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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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Abstract
OBJECTIVE Acute aneurysmal subarachnoid hemorrhage (SAH) is a complex multifaceted disorder that plays out over days to weeks. Many patients with SAH are seriously ill and require a prolonged intensive care unit stay. Cardiopulmonary complications are common. The management of patients with SAH focuses on the anticipation, prevention, and management of these secondary complications. DATA SOURCES Source data were obtained from a PubMed search of the medical literature. DATA SYNTHESIS AND CONCLUSION The rupture of an intracranial aneurysm is a sudden devastating event with immediate neurologic and cardiac consequences that require stabilization to allow for early diagnostic angiography. Early complications include rebleeding, hydrocephalus, and seizures. Early repair of the aneurysm (within 1-3 days) should take place by surgical or endovascular means. During the first 1-2 weeks after hemorrhage, patients are at risk of delayed ischemic deficits due to vasospasm, autoregulatory failure, and intravascular volume contraction. Delayed ischemia is treated with combinations of volume expansion, induced hypertension, augmentation of cardiac output, angioplasty, and intra-arterial vasodilators. SAH is a complex disease with a prolonged course that can be particularly challenging and rewarding to the intensivist.
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Yamaguchi K, Wakatsuki T, Kusunose K, Niki T, Koshiba K, Yamada H, Soeki T, Akaike M. A case of neurogenic myocardial stunning presenting transient left ventricular mid-portion ballooning simulating atypical takotsubo cardiomyopathy. J Cardiol 2008; 52:53-8. [DOI: 10.1016/j.jjcc.2008.03.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2007] [Revised: 03/12/2008] [Accepted: 03/12/2008] [Indexed: 11/16/2022]
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Lee VH, Abdelmoneim SS, Daugherty WP, Oh JK, Mulvagh SL, Wijdicks EFM. Myocardial contrast echocardiography in subarachnoid hemorrhage-induced cardiac dysfunction: case report. Neurosurgery 2008; 62:E261-2; discussion E262. [PMID: 18300884 DOI: 10.1227/01.neu.0000311088.26885.1d] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Cardiac dysfunction is a well-known complication of aneurysmal subarachnoid hemorrhage (SAH) that is generally regarded as secondary to catecholamine excess rather than overt ischemia. Myocardial contrast echocardiography (MCE) is a novel method of evaluating cardiac function and perfusion. We report the use of MCE in a patient with SAH and correlate the results to coronary angiography. METHODS Bedside MCE using Definity contrast agent (Bristol-Myers Squibb/Sanofi Pharmaceuticals, New York, NY) was performed at the onset of SAH and at the 1-week and 4-month follow-up evaluations. RESULTS A 64-year-old woman presented with aneurysmal SAH. She developed transient ST elevation on lateral electrocardiographic leads and elevated cardiac enzymes with creatine-kinase MB isoenzyme of 44.3 ng/ml and troponin of 0.62 ng/ml. An emergent coronary angiogram performed at the outside facility revealed normal coronary anatomy, ejection fraction of 30%, and midventricular akinesis. On transfer to our facility, MCE demonstrated an ejection fraction of 45% with normal coronary perfusion in the akinetic midventricular segments and normally contracting basal and apical segments. At the 4-month follow-up examination, her ejection fraction normalized to 67% and regional wall motion had improved. CONCLUSION To our knowledge, our case represents the first reported use of MCE in a patient with SAH. MCE demonstrating normal myocardium perfusion in the setting of normal coronary arteries on coronary angiogram and midventricular akinetic segments is compatible with nonischemic injury, which further supports the "catecholamine hypothesis" of neurogenic cardiac stunning. MCE may be a feasible noninvasive method to evaluate myocardial perfusion in the SAH population.
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Affiliation(s)
- Vivien H Lee
- Department of Neurological Sciences, Section of Cerebrovascular Disease, Rush University Medical Center, Chicago, Illinois, USA
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Schuiling WJ, Dennesen PJW, Rinkel GJE. Extracerebral organ dysfunction in the acute stage after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2006; 3:1-10. [PMID: 16159088 DOI: 10.1385/ncc:3:1:001] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
In patients with aneurysmal subarachnoid hemorrhage (SAH), secondary complications are an important cause of morbidity and case fatality. Delayed cerebral ischemia and hydrocephalus are important intracranial secondary complications. Potentially treatable extracranial complications are also frequently observed, and some are related to the occurrence of delayed cerebral ischemia and outcome. In addition to the occurrence of an inflammatory response and metabolic derangements, cardiac and pulmonary complications are the most common extracranial complications. This article provides an overview of the most common extracranial complications in patients with SAH and describes their effects on outcome and delayed cerebral ischemia.
