 38259653 PMCID: PMC10800534 DOI: 10.3389/fneur.2023.1280047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. Methods We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Results Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. Conclusion We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.
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Affiliation(s)
- Qing Mei
- Department of Neurology, Beijing Pinggu Hospital, Beijing, China
| | - Hui Shen
- Department of Interventional Neuroradiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Functional Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Centre of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou, China
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2
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Mazzaglia G, Bonomo G, Rubiu E, Murabito P, Amato A, Ferroli P, Gemma M. Anesthesia-induced Takotsubo cardiomyopathy in trigeminal neuralgia: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2023; 5:CASE22424. [PMID: 36593670 PMCID: PMC9811571 DOI: 10.3171/case22424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 10/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Takotsubo syndrome (TS) represents a form of nonischemic cardiomyopathy characterized by sudden and temporary weakening of the myocardium. Many data suggest a primary role for sympathetic overstimulation in its pathogenesis. Nevertheless, these correlates are less easily identified during anesthesia. OBSERVATIONS A 50-year-old female patient with a 4-year history of drug-resistant left trigeminal neuralgia. She was scheduled for surgical microvascular decompression. In the operating room, after induction of general anesthesia and oral intubation, the electrocardiogram revealed a significant ST segment elevation along with a sudden decrease in systolic blood pressure and heart rate. Administration of atropine caused a conversion into ventricular tachycardia. The advanced cardiac life support protocols were applied with prompt defibrillation and rapid recovery at sinus rhythm. A transthoracic echocardiogram revealed apical akinesia with ballooning of the left ventricle with a reduction of systolic function. An emergency coronary arteriography was performed, showing normal epicardial coronary vessels. After 4 days, echocardiography revealed normalization of the left ventricular function with improvement of the ejection fraction. LESSONS In patients affected by trigeminal neuralgia, chronic pain can lead to a state of adrenergic hyperactivation, which can promote TS during the induction of general anesthesia, probably through the trigeminocardiac reflex.
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Affiliation(s)
| | - Giulio Bonomo
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy,University of Milan, Milan, Italy; and
| | - Emanuele Rubiu
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy,University of Milan, Milan, Italy; and
| | | | - Alessia Amato
- Department of Child Neuropsychiatry, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Paolo Ferroli
- Neurosurgery, Fondazione IRCCS Istituto Neurologico C. Besta, Milan, Italy
| | - Marco Gemma
- Departments of Neuroanesthesia and Intensive Care and
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3
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Neulen A, Molitor M, Kosterhon M, Pantel T, Holzbach E, Rudi WS, Karbach SH, Wenzel P, Ringel F, Thal SC. Correlation of cardiac function and cerebral perfusion in a murine model of subarachnoid hemorrhage. Sci Rep 2021; 11:3317. [PMID: 33558609 PMCID: PMC7870815 DOI: 10.1038/s41598-021-82583-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 01/18/2021] [Indexed: 12/28/2022] Open
Abstract
Cerebral hypoperfusion is a key factor for determining the outcome after subarachnoid hemorrhage (SAH). A subset of SAH patients develop neurogenic stress cardiomyopathy (NSC), but it is unclear to what extent cerebral hypoperfusion is influenced by cardiac dysfunction after SAH. The aims of this study were to examine the association between cardiac function and cerebral perfusion in a murine model of SAH and to identify electrocardiographic and echocardiographic signs indicative of NSC. We quantified cortical perfusion by laser SPECKLE contrast imaging, and myocardial function by serial high-frequency ultrasound imaging, for up to 7 days after experimental SAH induction in mice by endovascular filament perforation. Cortical perfusion decreased significantly whereas cardiac output and left ventricular ejection fraction increased significantly shortly post-SAH. Transient pathological ECG and echocardiographic abnormalities, indicating NSC (right bundle branch block, reduced left ventricular contractility), were observed up to 3 h post-SAH in a subset of model animals. Cerebral perfusion improved over time after SAH and correlated significantly with left ventricular end-diastolic volume at 3, 24, and 72 h. The murine SAH model is appropriate to experimentally investigate NSC. We conclude that in addition to cerebrovascular dysfunction, cardiac dysfunction may significantly influence cerebral perfusion, with LVEDV presenting a potential parameter for risk stratification.
