Predictors of neurocardiogenic injury after subarachnoid hemorrhage

Relation of elevation in cardiac troponin I to clinical severity, cardiac dysfunction, and pulmonary congestion in patients with subarachnoid hemorrhage

An increase in cardiac troponin I (cTnI) occurs often after aneurysmal subarachnoid hemorrhage (SAH), but its significance is not well understood. One hundred three patients with SAH were prospectively evaluated in the SAHMII Study to determine the relations of cTnI to clinical severity, systolic and diastolic cardiac function, pulmonary congestion, and length of intensive care unit stay. Echocardiographic ejection fraction, wall motion score, mitral inflow early diastolic (E) and mitral annular early (E') velocities were assessed. Thirty patients (29%) had mildly positive cTnI (0.1 to 1.0 ng/ml), 24 (23%) had highly positive cTnI (>1.0 ng/ml), and 49 (48%) had negative cTnI (<0.1 ng/ml). Highly positive cTnI was associated with worse neurologic disease, longer intensive care unit stay, and slight depression of ejection fraction (51 +/- 11% [p <0.05] vs 59 +/- 8% and 63 +/- 6% in mildly positive or negative cTnI groups, respectively). Highly positive cTnI was also associated with abnormal wall motion acutely (>1.31 ng/ml; 76% sensitivity, 91% specificity), which typically resolved within 5 to 10 days. Both mildly or highly positive cTnI were associated with acute diastolic dysfunction, with E/E' of 17 +/- 6 and 16 +/- 6 (both p <0.05) vs 13 +/- 4 in patients with negative cTnI. Prevalences of pulmonary congestion were 79% (p <0.05) in patients with highly positive cTnI, 53% (p <0.05) in patients with mildly positive cTnI, and 29% in cTnI-negative patients. In conclusion, highly positive cTnI with SAH was associated with clinical neurologic severity, systolic and diastolic cardiac dysfunction, pulmonary congestion, and longer intensive care unit stay. Even mild increases in cTnI were associated with diastolic dysfunction and pulmonary congestion.

Neurogenic pulmonary edema in a fatal case of subarachnoid hemorrhage

Neurogenic pulmonary edema (NPE) is caused by a variety of central nervous system lesions and may appear as a subclinical complication. The fulminant form of NPE is always life-threatening. Many pathophysiologic mechanisms have been implicated in the development of NPE, but the exact interaction remains unknown. We report a case of a fulminant NPE with fatal consequences associated with a subarachnoid hemorrhage. Treatment focuses on ventilatory support and measures to reduce intracranial pressure.

Myocardial contrast echocardiography in subarachnoid hemorrhage-induced cardiac dysfunction: case report

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.

Intensive care management of patients with subarachnoid haemorrhage

PURPOSE OF REVIEW

The aim of this article is to summarize recent concepts regarding the intensive care management of patients with subarachnoid haemorrhage, emphasizing the detection and treatment of cerebral vasospasm and the management of systemic complications.

RECENT FINDINGS

Aneurysmal subarachnoid haemorrhage is a potentially devastating disease that requires complex treatment strategies and extended monitoring. The prognosis of subarachnoid haemorrhage depends on the severity of the initial bleed, the success of the procedure to secure the aneurysm and the occurrence and severity of sequelae, including cerebral vasospasm. Patients with subarachnoid haemorrhage benefit from multidisciplinary neurointensive care where management is targeted at securing the ruptured aneurysm, optimizing cardiovascular variables, detecting and treating cerebral vasospasm and managing systemic complications.

SUMMARY

The complex treatment strategies applied after subarachnoid haemorrhage call for interdisciplinary collaboration between neurosurgeons, neuroradiologists, neurointensivists and specialist nurses. Specialized neuromonitoring and neuroimaging techniques must also be available. The neurointensive care unit serves as the focal point for these combined efforts.

Troponin I in the intensive care unit setting: from the heart to the heart

When measured in the plasma, cardiac troponins T (cTnT) and I (cTnI) are considered to be highly specific markers of myocardial cell damage; however, research has demonstrated that troponin elevation may associated with causes other than coronary artery disease. In the intensive care unit (ICU) setting, increased cTnI levels are quite common findings and when documented, even on admission, intensivists should bear in mind that this laboratory finding holds a prognostic role independent of the reason for ICU admission. The mechanism(s) (such as demand ischemia, myocardial strain, etc.) and not simply the cause (i.e., renal failure) of the increment in serum cTnI should be investigated to better tailor the therapeutical regimen in the single patient. In this review, we therefore consider the nonthrombotic causes of troponin elevation in the critical setting.

Pheochromocytoma associated with apical-sparing left ventricular dysfunction due to acute afterload mismatch: a novel clinical entity?

