Neurogenic stress cardiomyopathy associated with subarachnoid hemorrhage

Acute pulmonary edema after subarachnoid hemorrhage: risk factors and comorbidities-an analysis of a nationwide database from the United States

BACKGROUND

Acute pulmonary edema (APE) is a rare complication of subarachnoid hemorrhage (SAH) that is associated with increased morbidity and poor clinical outcomes. There is limited literature addressing the incidence and risk factors of this complication, highlighting the need for further investigation as undertaken in the present study.

METHODS

The 2016 to 2021 National Inpatient Sample (NIS) was used to identify adult inpatients with a primary diagnosis of non-traumatic SAH. Univariate and multivariable analyses adjusting for patient demographics, and comorbidity status, were used to characterize statistical associations with APE.

RESULTS

A total of 42,141 patients were identified as having SAH from 2016 to 2021. Of these patients, 960 patients (2.3%) were found to have APE. APE was associated with increased length of stay (20.0 ± 18.9 days vs. 11.6 ± 14.3, p < 0.001), increased total costs ($503,671.3 ± 647,729.9 vs. $238,724.6 ± 328,062.1, p < 0.001), increased number of days from admission to first procedure (3.5 ± 7.3 vs. 1.9 ± 4.9, p < 0.001), increased Elixhauser comorbidity index ≥ 3 (77.5% vs. 66.0%, p < 0.001), and increased mortality (40.2% vs. 22.5%, p < 0.001). After controlling for confounding factors, independent risk factors for APE in patients with non-traumatic SAH included: Coagulopathies (adjusted Odds Ratio [aOR]: 1.57, 95% confidence interval [CI] 1.31-1.89, p < 0.001), Fluid and Electrolyte Disorders (aOR: 2.54, CI 2.13-3.03, p < 0.001), Liver Disease (aOR: 1.37, CI 1.07-1.76, p = 0.013), Obesity (aOR: 1.47, CI 1.19-1.81, p = 0.003), Pulmonary Circulatory Disorder (aOR: 1.72, CI 1.31-2.26, p = 0.001), and Weight Loss (aOR: 1.67, CI 1.36-2.04, p < 0.001).

CONCLUSION

APE after SAH is associated with increased complicated hospital course. Neurosurgeons and Neurocritical care medical professionals should be aware of the comorbidities and factors associated with increased APE after SAH to improve patient outcomes.

Takotsubo Cardiomyopathy After Subarachnoid Hemorrhage: Who Is At Risk?

INTRODUCTION

Takotsubo Cardiomyopathy (TCM) is a rare but well recognized complication of subarachnoid hemorrhage associated with increased morbidity and poor clinical outcomes. There is a scarcity of literature describing the prevalence and risk factors associated with this complication. The aim of this study was to identify patients who are at risk of developing TCM in non-traumatic subarachnoid hemorrhage.

METHODS

The 2016 to 2021 National Inpatient Sample (NIS) was used to identify adult inpatients with a primary diagnosis of non-traumatic subarachnoid hemorrhage. Univariate and multivariable analyses adjusting for patient demographics, comorbidity status, and hemorrhage etiology were used to characterize statistical associations with disease-related complications. Patients with TCM were further divided into those with "good" or "poor" functional outcomes and compared.

RESULTS

A total of 42 141 patients were identified as having a subarachnoid hemorrhage from 2016 to 2021. Of these patients 486 patients (1.2%) were found to have TCM. TCM was associated with increased length of stay (19.15 ± 17.8 days vs 11.72 ± 14.4, P < .001), increased total costs ($451 502.59 ± 443 777.9 vs $242 327.92 ± 338 862.3, P < .001), increased number of days from admission to first procedure (1.74 ± 4.5 vs 1.94 ± 5.0, P < .001), and increased mortality (31.7% vs 22.8%, P < .001). After controlling for confounding factors, independent risk factors for TCM in patients with non-traumatic subarachnoid hemorrhage included: Female (Odds Ratio [OR]: 3.11, 95% Confidence Interval [CI]: 2.50-3.89, P < .001), Congestive Heart Failure (OR:4.60, CI:3.70-5.71, P < .001), and Fluid and Electrolyte Disorders (OR: 2.52, CI: 2.05-3.11, P < .001). Patients with good functional outcomes were found to have younger age (54.85 years ± 14.0 vs 58.14 ± 14.7, P < .001), decreased length of stay (17.11 ± 16.9 vs 19.83 ± 18.1, P < .001), decreased total charge ($370 245.94 ± 517 702.8 vs $477 366.55 ± 417 122.4, P < .001), and decreased mortality (P < .001) compared to those with poor functional outcomes.