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Affiliation(s)
- Axel Neulen
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany.
| | - Michael Molitor
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Michael Kosterhon
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Tobias Pantel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Elisa Holzbach
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Wolf-Stephan Rudi
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Susanne H Karbach
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Philip Wenzel
- Center for Cardiology-Cardiology I, University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,Center for Thrombosis and Hemostasis (CTH), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.,German Center for Cardiovascular Research (DZHK)-Partner Site Rhine-Main, Mainz, Germany
| | - Florian Ringel
- Department of Neurosurgery, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany
| | - Serge C Thal
- Department of Anesthesiology, University Medical Center of the Johannes Gutenberg-University Mainz, Langenbeckstrasse 1, 55131, Mainz, Germany. .,Center for Molecular Surgical Research (MFO), University Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany.
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4
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Baker C, Muse J, Taussky P. Takotsubo Syndrome in Neurologic Disease. World Neurosurg 2021; 149:26-31. [PMID: 33556594 DOI: 10.1016/j.wneu.2021.01.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/09/2023]
Abstract
Transient cardiac dysfunction, or Takotsubo cardiomyopathy, is a well-known complication among patients presenting with neurologic insult, who are described as having takotsubo syndrome. This condition is commonly associated with aneurysmal subarachnoid hemorrhage but has also been described in patients after cerebral surgery or in those with ischemic stroke, seizure, and traumatic brain injury. Current evidence suggests that cardiac dysfunction in these patients is a result of increases in catecholamines that are induced by supraphysiologic levels of sympathetic activity. The cardiac injury is typically reversible and carries a good prognosis, but secondary complications may arise if the diagnosis is not recognized early.
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Affiliation(s)
- Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - John Muse
- Department of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Kishima H, Mine T, Ando T, Yamada Y, Tsuji M, Ohmura T, Miyake H, Ishihara M. Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage. J Clin Neurosci 2020; 79:7-11. [PMID: 33070921 DOI: 10.1016/j.jocn.2020.07.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Non-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. METHODS We studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. RESULTS Twenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). CONCLUSION Plasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.
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Affiliation(s)
- Hideyuki Kishima
- From the Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Takanao Mine
- From the Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
| | - Tomotaka Ando
- From the Department of Cardiovascular Division, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan.
| | - Yoshitaka Yamada
- From the Department of Neurosurgery Division, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan.
| | - Masao Tsuji
- From the Department of Neurosurgery Division, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan.
| | - Takehisa Ohmura
- From the Department of Neurosurgery Division, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan.
| | - Hiroji Miyake
- From the Department of Neurosurgery Division, Nishinomiya Kyoritsu Neurosurgical Hospital, Nishinomiya, Japan.
| | - Masaharu Ishihara
- From the Department of Cardiovascular and Renal Medicine, Hyogo College of Medicine, Nishinomiya, Japan.
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6
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Zahid T, Eskander N, Emamy M, Ryad R, Jahan N. Cardiac Troponin Elevation and Outcome in Subarachnoid Hemorrhage. Cureus 2020; 12:e9792. [PMID: 32821636 PMCID: PMC7431985 DOI: 10.7759/cureus.9792] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Many cardiopulmonary complications occur after aneurysmal subarachnoid hemorrhage. This is due to sympathetic nervous system activation which results in release of norepinephrine from myocardial sympathetic nerves. Cardiac troponin I is a marker for diagnosis of cardiac injury. Elevated levels of troponin in these patients are associated with worse clinical outcomes. PubMed was searched for literature using regular and Medical Subject Heading (MeSH) keywords for data collection. Papers published in English language involving human subjects within the last 20 years focusing on cardiac troponin elevation following subarachnoid hemorrhage were included. Systemic complications that occur after subarachnoid hemorrhage worsen the clinical outcome of patients and have negative effects on the mortality and morbidity of these patients. Cardiac troponin I elevation is significantly associated with the severity of the stroke, poor neurological status, longer ICU stay, and death. Cardiac troponin I should be measured in patients presented with acute stroke. Hemodynamic monitoring and appropriate supportive care can improve clinical outcomes.
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Affiliation(s)
- Tehrim Zahid
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Noha Eskander
- Psychiatry, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mina Emamy
- Department of Research, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Robert Ryad
- Internal Medicine, California Institute of Behavioural Neurosciences and Psychology, Brentwood, USA
| | - Nusrat Jahan
- Internal Medicine, California Institute of Behavioural Neurosciences and Psychology, Fairfield, USA
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7
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Mrozek S, Gobin J, Constantin JM, Fourcade O, Geeraerts T. Crosstalk between brain, lung and heart in critical care. Anaesth Crit Care Pain Med 2020; 39:519-530. [PMID: 32659457 DOI: 10.1016/j.accpm.2020.06.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 05/05/2020] [Accepted: 06/07/2020] [Indexed: 12/17/2022]
Abstract
Extracerebral complications, especially pulmonary and cardiovascular, are frequent in brain-injured patients and are major outcome determinants. Two major pathways have been described: brain-lung and brain-heart interactions. Lung injuries after acute brain damages include ventilator-associated pneumonia (VAP), acute respiratory distress syndrome (ARDS) and neurogenic pulmonary œdema (NPE), whereas heart injuries can range from cardiac enzymes release, ECG abnormalities to left ventricle dysfunction or cardiogenic shock. The pathophysiologies of these brain-lung and brain-heart crosstalk are complex and sometimes interconnected. This review aims to describe the epidemiology and pathophysiology of lung and heart injuries in brain-injured patients with the different pathways implicated and the clinical implications for critical care physicians.