The case of a patient with pheochromocytoma who presented with an unusual pattern of left ventricular dysfunction not previously described is reported. Although a triad of headaches, sweating attacks and palpitations is generally recognized as the classic mode of presentation of this pathology, this patient first presented with shock and pulmonary edema. Moreover, both echocardiography and angiography showed severe basal and mid-ventricular left ventricular dysfunction but preserved apical contractility. This hitherto unidentified finding was interpreted as being due to an afterload mismatch, rather than to an intrinsic myocardial injury, as is usually reported in such cases.

Prognostic implications of left ventricular wall motion abnormalities associated with subarachnoid hemorrhage

Left ventricular (LV) dysfunction generally occurs early in the course of subarachnoid hemorrhage (SAH). We evaluated the prognostic value of electrocardiographic (ECG) abnormalities and echocardiographic LV dysfunction evaluated shortly after SAH. We prospectively enrolled 47 SAH patients (62 +/- 14 years, mean +/- SD) who were admitted to the neurosurgical care unit of our institute. Neurological status was rated on the day of admission. Twelve-lead ECG and 2-dimensional echocardiography were recorded 2 +/- 1 day after onset of SAH. ECG abnormalities (pathological Q-wave, ST-segment deviation, T-wave inversion, and QT prolongation) were evaluated and the incidences of global (LV ejection fraction < 50%) and segmental (regional wall motion abnormality [RWMA]) LV dysfunction were measured. During a follow-up period of 44 +/- 23 days, 17 (36%) patients died. ECG abnormalities, LV ejection fraction < 50%, and RWMA were observed in 62%, 11%, and 28% of patients, respectively. Univariate Cox proportional hazards regression analysis revealed that neurological status, rate-corrected QT interval, LV ejection fraction, and RWMA were significant predictors of death. After adjustment for these significant clinical variables, and age and sex, independent predictors of mortality were neurological status and RWMA. RWMA may provide significant prognostic information in patients with SAH.

Stress (Takotsubo) cardiomyopathy--a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning

Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, is an increasingly recognized clinical syndrome characterized by acute reversible apical ventricular dysfunction. We hypothesize that stress cardiomyopathy is a form of myocardial stunning, but with different cellular mechanisms to those seen during transient episodes of ischemia secondary to coronary stenoses. In this syndrome, we believe that high levels of circulating epinephrine trigger a switch in intracellular signal trafficking in ventricular cardiomyocytes, from G(s) protein to G(i) protein signaling via the beta(2)-adrenoceptor. Although this switch to beta(2)-adrenoceptor-G(i) protein signaling protects against the proapoptotic effects of intense activation of beta(1)-adrenoceptors, it is also negatively inotropic. This effect is greatest at the apical myocardium, in which the beta-adrenoceptor density is greatest. Our hypothesis has implications for the use of drugs or devices in the treatment of patients with stress cardiomyopathy.

Stress cardiomyopathy: aetiology and management

Stress cardiomyopathy is a condition caused by intense emotional or physical stress leading to rapid and severe reversible cardiac dysfunction. It mimics myocardial infarction with changes in the electrocardiogram and echocardiogram, but without any obstructive coronary artery disease. Due to the awareness created by the media and internet, every patient is aware that they should seek help immediately for chest pain. Therefore physicians should be aware of this new condition and how to diagnose and treat it, even though the causal mechanisms are not yet fully understood.

Intensive care unit management of patients with stroke

Patients admitted with the diagnosis of "stroke" have a variety of different disorders that require specific treatment approaches in the critical care unit. Early thrombolysis for ischemic stroke and improvements in surgical and neurointerventional techniques for the treatment of aneurysms and arteriovenous malformations in patients with subarachnoid hemorrhage have been milestones in the past decade, but the evolvement of general management principles in critical care and the dedication of neurointensivists are equally important for improved outcomes. Strategies, which have been developed in other areas of intensive care medicine (eg, in patients with septic shock, acute respiratory distress syndrome, or trauma), need to be adopted and modified for the stroke patient. Prevention of iatrogenic complications and nosocomial infections is of utmost importance and requires sufficient numbers of trained personnel and high-quality equipment. Although the focus of attention in stroke patients is "brain resuscitation," comorbidities often limit the diagnostic and therapeutic options, and overall cardiopulmonary and metabolic functions need to be optimized in order to prevent secondary injury and allow the brain to recover. As part of a holistic approach to the rehabilitation process, psychologic and spiritual support for the patient must start early on in the intensive care unit, and family members should be involved in the patient's care and provided with special support as well.

Myocardial stress in patients with acute cerebrovascular events

Signs of myocardial involvement are common in patients with acute cerebrovascular events. ST segment deviations, abnormal left ventricular function, increased N-terminal pro-brain natriuretic peptide (NT-proBNP), prolonged QT interval, and/or raised troponins are observed in up to one third of the patients. The huge majority of these findings are fully reversible. The changes may mimic myocardial infarction, but are not necessarily identical to coronary thrombosis. Based on the literature these signs may represent an acute catecholamine release provoked by the cerebrovascular catastrophe itself and not coronary thrombosis. However, all patients with signs of cardiac involvement during acute cerebrovascular events should receive a cardiological follow-up in order to exclude concomitant ischemic heart disease.