CONCLUSION

TCM after subarachnoid hemorrhage is associated with increased mortality, length of stay, total cost, number of procedures in patients, and number of days to first procedure. Neurosurgeons and Neurocritical care medical professionals should be aware of the comorbidities and factors associated with increased TCM after subarachnoid hemorrhage in order to improve patient outcomes.

Myocardial dysfunction assessed by speckle-tracking in good-grade subarachnoid hemorrhage patients (WFNS 1-2): a prospective observational study

BACKGROUND

Cardiac complications due to non-traumatic subarachnoid hemorrhage (SAH) are usually described using classical echocardiographic evaluation. Strain imaging appears to have better sensitivity than standard echocardiographic markers for the diagnosis of left ventricular dysfunction. The aim of this study was to determine the prevalence of cardiac dysfunction defined as a Global Longitudinal Strain (GLS) ≥  - 20% in patients with good-grade SAH (WFNS 1 or 2).

METHODS

Seventy-six patients with good-grade SAH were prospectively enrolled and analyzed at admission for neurocritical care. Transthoracic echocardiography was performed on days 1, 3, and 7 after hemorrhage. Routine measurements, including left ventricular ejection fraction (LVEF), were performed, and off-line analysis was performed by a blinded examiner, to determine 2-, 3-, and 4-cavity longitudinal strain and left ventricular GLS. GLS was considered altered if it was ≥  - 20%, we also interested the value of ≥  - 17%. LVEF was considered altered if it was < 50%.

RESULTS

On day 1, 60.6% of patients had GLS ≥  - 20% and 21.2% of patient had GLS ≥  - 17%. In comparison, alteration of LVEF was present in only 1.7% of patients. The concordance rate between LVEF < 50% and GLS ≥  - 20% and LVEF ≥ 50% and GLS <  - 20% was 46%.

CONCLUSION

Strain imaging showed a higher prevalence (60.6%) of left ventricular dysfunction during the acute phase of good-grade SAH (WFNS 1 or 2) than previously described.

Endocrine dysregulation in aneurysmal subarachnoid haemorrhage

INTRODUCTION

Aneurysmal Subarachnoid haemorrhage (aSAH) is one of the most common causes of neurocritical care admission. Consistent evidence has been suggestive of endocrine dysregulation in aSAH. This review aims to provide an up-to-date presentation of the available evidence regarding endocrine dysregulation in aneurysmal subarachnoid haemorrhage.

METHODS

A comprehensive literature search was performed using PubMed database. All available evidence related to endocrine dysregulation in hypothalamic-pituitary hormones, adrenal hormones and natriuretic peptides after aSAH, published since 2010, were reviewed.

RESULTS

There have been reports of varying prevalence of dysregulation in hypothalamic-pituitary and adrenal hormones in aSAH. The cause of this dysregulation and its pattern remain unclear. Hypothalamic-pituitary and adrenal dysregulation have been associated with higher incidence of poor neurological outcome and increased mortality. Whilst there is evidence that long-term dysregulation of these axes may also develop, it appears to be less frequent than the acute-phase dysregulation and transient in pattern. Increased levels of catecholamines have been reported in the hyper-acute phase of aSAH with reported inconsistent correlation with the outcomes and the complications of the disease. There is growing evidence that of a causal link between the endocrine dysregulation and the development of hyponatraemia and delayed cerebral ischaemia, in the acute phase of aSAH. However, the pathophysiological mechanism and pattern of endocrine dysregulation which could be causally associated with these complications still remain debatable.

CONCLUSION

The evidence, mainly from small observational and heterogeneous in methodology studies, is suggestive of adverse effects of the endocrine dysregulation on the outcome and the incidence of complications of the disease. However, the cause of this dysregulation and a pathophysiological mechanism that could link its presence with the development of acute complications and the outcome of the aSAH remain unclear. Further research is warranted to elucidate the clinical significance of endocrine dysregulation in subarachnoid haemorrhage.

Immediate pneumothorax after neurosurgical procedures

Objective

Pneumothorax after neurosurgical procedures is very rare and incompletely understood. This study was performed to explore the clinical characteristics and pathogenesis of pneumothorax after neurosurgery.

Methods

We retrospectively evaluated patients admitted from December 2016 to April 2019 for treatment of spontaneous intracranial hemorrhage. The inclusion criteria were neurosurgical procedures (open surgeries or endovascular intervention) performed under general anesthesia, no performance of central venous puncture during surgery, and occurrence of pneumothorax immediately after the neurosurgical procedure.

Results

Eight patients developed pneumothorax after neurosurgical procedures for spontaneous intracranial hemorrhage under general anesthesia. Of the eight patients, seven had aneurysmal subarachnoid hemorrhage and one had left temporal–parietal hemorrhage. The lung injury prediction score (LIPS) was 3, 4, 5, 6, and 9.5 in three, one, two, one, and one patient, respectively. During the operation, volume-controlled ventilation (tidal volume, 8–10 mL/kg) was selected for all patients.