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Affiliation(s)
- Ségolène Mrozek
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France.
| | - Julie Gobin
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Jean-Michel Constantin
- Department of anaesthesia and critical care, Sorbonne university, La Pitié-Salpêtrière hospital, Assistance publique-Hôpitaux de Paris, Paris, France
| | - Olivier Fourcade
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
| | - Thomas Geeraerts
- Department of anaesthesia and critical care, university hospital of Toulouse, university Toulouse 3 Paul Sabatier, Toulouse, France
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8
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Megjhani M, Kaffashi F, Terilli K, Alkhachroum A, Esmaeili B, Doyle KW, Murthy S, Velazquez AG, Connolly ES, Roh DJ, Agarwal S, Loparo KA, Claassen J, Boehme A, Park S. Heart Rate Variability as a Biomarker of Neurocardiogenic Injury After Subarachnoid Hemorrhage. Neurocrit Care 2020; 32:162-171. [PMID: 31093884 PMCID: PMC6856427 DOI: 10.1007/s12028-019-00734-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND The objective of this study was to examine whether heart rate variability (HRV) measures can be used to detect neurocardiogenic injury (NCI). METHODS Three hundred and twenty-six consecutive admissions with aneurysmal subarachnoid hemorrhage (SAH) met criteria for the study. Of 326 subjects, 56 (17.2%) developed NCI which we defined by wall motion abnormality with ventricular dysfunction on transthoracic echocardiogram or cardiac troponin-I > 0.3 ng/mL without electrocardiogram evidence of coronary artery insufficiency. HRV measures (in time and frequency domains, as well as nonlinear technique of detrended fluctuation analysis) were calculated over the first 48 h. We applied longitudinal multilevel linear regression to characterize the relationship of HRV measures with NCI and examine between-group differences at baseline and over time. RESULTS There was decreased vagal activity in NCI subjects with a between-group difference in low/high frequency ratio (β 3.42, SE 0.92, p = 0.0002), with sympathovagal balance in favor of sympathetic nervous activity. All time-domain measures were decreased in SAH subjects with NCI. An ensemble machine learning approach translated these measures into a classification tool that demonstrated good discrimination using the area under the receiver operating characteristic curve (AUROC 0.82), the area under precision recall curve (AUPRC 0.75), and a correct classification rate of 0.81. CONCLUSIONS HRV measures are significantly associated with our label of NCI and a machine learning approach using features derived from HRV measures can classify SAH patients that develop NCI.
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Affiliation(s)
- Murad Megjhani
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Farhad Kaffashi
- Case School of Engineering, Case Western Reserve University, Cleveland, USA
| | - Kalijah Terilli
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Ayham Alkhachroum
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Behnaz Esmaeili
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Kevin William Doyle
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York, USA
| | - Angela G Velazquez
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, USA
| | - David Jinou Roh
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Sachin Agarwal
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Ken A Loparo
- Case School of Engineering, Case Western Reserve University, Cleveland, USA
| | - Jan Claassen
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Amelia Boehme
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA
| | - Soojin Park
- Department of Neurology, Columbia University Irving Medical Center, 177 Fort Washington Ave, 8 Milstein-300 Center, New York, NY, 10032, USA.