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Affiliation(s)
- Wouter J Schuiling
- Department of Neurology and Clinical Neurophysiology, Medical Center Leeuwarden, the Netherlands.
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Oropello JM, Weiner L, Benjamin E. Hypertensive, hypervolemic, hemodilutional therapy for aneurysmal subarachnoid hemorrhage. Is it efficacious? No. Crit Care Clin 1996; 12:709-30. [PMID: 8839602 DOI: 10.1016/s0749-0704(05)70274-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Many neurosurgeons routinely use hypertensive, hypervolemic, hemodilutional, or hyperdynamic therapy (HT) in some form to prevent or to treat vasospasm. Despite the widespread use of this therapy during the past 20 years, however, there are no randomized, prospective, controlled clinical studies demonstrating that HT improves the short- or long-term neurologic outcome or survival after subarachnoid hemorrhage. Guidelines need to be developed to standardize the clinical application of HT, and well-controlled, prospective, randomized clinical trials must be conducted before HT can become an accepted treatment for vasospasm.
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Affiliation(s)
- J M Oropello
- Department of Surgery, Mount Sinai Medical Center, City University of New York, New York, USA
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Mayer SA, LiMandri G, Sherman D, Lennihan L, Fink ME, Solomon RA, DiTullio M, Klebanoff LM, Beckford AR, Homma S. Electrocardiographic markers of abnormal left ventricular wall motion in acute subarachnoid hemorrhage. J Neurosurg 1995; 83:889-96. [PMID: 7472560 DOI: 10.3171/jns.1995.83.5.0889] [Citation(s) in RCA: 132] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
A reversible and presumably neurogenic form of myocardial dysfunction may occur following subarachnoid hemorrhage (SAH), but the relationship of this finding to electrocardiographic abnormalities remains unclear. To clarify this issue, serial electrocardiograms (ECGs, mean 6.2 per patient) and echocardiograms (mean 3.4 days after SAH) were obtained in 57 SAH patients without preexisting cardiac disease. The goal was to determine which specific electrocardiographic changes, if any, reflect abnormal left ventricular wall motion in acute SAH. Wall motion abnormalities were identified in five (8%) of 57 patients. Four of these affected patients experienced hypotension (systolic blood pressure < 100 mm Hg) and three exhibited pulmonary edema within 6 hours of SAH, compared to none of the 52 patients with normal wall motion (p < 0.0001). Patients with abnormal wall motion were more likely than patients with normal echocardiograms to have symmetrical T wave inversion (five of five vs. seven of 52, p < 0.001) and severe (> or = 500 msec) QTc segment prolongation (five of five vs. three of 52, p < 0.001) on serial ECGs. These associations maintained their significance with analysis limited to single ECGs performed on or near the day of echocardiography. Abnormal wall motion was also associated with borderline (2% to 5%) creatine kinase MB elevation (five of five vs. three of 52, p < 0.001) and poor neurological grade (p < 0.0001). Although no combination of findings on a single ECG resulted in 100% sensitivity for abnormal wall motion, the presence of either inverted T waves or severe QTc segment prolongation on serial ECGs was associated with 100% sensitivity and 81% specificity. These results demonstrate an association between reduced left ventricular systolic function, mild creatine kinase MB elevation, and electrocardiographic repolarization abnormalities in acute SAH. Symmetrical T wave inversion and severe QTc segment prolongation best identified patients at risk for myocardial dysfunction and may serve as useful criteria for echocardiographic screening following SAH.
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Affiliation(s)
- S A Mayer
- Department of Neurology Critical Care Neurology, Columbia University, College of Physicians and Surgeons, New York, New York, USA
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Boeve BF, Rummans TA, Philbrick KL, Callahan MJ. Electrocardiographic and echocardiographic changes associated with malignant catatonia. Mayo Clin Proc 1994; 69:645-50. [PMID: 7864927 DOI: 10.1016/s0025-6196(12)61341-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
We describe a case of malignant catatonia manifested by catatonic symptoms, fever, hemodynamic instability, and acute neurologic decline that was associated with electrocardiographic and echocardiographic abnormalities similar to those noted in patients with other central nervous system processes. The patient's electrocardiographic and echocardiographic abnormalities resolved after successful electroconvulsive therapy for the underlying neuropsychiatric disorder. The theoretic, physiologic, and clinical significances of this case are discussed.
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Affiliation(s)
- B F Boeve
- Department of Neurology, Mayo Clinic Rochester, Minnesota 55905
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