Admission Hunt-Hess Grade Research Articles

Clinical Outcomes of Diffuse Angiogram-Negative Subarachnoid Hemorrhage Versus Aneurysmal Subarachnoid Hemorrhage: A Propensity Score-Matched Analysis.

The outcome of diffuse angiogram-negative subarachnoid hemorrhage (dan-SAH) compared with aneurysmal SAH (aSAH) remains unclear. This study aimed to compare outcomes using propensity score matching. Sixty-five patients with dan-SAH and 857 patients with aSAH admitted between January 2018 and December 2022 were retrospectively reviewed. Propensity score matching resulted in matching 65 patients with dan-SAH to 260 patients with aSAH, and clinical outcomes were compared between the groups. Compared with patients with dan-SAH, patients with aSAH were more likely to experience rehemorrhage (8.8% versus 0%, P=0.027), death (11.2% versus 1.5%; odds ratios [OR] 8.04 [95% CI, 1.07-60.12]; P=0.042), or delayed cerebral ischemia (12.3% versus 3.1%; OR, 4.42 [95% CI, 1.03-18.95]; P=0.045). Multivariate analysis revealed that Hunt-Hess grade 4 to 5 (OR, 3.13 [95% CI, 2.11-4.64]; P<0.001), presence of intraventricular hemorrhage (OR, 3.58 [95% CI, 1.72-7.46]; P=0.001), and smoking (OR, 2.44 [95% CI, 1.12-5.28]; P=0.024) were independently associated with the incidence of unfavorable outcomes (modified Rankin scale score >2 at 3 months), whereas dan-SAH was not (OR, 0.66 [95% CI, 0.25-1.73]; P=0.40). Compared with patients with dan-SAH, patients with aSAH had higher rehemorrhage rates and in-hospital mortality, as well as a higher incidence of delayed cerebral ischemia. Unfavorable outcomes were associated with admission Hunt-Hess grade, the presence of intravenetricular hemorrhage, and smoking history, but there was no relation with the pathogenesis of the hemorrhage (dan-SAH versus aSAH).

Prognostic Significance of Sentinel Headache Preceding Aneurysmal Subarachnoid Hemorrhage

Sentinel headache (SH) is often assumed to portend an increased risk of delayed cerebral ischemia (DCI) and aneurysm rebleeding. This study aimed to re-evaluate the associations between SH and aneurysm rebleeding, DCI, and outcome after SAH. We retrospectively analyzed 1102 patients with spontaneous SAH and available data regarding history of SH who were enrolled in the Columbia University SAH Outcomes Project between 1996 and 2009. Patients were asked whether they had experienced any episodes of acute, sudden-onset severe headache in the 2 weeks preceding the most recent bleeding event. DCI was defined as neurologic deterioration, infarction, or both due to vasospasm. Rebleeding was defined as the appearance of new hemorrhage on computed tomography. Outcome was assessed at 3 months by telephone interview using the modified Rankin Scale. SH was reported in 152 (14%) of 1102 patients. There were no significant differences between patients with and without SH with regard to admission Hunt-Hess grade or modified Fisher Scale. There was also no difference with regard to the frequency of aneurysm rebleeding (10% vs. 8%, P= 0.42), DCI (18% vs, 20%, P= 0.64), moderate-or-severe angiographic vasospasm on follow-up angiography (51% vs. 56%, P= 0.43), highest recorded mean middle cerebral artery flow velocity on transcranial Doppler (134 versus 128 cm/s, P= 0.30), or the distribution of modified Rankin Scale scores at 3 months. A history of sentinel headache before the clinical diagnosis of SAH does not imply an increased risk of DCI or further rebleeding, and carries no prognostic significance.

Lower Serum Iron and Hemoglobin Levels are Associated with Acute Seizures in Patients with Ruptured Cerebral Aneurysms.