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Kim W, Choi KS, Lim T, Ahn C, Cho Y, Yi HJ, Lee SH. Prognostic Value of Echocardiography for Left Ventricular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. World Neurosurg 2019; 126:e1099-e1111. [PMID: 30880203 DOI: 10.1016/j.wneu.2019.03.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 03/05/2019] [Accepted: 03/06/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Cardiac dysfunction may worsen outcomes after aneurysmal subarachnoid hemorrhage (SAH). This study quantitatively assessed the prognostic value of left ventricular dysfunction with respect to functional outcomes and mortality in patients with aneurysmal SAH. METHODS We searched MEDLINE and EMBASE databases to retrieve relevant studies evaluating echocardiographic left ventricular dysfunction following aneurysmal SAH. Fourteen relevant observational studies evaluating 2234 patients were finally included in this study. RESULTS Echocardiographic regional wall motion abnormalities (RWMA) and neurogenic cardiomyopathy (NCM) of the left ventricle occurring after SAH were significantly related to an increase of in-hospital mortality (in 8 studies for RWMA, odds ratio [OR] 2.37; 95% confidence interval [CI] 1.74-3.25 and in 5 studies for NCM, OR 2.82; 95% CI 1.2-6.6). Decreased ejection fraction on echocardiography was not associated with the increase of in-hospital mortality (in 4 studies, OR 1.76; 95% CI 0.86-3.61). The heterogeneities of decreased ejection fraction and NCM were significantly resolved by analyzing only the studies based on echocardiogram measurements obtained within 72 hours after admission. CONCLUSIONS The present meta-analysis suggests that the identification of echocardiographic left ventricular dysfunction identified by RWMA and NCM after SAH could provide better prognostic information for in-hospital mortality.
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Affiliation(s)
- Wonhee Kim
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Taeho Lim
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Chiwon Ahn
- Department of Emergency Medicine, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Youngsuk Cho
- Department of Emergency Medicine, College of Medicine, Hallym University, Seoul, Republic of Korea
| | - Hyeong-Joong Yi
- Department of Neurosurgery, College of Medicine, Hanyang University, Seoul, Republic of Korea
| | - Seon-Heui Lee
- Department of Nursing Science, College of Nursing, Gachon University, Incheon, Republic of Korea.
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10
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Autonomic Disturbances in Acute Cerebrovascular Disease. Neurosci Bull 2018; 35:133-144. [PMID: 30311072 DOI: 10.1007/s12264-018-0299-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/14/2018] [Indexed: 01/01/2023] Open
Abstract
Autonomic disturbances often occur in patients with acute cerebrovascular disease due to damage of the central autonomic network. We summarize the structures of the central autonomic network and the clinical tests used to evaluate the functions of the autonomic nervous system. We review the clinical and experimental findings as well as management strategies of post-stroke autonomic disturbances including electrocardiographic changes, cardiac arrhythmias, myocardial damage, thermoregulatory dysfunction, gastrointestinal dysfunction, urinary incontinence, sexual disorders, and hyperglycemia. The occurrence of autonomic disturbances has been associated with poor outcomes in stroke patients. Autonomic nervous system modulation appears to be an emerging therapeutic strategy for stroke management in addition to treatments for sensorimotor dysfunction.
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11
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Acute Brain Diseases as Triggers for Stress Cardiomyopathy: Clinical Characteristics and Outcomes. Neurocrit Care 2018; 27:356-361. [PMID: 28612130 DOI: 10.1007/s12028-017-0412-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To determine the clinical characteristics and outcomes of patients with neurogenic stress cardiomyopathy (NSC) among patients admitted to our neuroscience intensive care unit (NICU). METHODS Following institutional review board approval, consecutive adult patients admitted to the NICU between 2009 and 2013 with definite and possible NSC were included. Data on patient demographics, baseline clinical information, cardiac function, and laboratory values were collected. Outcomes included length of stay, modified Rankin Scale (mRS) at discharge and long-term follow-up. Continuous variables were compared using a student's t test, and categorical variables were compared using a Chi-square test. RESULTS Among 34 patients included in the study, the most common presenting symptom was dyspnea (17 patients, 50%). Subarachnoid hemorrhage (SAH) was the most common neurological inciting event (11 patients, 32.4%), but two-thirds of this cohort had other neurological triggers. The most common electrocardiogram changes were QT-interval prolongation (30 patients, 88.2%) and T-wave inversion (22 patients, 64.7%). The most common echocardiographic pattern was the apical variant (14 patients, 41.2%), and 26% of patients had right ventricular involvement (P = 0.03) which was a predictor of poor outcome along with inotropic support (P = 0.006). Functional outcome was poor (mRS > 3) in 53% of patients at discharge, but function improved over time in most survivors. CONCLUSIONS NSC is most common after SAH, but can result from a wide spectrum of acute brain insults. Requirement of inotropic support was the strongest indicator of prognosis at last follow-up. Patients with NSC often have poor function at discharge but many improve over time.
