Unaccounted for enteral volume loss linked to delayed cerebral ischemia after subarachnoid hemorrhage

Abstract

Delayed ischemic neurological deficit (DIND) is seen as a clinical manifestation of cerebral vasospasm and is a significant cause of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH). Currently, the standard of care for DIND prevention in patients who have sustained aSAH is prophylactic nimodipine therapy and ensuring adequate fluid intake, alongside other treatments such as bowel care. Osmotic laxatives trap water within the bowel lumen to accelerate the transport of the gut contents through the bowel. Given the potential for DIND secondary to cerebral vasospasm, it is perhaps counterintuitive that gastrointestinal fluid loss and use of osmotic laxatives are not commonly considered in many aSAH management protocols. A retrospective case note analysis was performed for all adult patients (aged > 16 years) admitted to the Department of Neurosurgery at Leeds General Infirmary with a diagnosis of aSAH between August 2019 and September 2020. A total of 105 patients were included, 62% of whom were female, with a mean and median age of 54 years (range 24-84 years). Diarrhea was noted in 12 patients (11.4%), 58% of whom subsequently developed DIND (OR 15.30, CI 3.92-59.14; p = 0.0001). All patients received osmotic laxatives (97% having received ≥ 2 laxative agents). Patients with aSAH who subsequently developed diarrhea had significantly increased odds of developing DIND. Enteral volume loss due to osmotic laxative use is a potential risk factor for DIND after aSAH.