The aim of the study is to investigate the value of serum iron and hemoglobin levels for predicting acute seizures following aneurysmal subarachnoid hemorrhage (aSAH). Clinical and laboratorial data from patients with ruptured intracranial aneurysms were collected in the retrospective study. Age, sex, symptom onset, history of diabetes and hypertension, history of coronary artery disease, temperature, Hunt-Hess grade, Fisher grade, aneurysm location, hemoglobin, serum potassium, sodium, calcium, phosphorus, and iron were collected. Acute seizures were determined as seizures within 1week following aSAH. Propensity score matching (PSM) analyses were performed to correct imbalances in patient characteristics between seizure and non-seizure groups. A total of 760 patients were included. Incidence of acute seizures following aSAH was 6.4%. In the univariate analysis, significant differences were detected in age, admission Hunt-Hess grade, Fisher grade, hemoglobin, serum sodium, and serum iron between seizure and non-seizure groups. In multivariate logistic regression model, lower serum iron was considered as a risk factor for acute seizures (OR 0.182, 95% CI 0.084-0.393, p = 0.000), as well as lower hemoglobin (OR 0.977, 95% CI 0.962-0.993, p = 0.004) and higher serum sodium (OR 1.072, 95% CI 1.003-1.145, p = 0.039). After PSM, there were no significant differences in age, admission Hunt-Hess grade, Fisher grade, and serum sodium between seizure and non-seizure groups. The matched seizure group had lower serum iron and hemoglobin levels compared with the matched non-seizure group (p < 0.05). The optimal cutoff value for serum iron and hemoglobin levels as a predictor of acute seizure after aSAH was determined as 9.9mmol/L (sensitivity was 81.63% and the specificity was 65.40%) and 119g/L (sensitivity was 63.27% and the specificity was 70.18%), respectively. Serum iron and hemoglobin levels were inversely associated with a high risk of acute seizures following aSAH.

Lower Hemoglobin Levels Are Associated with Acute Seizures in Patients with Ruptured Cerebral Aneurysms

We tested the hypothesis that low hemoglobin levels are associated with acute seizures after aneurysmal subarachnoid hemorrhage (aSAH). Patients with ruptured intracranial aneurysms were enrolled in the observational cohort study that prospectively collected age, sex, symptom onset, history of diabetes and hypertension, history of coronary artery disease, temperature, Hunt-Hess grade, Fisher grade, aneurysm location, hemoglobin, hematocrit, serum potassium, sodium, calcium, phosphorus, iron, and modified Rankin Scale. Acute seizures were determined as seizures within 1 week after aSAH. We included 554 patients with requisite data for analysis in the prospective study. Incidence of acute seizures following aSAH was 3.61%. In the univariate analysis, significant differences were detected in admission Hunt-Hess grade, Fisher grade, hemoglobin, and serum iron between epilepsy and nonepilepsy groups. Furthermore, acute seizures were associated with higher modified Rankin Scale score and poor outcome (P= 0.004). Serum hemoglobin levels were 114.30 ± 20.08 g/L in the epilepsy group, which were lower than those in the nonepilepsy group (128.64 ± 17.94 mmol/L, P= 0.001). Serum iron levels were 8.89 ± 5.03 g/L in the epilepsy group, which were also lower than those in the nonepilepsy group (13.71 ± 6.70 mmol/L, P= 0.002). The hemoglobin level was positively correlated with serum iron on admission (ρ= 0.321, P= 0.000). In the multivariate logistic regression model, lower hemoglobin was considered as an independent risk factor of acute seizures (odds ratio 4.286, 95% confidence interval 1.492-12.315, P= 0.007). The optimal cutoff value for hemoglobin level as a predictor for acute epilepsy after aSAH was determined as 119 g/L in the receiver operating characteristic curve (sensitivity was 75.00%, and specificity was 69.48%). These data support the hypothesis that hemoglobin was inversely associated with acute seizures following aSAH.

Admission neutrophil–lymphocyte ratio predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage

BackgroundDelayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) has a multifactorial pathophysiology, with immune dysregulation being an important component. The neutrophil–lymphocyte ratio (NLR) is an established prognostic marker in...

Prolonged Elevated Heart Rate is a Risk Factor for Adverse Cardiac Events and Poor Outcome after Subarachnoid Hemorrhage

Sympathetic nervous system hyperactivity is common after subarachnoid hemorrhage (SAH). We sought to determine whether uncontrolled prolonged heart rate elevation is a risk factor for adverse cardiopulmonary events and poor outcome after SAH. We prospectively studied 447 SAH patients between March 2006 and April 2012. Prior studies define prolonged elevated heart rate (PEHR) as heart rate >95 beats/min for >12 h. Major adverse cardiopulmonary events were documented according to the predefined criteria. Global outcome at 3 months was assessed with the modified Rankin Scale (mRS). 175 (39 %) patients experienced PEHR. Nonwhite race/ethnicity, admission Hunt-Hess grade ≥4, elevated APACHE-2 physiological subscore, and modified Fisher score were significant admission predictors of PEHR, whereas documented pre-hospital beta-blocker use was protective. After controlling for admission Hunt-Hess grade, Cox regression using time-lagged covariates revealed that PEHR onset in the previous 48 h was associated with an increased hazard for delayed cerebral ischemia, myocardial injury, and pulmonary edema. PEHR was associated with 3-month poor outcome (mRS 4-6) after controlling for known predictors. PEHR is associated with major adverse cardiopulmonary events and poor outcome after SAH. Further study is warranted to determine if early sympatholytic therapy targeted at sustained heart rate control can improve outcome after SAH.