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12
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Zhang L, Zhang B, Qi S. Impact of echocardiographic wall motion abnormality and cardiac biomarker elevation on outcome after subarachnoid hemorrhage: a meta-analysis. Neurosurg Rev 2018; 43:59-68. [PMID: 29804158 DOI: 10.1007/s10143-018-0985-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/30/2018] [Accepted: 05/15/2018] [Indexed: 11/24/2022]
Abstract
Cardiac abnormalities (echocardiographic wall motion abnormality (WMA), biomarker elevation of cardiac troponin (cTn), B-type natriuretic peptide (BNP), or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP)) frequently occur after subarachnoid hemorrhage (SAH). The clinical significance of cardiac abnormalities after SAH remains controversial. This meta-analysis was performed to assess the association between cardiac abnormalities and patient outcomes, including delayed cerebral ischemia (DCI), poor outcome, and death in SAH patients. PubMed and Embase were searched for observational studies reporting an association between cardiac abnormalities and outcome after SAH that were published before 31 December 2017. We extracted data regarding patient characteristics, cardiac abnormalities, and outcome measurements (DCI, poor outcome, or death). Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-six studies involving 3917 patients were included in our data analysis. WMA showed significant associations with higher rates of DCI (RR, 2.03; 95% CI, 0.99-4.15), poor outcome (RR, 1.45; 95% CI, 1.08-1.93), and death (RR, 2.54; 95% CI, 1.59-4.05). cTn elevation was associated with an increased risk of DCI (RR, 1.48; 95% CI, 1.23-1.79), poor outcome (RR, 1.85; 95% CI, 1.49-2.30), and death (RR, 2.68; 95% CI, 2.19-3.27). Elevation of BNP or NT-proBNT was significantly associated with higher rates of DCI (RR, 1.87; 95% CI, 1.16-3.02). WMA and elevation of cTn, BNP, and NT-proBNP in SAH patients are associated with an increased risk of DCI, poor outcome, and death after SAH.
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Affiliation(s)
- Limin Zhang
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China
| | - Bing Zhang
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China.
| | - Sihua Qi
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China.
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Ranieri M, Finsterer J, Bedini G, Parati EA, Bersano A. Takotsubo Syndrome: Clinical Features, Pathogenesis, Treatment, and Relationship with Cerebrovascular Diseases. Curr Neurol Neurosci Rep 2018; 18:20. [PMID: 29569186 DOI: 10.1007/s11910-018-0833-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
PURPOSE OF REVIEW This review paper aims to provide a complete and updated overview on the clinical and pathophysiological aspects of Takotsubo syndrome (TTS), including prognosis, therapy, and the association with cerebrovascular conditions. RECENT FINDINGS TTS is an increasingly recognized non-ischemic cardiomyopathy characterized by sudden, temporary weakening of the myocardium, of which the pathogenesis is unknown. Although pathogenesis of TTS remains unclear, a complex interaction between catecholamine-mediated stimulation, myocardial stunning, and subsequent stress-related myocardial dysfunction seems to be the main pathophysiological mechanism. Stroke is linked to TTS by a dual relationship since it may induce TTS by catecholamine release even if TTS itself also may be complicated by left ventricular thrombi leading to stroke. Given its possible complications, including the association with neurological diseases, both cardiologist and neurologists should be aware about TTS in order to diagnose it promptly and to initiate appropriate therapeutic measures.
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Affiliation(s)
- M Ranieri
- Cerebrovascular Disease Unit, IRCCS Foundation "C. Besta", Neurological Institute, Milan, Italy
| | - J Finsterer
- Krankenanstalt Rudolfstiftung, Vienna, Austria
| | - G Bedini
- Laboratory of Cellular Neurobiology, IRCCS Foundation "C. Besta", Neurological Institute, Milan, Italy
| | - E A Parati
- Cerebrovascular Disease Unit, IRCCS Foundation "C. Besta", Neurological Institute, Milan, Italy
| | - A Bersano
- Cerebrovascular Disease Unit, IRCCS Foundation "C. Besta", Neurological Institute, Milan, Italy. .,Fondazione IRCCS Istituto Neurologico "Carlo Besta", Via Celoria 11, 20133, Milan, Italy.