Conclusions

Neurogenic pulmonary edema, inappropriate mechanical ventilation, and stimulation by endotracheal intubation might conjointly contribute to postoperative pneumothorax. To avoid this rare entity, mechanical ventilation with a low tidal volume or low pressure during general anesthesia should be adopted for patients with hemorrhagic cerebrovascular diseases involving the temporal lobe and a LIPS of >3.

Stress cardiomyopathy misinterpreted as ST-segment elevation myocardial infarction in a patient with aneurysmal subarachnoid hemorrhage: a case report

Cardiac abnormalities are frequently reported in acute subarachnoid hemorrhage (SAH) patients. However, frank ST-elevation and myocardial dysfunction mimicking acute coronary syndrome is a rare occurrence. Systemic and local catecholamine release mediate myocardial injury and may explain raised troponin levels, concordant regional wall motion abnormalities and systolic dysfunction. These findings can pose a significant problem in the acute setting where "time-is-muscle" paradigm can rush clinicians towards a "rule-in" diagnosis of acute myocardial infarction. We present the case of a 60-year-old male who arrived at a regional emergency department with loss of consciousness, chest pain and headache. His ECG showed ST-elevation in precordial leads with corresponding region wall motion abnormalities and dynamically elevated troponin levels which supported a diagnosis of acute myocardial infarction. Percutaneous coronary intervention was attempted but found no hemodynamically significant lesions and the patient was managed conservatively with antithrombotic treatment. Further work-up for his headache led to the diagnosis of aneurysmal SAH and subsequent endovascular coiling. The patient was discharged with a good clinical outcome. We discuss the potential catastrophic consequences of interpreting neurologic myocardial stunning as STEMI. Use of potent antithrombotic therapies, like bridging thrombolysis, in this setting can lead to dismal consequences. Clinical history should still be carefully obtained in the acute setting in this era of sensitive biomarkers.

Echocardiographic wall motion abnormalities in patients with stroke may warrant cardiac evaluation

Background

The aetiology of wall motion abnormalities (WMA) in patients with ischaemic stroke is unclear. We hypothesised that WMAs on transthoracic echocardiography (TTE) in the setting of ischaemic stroke mostly reflect pre-existing coronary heart disease rather than simply an isolated neurocardiogenic phenomenon.

Methods

Data were retrospectively abstracted from a prospective ischaemic stroke database over 18 months and included patients with ischaemic stroke who underwent a TTE. Coronary artery disease was defined as history of myocardial infarction (MI), coronary intervention or ECG evidence of prior MI. The presence (vs absence) of WMA was abstracted. Multivariable logistic regression was used to determine the association between coronary artery disease and WMA in models adjusting for potential confounders.

Results

We identified 1044 patients who met inclusion criteria; 139 (13.3%, 95% CI 11.2% to 15.4%) had evidence of WMA of whom only 23 (16.6%, 95% CI 10.4% to 22.8%) had no history of heart disease or ECG evidence of prior MI. Among these 23 patients, 12 had a follow-up TTE after the stroke and WMA persisted in 92.7% (11/12) of patients. In fully adjusted models, factors associated with WMA were older age (OR per year increase 1.03, 95% 1.01 to 1.05, p=0.009), congestive heart failure (OR 4.44, 95% CI 2.39 to 8.33, p<0.001), history of coronary heart disease or ECG evidence prior MI (OR 27.03, 95% CI 14.93 to 50.0, p<0.001) and elevated serum troponin levels (OR 2.00, 95% CI 1.06 to 3.75, p=0.031).

Conclusion

In patients with ischaemic stroke, WMA on TTE may reflect underlying cardiac disease and further cardiac evaluation may be considered.

Epidemiology, pathogenesis, and management of takotsubo syndrome

Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.

The Neurocardiogenic Spectrum in Subarachnoid Hemorrhage: A Case Report and Review of the Literature

A 36-year-old man was brought to our emergency department after successful resuscitation of out-of-hospital cardiac arrest with the whole spectrum of neurocardiogenic effects in subarachnoid hemorrhage: electrocardiographic changes, regional wall motion abnormalities, and elevations of cardiac enzymes. Coronary angiography revealed normal coronary arteries but showed the midventricular type of Takotsubo cardiomyopathy in the left ventriculography. Subsequently, cerebral computed tomography revealed diffuse subarachnoid hemorrhage and generalized cerebral edema with brain herniation. Brain death was diagnosed. This case highlights the possibility of an acute cerebral illness (especially subarachnoid hemorrhage) as an underlying cause of cardiac abnormalities mimicking myocardial ischemia.