Relationship Between C-Reactive Protein, Systemic Oxygen Consumption, and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Subarachnoid hemorrhage (SAH) is known to result in elevated systemic oxygen consumption (Vo(2)) and increases in high-sensitivity C-reactive protein (hsCRP), although the relationship among hsCRP, Vo(2), and delayed cerebral ischemia (DCI) after SAH remains unknown. We hypothesized that hsCRP is directly associated with Vo(2) and that elevated Vo(2) is a predictor of DCI after SAH. Prospective serial assessments of Vo(2) and hsCRP over 4 prespecified time periods during the first 14 days after bleed in consecutive SAH patients admitted to a single academic medical center for a 2-year period. One hundred ten SAH patients met study criteria (mean age, 55±16 years; 62% women), with a median admission Hunt Hess grade of 3 (interquartile range, 2-4). In multivariate generalized estimating equation model of the first 14 days after bleed, Vo(2) was associated with younger age (P=0.01), male gender (P=0.01), and hsCRP levels (P=0.03). Twenty-four (22%) patients had DCI develop, with a median onset on day 7 after bleed (interquartile range, 5-11). The mean Vo(2) (291±65 mL/min versus 226±55 mL/min; P=0.003) was higher in DCI patients. In a multivariable Cox proportional hazards model, younger age (hazard ratio, 1.2 per 5 years; 95% CI, 1.1-1.3), a higher modified Fisher scale score (hazard ratio, 3.4 per 1-point increase; 95% CI, 1.7-6.9), and higher Vo(2) (HR, 1.2 per 50-mL/min increase; 95% CI, 1.1-1.3) were predictive of DCI. Systemic oxygen consumption is associated with hsCRP levels in the first 14 days after SAH and is an independent predictor of DCI.

Cerebral Perfusion Pressure Thresholds for Brain Tissue Hypoxia and Metabolic Crisis After Poor-Grade Subarachnoid Hemorrhage

To identify a minimally acceptable cerebral perfusion pressure threshold above which the risks of brain tissue hypoxia (BTH) and oxidative metabolic crisis are reduced for patients with subarachnoid hemorrhage (SAH). We studied 30 poor-grade SAH patients who underwent brain multimodality monitoring (3042 hours). Physiological measures were averaged over 60 minutes for each collected microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio>40 with a brain glucose concentration≤0.7 mmol/L. BTH was defined as PbtO2<20 mm Hg. Outcome was assessed at 3 months with the Modified Rankin Scale. Multivariable analyses adjusting for admission Hunt-Hess grade, intraventricular hemorrhage, systemic glucose, and end-tidal CO2 revealed that cerebral perfusion pressure≤70 mm Hg was significantly associated with an increased risk of BTH (OR, 2.0; 95% CI, 1.2-3.3; P=0.007) and metabolic crisis (OR, 2.1; 95% CI, 1.2-3.7; P=0.007). Death or severe disability at 3 months was significantly associated with metabolic crisis (OR, 5.4; 95% CI, 1.8-16; P=0.002) and BTH (OR, 5.1; 95% CI, 1.2-23; P=0.03) after adjusting for admission Hunt-Hess grade. Metabolic crisis and BTH are associated with mortality and poor functional recovery after SAH. Cerebral perfusion pressure levels<70 mm Hg was associated with metabolic crisis and BTH, and may increase the risk of secondary brain injury in poor-grade SAH patients.