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McAteer A, Hravnak M, Chang Y, Crago EA, Gallek MJ, Yousef KM. The Relationships Between BNP and Neurocardiac Injury Severity, Noninvasive Cardiac Output, and Outcomes After Aneurysmal Subarachnoid Hemorrhage. Biol Res Nurs 2017. [PMID: 28627225 DOI: 10.1177/1099800417711584] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Neurocardiac injury, a type of myocardial dysfunction associated with neurological insult to the brain, occurs in 31-48% of aneurysmal subarachnoid hemorrhage (aSAH) patients. Cardiac troponin I (cTnI) is commonly used to diagnose neurocardiac injury. Brain natriuretic peptide (BNP), another cardiac marker, is more often used to evaluate degree of heart failure. The purpose of this study was to examine the relationships between BNP and (a) neurocardiac injury severity according to cTnI, (b) noninvasive continuous cardiac output (NCCO), and (c) outcomes in aSAH patients. METHOD This descriptive longitudinal study enrolled 30 adult aSAH patients. Data collected included BNP and cTnI levels and NCCO parameters for 14 days and outcomes (modified Rankin Scale [mRS] and mortality) at discharge and 3 months. Generalized estimating equations were used to evaluate associations between BNP and cTnI, NCCO, and outcomes. RESULTS BNP was significantly associated with cTnI. For every 1 unit increase in log BNP, cTnI increased by 0.05 ng/ml ( p = .001). Among NCCO parameters, BNP was significantly associated with thoracic fluid content ( p = .0003). On multivariable analyses, significant associations were found between BNP and poor mRS. For every 1 unit increase in log BNP, patients were 3.16 times more likely to have a poor mRS at discharge ( p = .021) and 5.40 times more likely at 3 months ( p < .0001). CONCLUSION There were significant relationships between BNP and cTnI and poor outcomes after aSAH. BNP may have utility as a marker of neurocardiac injury and outcomes after aSAH.
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Affiliation(s)
- Amber McAteer
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marilyn Hravnak
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yuefang Chang
- 2 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Elizabeth A Crago
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Tahsili-Fahadan P, Geocadin RG. Heart-Brain Axis: Effects of Neurologic Injury on Cardiovascular Function. Circ Res 2017; 120:559-572. [PMID: 28154104 DOI: 10.1161/circresaha.116.308446] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 01/06/2017] [Accepted: 01/06/2017] [Indexed: 01/23/2023]
Abstract
A complex interaction exists between the nervous and cardiovascular systems. A large network of cortical and subcortical brain regions control cardiovascular function via the sympathetic and parasympathetic outflow. A dysfunction in one system may lead to changes in the function of the other. The effects of cardiovascular disease on the nervous system have been widely studied; however, our understanding of the effects of neurological disorders on the cardiovascular system has only expanded in the past 2 decades. Various pathologies of the nervous system can lead to a wide range of alterations in function and structure of the cardiovascular system ranging from transient and benign electrographic changes to myocardial injury, cardiomyopathy, and even cardiac death. In this article, we first review the anatomy and physiology of the central and autonomic nervous systems in regard to control of the cardiovascular function. The effects of neurological injury on cardiac function and structure will be summarized, and finally, we review neurological disorders commonly associated with cardiovascular manifestations.
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Affiliation(s)
- Pouya Tahsili-Fahadan
- From the Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology & Critical Care Medicine, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Romergryko G Geocadin
- From the Neurosciences Critical Care Division, Departments of Neurology, Anesthesiology & Critical Care Medicine, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD.
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Roy B, McCullough LD, Dhar R, Grady J, Wang YB, Brown RJ. Comparison of Initial Vasopressors Used for Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. Cerebrovasc Dis 2017; 43:266-271. [PMID: 28319954 DOI: 10.1159/000458536] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2016] [Accepted: 01/30/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The main reason for morbidity after aneurysmal subarachnoid hemorrhage (aSAH) is delayed cerebral ischemia (DCI). The mainstay of medical therapy for treating DCI is induced hypertension with vasopressors to restore cerebral perfusion. Both phenylephrine (PE) and norepinephrine (NE) are commonly used for induced hypertension, but the impact of the initial choice of vasopressor on the efficacy, adverse effects, or outcome after hemodynamic therapy for DCI is unknown. METHODS Sixty-three patients with aSAH between January 2012 and October 2014, who developed DCI (defined as new focal deficit or decline in Glasgow Coma Score) and in which PE (n = 45) or NE (n = 18) treatment was initiated were evaluated in this retrospective study. Baseline characteristics, adverse effects, the need to change or add vasopressors, the response to therapy, the need for endovascular therapy, new infarct development, discharge disposition, and 3 months modified Rankin score were all compared between pressor groups. RESULTS Baseline characteristics (e.g., Hunt Hess and Fisher grades) were similar. There were no differences in the overall rate of complications including arrhythmia, pulmonary edema, or kidney injury. However, those initiated on PE were more likely to be changed to an alternate vasopressor (64 vs. 33%, p = 0.016), mostly for bradycardia or failure to reach therapeutic targets. Patients initially treated with PE were less likely to respond neurologically (71 vs. 94%, p = 0.01) or to be discharged to home or acute rehabilitation facilities (73 vs. 94%, p = 0.02) and were more likely to have a delayed infarct on imaging (62 vs. 33%, p = 0.04). CONCLUSIONS Our study suggests that patients with DCI after aSAH initiated on PE are more likely to require treatment change to another vasopressor and are at greater risk for poor clinical outcomes compared to patients started on NE. Larger comparative studies are warranted.