Neurocardiac Injury After Cerebral and Subarachnoid Hemorrhages

Cerebrovascular events are associated with high mortality and morbidity rates. Neurocardiac injury after a subarachnoid hemorrhage and cerebral hemorrhage further worsen clinical outcomes. Excess catecholamine-induced cardiotoxicity is currently the most widely accepted pathophysiologic mechanism. Awareness of neurocardiac injury and the cardiac manifestations associated with it will allow for early diagnosis and appropriate management.

Contemporary review on the pathogenesis of takotsubo syndrome: The heart shedding tears: Norepinephrine churn and foam at the cardiac sympathetic nerve terminals

Takotsubo syndrome (TS), an increasingly recognized acute cardiac disease entity, is characterized by a unique pattern of circumferential and typically regional left ventricular wall motion abnormality resulting in a conspicuous transient ballooning of the left ventricle during systole. The mechanism of the disease remains elusive. However, the sudden onset of acute myocardial stunning in a systematic pattern extending beyond a coronary artery territory; the history of a preceding emotional or physical stress factor in two thirds of cases; the signs of sympathetic denervation at the regions of left ventricular dysfunction on sympathetic scintigraphy; the finding of myocardial edema and other signs consistent with (catecholamine-induced) myocarditis shown by cardiac magnetic resonance imaging; and the contraction band necrosis on histopathological examination all argue strongly for the involvement of the cardiac sympathetic nervous system in the pathogenesis of TS. In this narrative review, extensive evidence in support of local cardiac sympathetic nerve hyperactivation, disruption and norepinephrine spillover causing TS in predisposed patients is provided.

Takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: Institutional experience and literature review

OBJECTIVES

To review the current practice in the diagnosis, monitoring and management of TCM in SAH patients at our tertiary referral institution and the relevant literature, and to evaluate the effect of certain treatment modalities on the outcome of those patients.

PATIENTS AND METHODS

A retrospective institutional chart review of 800 patients with aneurysmal SAH from 2007 to 2014. Eighteen patients were identified to have both aneurysmal SAH and TCM based on echocardiogram. Demographic data, clinical parameters, radiographic findings, treatment modalities, and laboratory results were analyzed.

RESULTS

The incidence of typical TCM in our patients was 2.2%. Mortality rate of TCM in SAH was 22% compared to the total mortality rate of all non-traumatic SAH patients of 15% in our institution over the same time period. Use of beta blockers prior to or after the diagnosis of TCM did not seem to affect their outcome. Majority of patients (61%) were on vasopressors prior to the diagnosis of TCM. Of those, 73% had good outcomes. Even after the diagnosis of TCM, good outcomes were observed in 6 of 7 patients who remained on vasopressors.

CONCLUSION

Despite the general agreement on the importance of the avoidance of vasopressors in TCM, our experience showed that the use of vasopressors is safe in these patients. The use of beta blockers in our patients was not associated with significantly better outcomes despite multiple previous reports on beta blocker usage in TCM.

Unraveling of the Effect of Nodose Ganglion Degeneration on the Coronary Artery Vasospasm After Subarachnoid Hemorrhage: An Experimental Study

BACKGROUND

Cardiac arrest is a major life-threatening complication of subarachnoid hemorrhage (SAH). Although medullary cardiocirculatuar center injury and central sympathetic overactivity have been suspected of initiating coronary artery spasm-induced cardiac arrest, we aimed to elucidate the effects of vagal ischemia at the brainstem on coronary vasospasm and sudden death in SAH.

METHODS

Twenty-six rabbits were randomly divided into 3 groups. Control (n = 5); SHAM (n = 8), and SAH group (n = 13). Experimental SAH was applied by injecting homologous blood into the cisterna magna, and the SHAM group was injected with isotonic saline solution also in the cisterna magna., Twenty-one days after the injection, histopathologic changes of the neuron density of nodose ganglia, the vasospasm index values of the coronary arteries, and the electrocardiographic events were analyzed.

RESULTS

Increased vasospasm index of the coronary arteries and degenerated neuron density of nodose ganglion were significantly different between animals with SAH, control, and SHAM groups (P < 0.005). If neurons of the nodose ganglia are lesioned due to ischemic insult during SAH, the heart rhythm regulation by vagus afferent reflexes is disturbed.

CONCLUSIONS

We found that there is causal relationship between nodose ganglion degeneration and coronary vasospasm. Our finding could be the reason that many cardiac events occur in patients with SAH. Vagal pathway paralysis induced by indirect sympathetic overactivity may trigger coronary vasospasm and heart rhythm disturbances. Our findings will aid in the planning of future experimental studies and in determining the clinical relevance of such studies.