Transdermal Nicotine Replacement Therapy in Cigarette Smokers with Acute Subarachnoid Hemorrhage

We evaluated the safety of nicotine replacement therapy (NRT) in active smokers with acute (aneurysmal) subarachnoid hemorrhage (SAH). A retrospective observational cohort study was conducted in a prospectively collected database including all SAH patients admitted to an 18-bed neuro-ICU between January 1, 2001 and October 1, 2007. Univariate and multivariable models were constructed, employing stepwise logistic regression. The primary endpoint was 3-month mortality. Delayed cerebral ischemia (DCI) due to vasospasm, angiographic and TCD evidence of vasospasm, and delirium were secondary endpoints. Active cigarette smokers admitted with SAH included 128 that received NRT and 106 that did not. Patients were well-matched for age, admission Hunt-Hess Grade, radiographic findings, and APACHE II scores, but those who received NRT were more likely to be heavy smokers (>10 cigarettes daily), diabetic, heavy alcohol users, and to have cerebral edema on admission. NRT was associated in multivariate analysis with a lower risk of death at 3 months (OR 0.12, 95% CI 0.04-0.37, P < 0.001). There were no differences in the frequency of DCI and most other medical complications, but delirium (19 vs. 9%, P = 0.006) and seizures (9 vs. 2%, P = 0.024) were more common in patients who received NRT. Despite vasoactive properties, administration of NRT among active smokers with acute SAH appeared to be safe, with similar rates of vasospasm and DCI, and a slightly higher rate of seizures. The association of NRT with lower mortality could be due to chance, to uncontrolled factors, or to a neuroprotective effect of nicotine in active smokers hospitalized with SAH, and should be tested prospectively.

Cerebral inflammatory response and predictors of admission clinical grade after aneurysmal subarachnoid hemorrhage

Poor admission clinical grade is the most important determinant of outcome after aneurysmal subarachnoid hemorrhage (aSAH); however, little attention has been focused on independent predictors of poor admission clinical grade. We hypothesized that the cerebral inflammatory response initiated at the time of aneurysm rupture contributes to ultra-early brain injury and poor admission clinical grade. We sought to identify factors known to contribute to cerebral inflammation as well as markers of cerebral dysfunction that were associated with poor admission clinical grade. Between 1997 and 2008, 850 consecutive SAH patients were enrolled in our prospective database. Demographic data, physiological parameters, and location and volume of blood were recorded. After univariate analysis, significant variables were entered into a logistic regression model to identify significant associations with poor admission clinical grade (Hunt–Hess grade 4–5). Independent predictors of poor admission grade included a SAH sum score >15/30 (odds ratio [OR] 2.3, 95% confidence interval [CI] 1.5–3.6), an intraventricular hemorrhage sum score >1/12 (OR 3.1, 95% CI 2.1–4.8), aneurysm size >10 mm (OR 1.7, 95% CI 1.1–2.6), body temperature ⩾38.3 °C (OR 2.5, 95% CI 1.1–5.4), and hyperglycemia >200 mg/dL (OR 2.7, 95% CI 1.6–4.5). In a large, consecutive series of prospectively enrolled patients with SAH, the inflammatory response at the time of aneurysm rupture, as reflected by the volume and location of the hemoglobin burden, hyperthermia, and perturbed glucose metabolism, independently predicts poor admission Hunt–Hess grade. Strategies for mitigating the inflammatory response to aneurysmal rupture in the hyper-acute setting may improve the admission clinical grade, which may in turn improve outcomes.

Predictors of cognitive dysfunction after subarachnoid hemorrhage.

Cognitive dysfunction is a common and disabling sequela of subarachnoid hemorrhage (SAH). Although several clinical and radiographic findings have been implicated in the pathogenesis of cognitive dysfunction after SAH, few prospective studies have comprehensively and simultaneously evaluated these risk factors. Between July 1996 and March 2000, we prospectively evaluated 113 of 248 consecutively admitted nontraumatic SAH patients alive at 3 months with a comprehensive neuropsychological evaluation. Summary scores for 8 cognitive domains were calculated to express test performance relative to the entire study population. Clinical and radiographic variables associated with domain-specific cognitive dysfunction were identified with forward stepwise multiple regression, with control for the influence of demographic factors. The study participants were younger (P=0.005), less often white (P=0.006), and had better 3-month modified Rankin scores (P=0.001) than those who did not undergo neuropsychological testing. The proportion of subjects who scored in the impaired range (>2 SD below the normative mean) on each neuropsychological test ranged from 10% to 50%. Predictors of cognitive dysfunction in 2 or more domains in the multivariate analysis included global cerebral edema (4 domains), left-sided infarction (3 domains), and lack of a posterior circulation aneurysm (2 domains). Other variables consistently associated with cognitive dysfunction in the univariate analysis included admission Hunt-Hess grade >2 and thick SAH in the anterior interhemispheric and sylvian fissures. Global cerebral edema and left-sided infarction are important risk factors for cognitive dysfunction after SAH. Treatment strategies aimed at reducing neurological injury related to generalized brain swelling, infarction, and clot-related hemotoxicity hold the best promise for improving cognitive outcomes after SAH.