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Affiliation(s)
- Bhaskar Roy
- University of Connecticut, Farmington, CT, USA
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Subarachnoid Hemorrhage Patients Admitted to Intensive Care in Australia and New Zealand. Crit Care Med 2017; 45:e138-e145. [DOI: 10.1097/ccm.0000000000002059] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Elgendy AY, Elgendy IY, Mansoor H, Mahmoud AN. Clinical presentations and outcomes of Takotsubo syndrome in the setting of subarachnoid hemorrhage: A systematic review and meta-analysis. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 7:236-245. [DOI: 10.1177/2048872616679792] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Background: Evidence remains inconsistent regarding the incidence and prognosis of Takotsubo syndrome in the setting of subarachnoid hemorrhage. Thus, we aimed to evaluate the clinical presentation and in-hospital mortality of these patients. Methods: A systematic review of the electronic databases was conducted for studies involving patients with spontaneous subarachnoid hemorrhage and concomitant findings of classical Takotsubo syndrome on transthoracic echocardiogram. A meta-analysis was conducted for the primary outcome of in-hospital mortality using the Mantel–Haenszel method for fixed effects and the DerSimonian and Laird method for random effects, with 95% confidence interval and a p-value <0.05 for statistical significance. Results: Ten studies were retrieved with a total of 157 patients presenting with classical Takotsubo syndrome, representing 4.4% of the subarachnoid hemorrhage total population. The overall incidence of in-hospital mortality was 30% in the patients who developed Takotsubo syndrome. Meta-analysis illustrated a significant increase in the odds of in-hospital mortality for the Takotsubo syndrome patients by fixed effects model (odds ratio 2.6, 95% confidence interval 1.16–5.85, p=0.02, I2=39%), with a trend towards increased risk of in-hospital mortality by random effects model (odds ratio 3.00, 95% confidence interval 0.90–9.77, p = 0.07). Conclusions: The incidence of Takotsubo syndrome in patients with spontaneous subarachnoid hemorrhage seems to be high with a trend towards higher risk of in-hospital mortality in those patients. Thus, patients presenting with subarachnoid hemorrhage might benefit from a comprehensive cardiac evaluation upon presentation for early detection and proper triage of this high-risk population.
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Affiliation(s)
- Akram Y Elgendy
- Department of Medicine, University of Florida, Gainesville, USA
| | - Islam Y Elgendy
- Division of Cardiovascular Medicine, University of Florida, Gainesville, USA
| | - Hend Mansoor
- Department of Pharmaceutical Outcomes and Policy, University of Florida, Gainesville, USA
| | - Ahmed N Mahmoud
- Division of Cardiovascular Medicine, University of Florida, Gainesville, USA
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Elgendy AY, Mahmoud A, Elgendy IY, Mansoor H, Conti CR. Cardiovascular Abnormalities Among Patients with Spontaneous Subarachnoid Hemorrhage. A Single Center Experience. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2016. [DOI: 10.15212/cvia.2016.0024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Brown RJ, Kumar A, McCullough LD, Butler K. A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage. Int J Neurosci 2016; 127:51-58. [PMID: 26822716 DOI: 10.3109/00207454.2016.1138952] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Purpose/aim: Blood pressure (BP) regulation is recommended following aneurysmal subarachnoid hemorrhage (aSAH) to prevent re-bleeding and to treat delayed cerebral ischemia. However, optimal BP thresholds are not well established. There is also variation with regard to the BP component (e.g. systolic vs. mean) that is targeted or manipulated. MATERIALS AND METHODS An 18-question survey was distributed to physicians and advanced practitioner members of the Neurocritical Care Society. Respondents were asked which BP parameter they manipulated and what their thresholds were in different clinical scenarios. They were also asked whether they were influenced by the presence of incidental aneurysms. Answers were analyzed for differences in training background and treatment setting. RESULTS There were 128 responses. The majority were neurointensivists (47 neurology and 37 non-neurology) and treated patients in dedicated neurointensive care units (n = 98). Systolic BP (SBP) was preferred over mean arterial pressure (MAP). Prior to aneurysm treatment, SBP limits ranged from 140 to 180 mm Hg. After aneurysm treatment, SBP limits ranged from 160 to 240 mm Hg. The maximum and minimum MAPs varied by as much as 50%. Nearly two-thirds of the respondents were influenced by the presence of incidental aneurysms. Training background influenced tolerance to BP limits with neurology-trained neurointensivists accepting higher BP limits when treating delayed ischemia ( p = .018). They were also more likely to follow SBP ( p = .018) and have a limit of 140 mm Hg prior to aneurysm treatment ( p = .001). CONCLUSIONS There is large practice variability in BP management following aSAH. There is also uncertainty over the importance of incidental aneurysms. Further research could evaluate whether this variability has clinical significance.