Influence of Depression on Return to Work after Subarachnoid Hemorrhage

123 Depression occurs in about 30% of subjects with subarachnoid hemorrhage (SAH) and is associated with impaired quality of life (QoL). However, the influence of depression on return to work (RTW) after SAH is not known. We prospectively studied a consecutive series of 121 SAH subjects, working premorbidly, who completed a Center for Epidemiological Studies-Depression Scale (CES-D) at 3 months post-SAH (63% women, mean age = 47 years). Depression was defined as a score ≥ 16 on the CES-D, and work status as working vs. not working. Potential predictors of post-SAH depression and RTW were screened with univariate tests and included: basic demographics, pre- and post-SAH psychiatric status, and acute physiologic parameters of SAH. Variables deemed significant in the univariate models (p&lt;.05) were entered into a forward, stepwise binary logistic model with 3-month work status as the dependent measure. In our population, premorbid lifetime diagnosis or treatment for depression was present in 17% of the subjects (20/121), but rose to 40% (48/121) at 3 months post-SAH (M3). Only 42% (51/121) reported that they had resumed their pre-morbid work status either at the same level (36/121) or at a decreased level (15/121). For non-depressed subjects, half (38/73) were able to return to work, however, only 27% (13/48) of the depressed subjects were able to return (p&lt;.008). Significant univariate predictors of RTW were: education (p&lt;.007), race (p&lt;.044), admission Hunt Hess grade (p&lt;.006), and cerebral edema (p&lt;.001). The final multivariate model for the prediction of return to work identified 3 risk factors: cerebral edema (OR=9.4, 95% CI 2.51–35.46, p&lt;.001), lower education (OR=1.1, 95% CI 1.02–1.29, p&lt;.025), and depression at M3 (OR=2.4, 95% CI 1.01–5.73, p&lt;.048). Overall, depression occurred in about 40% of subjects when assessed 3 months after SAH. The association of depression with work status remains significant, even after controlling for factors that contribute to occupational disability, including lower education and cerebral edema. Early diagnosis and treatment of acute edema and delayed depression in these patients may lead to significant improvement in employment rates after SAH.

Ventricular Cerebrospinal Fluid and Serum Concentrations of sTNFR-I, IL-1ra, and IL-6 After Aneurysmal Subarachnoid Hemorrhage

Postsubarachnoid hemorrhage, systemic inflammatory response syndrome and associated organ system failure are more frequently found in patients in poor neurologic condition. Since subarachnoid hemorrhage causes a profound intrathecal inflammatory response with production of proinflammatory cytokines TNFalpha, IL-1beta, and IL-6, a possible explanation for this association is that brain-derived cytokines may enter the systemic circulation in the presence of postsubarachnoid hemorrhage blood brain barrier disruption to systemically activate inflammatory cascades and thereby contribute to the development of postsubarachnoid hemorrhage systemic inflammatory response syndrome and extracerebral organ system failures. In 44 patients with aneurysmal subarachnoid hemorrhage admitted within 3 days of the initial bleed, extracerebral organ system functions were assessed individually and in aggregate using the modified Multiple Organ Dysfunction Score. Serum and cerebrospinal fluid concentrations of soluble tumor necrosis factor-alpha receptor-I, interleukin-1beta receptor antagonist, and IL-6 were determined during the first 2 weeks after subarachnoid hemorrhage and tested for correlation with (1) admission Hunt-Hess grade, (2) development of systemic inflammatory response syndrome and extracerebral organ system failures, and (3) neurologic outcome. The development of postsubarachnoid hemorrhage systemic inflammatory response syndrome and extracerebral organ system failures was paralleled by a significant increase in serum but not in cerebrospinal fluid levels of soluble tumor necrosis factor-alpha receptor-I and IL-1ra, that is, patients with and without extracerebral organ system failures did not differ in pattern and time course of cerebrospinal fluid cytokine concentrations. In contrast, increasing soluble tumor necrosis factor-alpha receptor-I and interleukin-1beta receptor antagonist serum levels correlated with a higher Multiple Organ Dysfunction score and with individual organ system dysfunctions. Postsubarachnoid hemorrhage, systemic inflammatory response syndrome and extracerebral organ system failures could therefore not be linked to changes in cerebrospinal fluid cytokine concentration profiles.