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Affiliation(s)
- Robert J Brown
- a Department of Surgery, Division of Critical Care , Hartford Hospital , Hartford , CT , USA
| | - Abhay Kumar
- b Department of Neurology and Psychiatry , Saint Louis University , SaintLouis , MO , USA
| | - Louise D McCullough
- c Department of Neurology , University of Connecticut School of Medicine , Farmington , CT , USA
| | - Karyn Butler
- a Department of Surgery, Division of Critical Care , Hartford Hospital , Hartford , CT , USA
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Brown RJ, Epling BP, Staff I, Fortunato G, Grady JJ, McCullough LD. Polyuria and cerebral vasospasm after aneurysmal subarachnoid hemorrhage. BMC Neurol 2015; 15:201. [PMID: 26462796 PMCID: PMC4604625 DOI: 10.1186/s12883-015-0446-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/29/2015] [Indexed: 12/29/2022] Open
Abstract
Background Natriuresis with polyuria is common after aneurysmal subarachnoid hemorrhage (aSAH). Previous studies have shown an increased risk of symptomatic cerebral vasospasm or delayed cerebral ischemia (DCI) in patients with hyponatremia and/or the cerebral salt wasting syndrome (CSW). However, natriuresis may occur in the absence of hyponatremia or hypovolemia and it is not known whether the increase in DCI in patients with CSW is secondary to a concomitant hypovolemia or because the physiology that predisposes to natriuretic peptide release also predisposes to cerebral vasospasm. Therefore, we investigated whether polyuria per se was associated with vasospasm and whether a temporal relationship existed. Methods A retrospective review of patients with aSAH was performed. Exclusion criteria were admission more than 48 h after aneurysmal rupture, death within 5 days, and the development of diabetes insipidus or acute renal failure. Polyuria was defined as >6 liters of urine in a 24 h period. Vasospasm was defined as a mean velocity > 120 m/s on Transcranial Doppler Ultrasonography (TCDs) or by evidence of vasospasm on computerized tomography (CT) or catheter angiography. Multivariable logistic regression was performed to assess the relationship between polyuria and vasospasm. Results 95 patients were included in the study. 51 had cerebral vasospasm and 63 met the definition of polyuria. Patients with polyuria were significantly more likely to have vasospasm (OR 4.301, 95 % CI 1.378–13.419) in multivariate analysis. Polyuria was more common in younger patients (52 vs 68, p <.001) but did not impact mortality after controlling for age and disease severity. The timing of the development of polyuria was clustered around the diagnosis of vasospasm and patients with polyuria developed vasospasm faster than those without polyuria. Conclusions Polyuria is common after aSAH and is significantly associated with cerebral vasospasm. The development of polyuria may be temporally related to the development of vasospasm. An increase in urine volume may be a useful clinical predictor of patients at risk for vasospasm.
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Affiliation(s)
- Robert J Brown
- Department of Surgery, Division of Critical Care, Hartford Hospital, 80 Seymour Street, Hartford, 06102, USA. .,Department of Neurology, University of Connecticut Medical Center, 263 Farmington Avenue, Farmington, 06030, USA.
| | - Brian P Epling
- University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, 06030, USA.
| | - Ilene Staff
- Department of Research, Hartford Hospital, 80 Seymour Street, Hartford, 06102, USA.
| | - Gilbert Fortunato
- Department of Research, Hartford Hospital, 80 Seymour Street, Hartford, 06102, USA.
| | - James J Grady
- University of Connecticut School of Medicine, 263 Farmington Avenue, Farmington, 06030, USA.
| | - Louise D McCullough
- Department of Neurology, University of Connecticut Medical Center, 263 Farmington Avenue, Farmington, 06030, USA.
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Finsterer J, Bersano A. Subarachnoid bleeding triggering Takotsubo syndrome. Int J Cardiol 2015; 197:107-9. [DOI: 10.1016/j.ijcard.2015.06.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/16/2015] [Indexed: 02/08/2023]
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