When the worst headache becomes the worst heartache!

BACKGROUND AND PURPOSE

Although a great deal of literature has been generated regarding left ventricular wall abnormalities, ECG changes and cardiac enzyme leaks associated with subarachnoid hemorrhage (SAH), there have been only a few reports of true transient left ventricular apical ballooning syndrome in patients with SAH. Several pathophysiological mechanisms have been proposed to explain the unusual features of this syndrome, such as multivessel coronary vasospasm, abnormalities in coronary microvascular function, and catecholamine-mediated cardiotoxicity. Summary of Case- A previously healthy 64-year-old woman with no history of vascular disease was found unresponsive at home. She was taken to the emergency room where a CT head revealed an SAH due to a ruptured aneurysm of the posterior communicating artery. On admission, an ECG showed deeply inverted T-waves and QT prolongation, typical of SAH. Cardiac troponin was measured at 1.2 ng/mL, and later increased to 3.7 ng/mL. A transthoracic echocardiogram on the next day revealed a large left ventricular wall abnormality, characteristic of apical ballooning with an ejection fraction of 25% to 30%. The patient remained hemodynamically stable and was started on low dose beta-blocker and angiotensin-converting enzyme inhibitor. She had an uneventful cardiac recovery within 5 days at which time a repeat transthoracic echocardiogram revealed a normal ejection fraction with no wall motion abnormality.

CONCLUSIONS

This report adds to the growing list of "stressors" for Takotsubo cardiomyopathy. Clinicians should be aware of the existence and the typical clinical manifestations of this syndrome, which is increasingly recognized in various populations. In particular, neurologists should consider this syndrome in the differential diagnosis of ECG changes and apical wall motion abnormalities in patients with SAH. Prognosis is generally very good with full recovery in most patients; however, there may be increased morbidity associated in patients with SAH.

The systemic implications of aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (SAH) is analogous to a pathophysiological watershed, disrupting brain integrity and function and precipitating an array of systemic derangements including cardiovascular, respiratory, endocrine, hematological, and immune dysfunction. Extracerebral organ dysfunction is closely linked to the magnitude of the primary neurological insult, suggesting neurogenic, neuroendocrine and neuroimmunomodulatory mechanisms. Systemic organ involvement is associated with increased mortality and neurological impairment, even after adjustment for other outcome predictors such as the severity of the initial neurological injury. This may be a reflection of secondary brain injury precipitated by hypoxemia, circulatory failure, fever, or hyperglycemia, all of which have been linked to adverse clinical outcomes. Interventions to avert or reverse these and other perturbations need to be tested in clinical trials as they represent opportunities to improve survival and neurological recovery in patients with SAH.

[Cerebral salt wasting syndrome: experimental study in rats]

INTRODUCTION

The cerebral salt wasting syndrome (CSWS) is characterized by hyponatraemia secondary to excessive natriuesis with osmotic duiresis. This syndrome, frequently, occurs after subarachnoid haemorrhage (SAH), but may occur after any acute cerebral aggression.

OBJECTIVES

The aim of the study was to assess the frequency of the CSWS in animal models with, SAH, cerebral ischemia (CI), and cranial trauma (CT), and its correlation with the secretion of brain natriuretic peptide (BNP).

METHOD

Four groups of rats were selected: group SAH (n=7) consisted of SAH induced by perforation of the carotid artery in its intracerebral part; group CI (n=7) consisted of CI induced by ligature of the carotid artery; group CT (n=7) consisted of induced CT; and a control group Sham (n=7). Weight, serum sodium, BNP, and urinary sodium, were measured at baseline and 24 hours after.

RESULTS

Rats with SAH had significant natriuresis and diuresis with negative sodium balance (-95.9+/-447.4 mumol) with a significant difference (P<0.05) compared to the rats of the CI and the Sham groups. There was no difference in the 24 hours level of BNP between the four different groups.

CONCLUSION

We conclude that SAH, in animal models, induced high diuresis with negative sodium balance in the first 24 hours. These findings were absents in the others groups. This was independent of the BNP secretion and may correspond to the early occurrence of a CSWS.

Aneurysmal subarachnoid haemorrhage and the anaesthetist

The anaesthetist may be involved at various stages in the management of subarachnoid haemorrhage (SAH). Thus, familiarity with epidemiological, pathophysiological, diagnostic, and therapeutic issues is as important as detailed knowledge of the optimal intraoperative anaesthetic management. As the prognosis of SAH remains poor, prompt diagnosis and appropriate treatment are essential, because early treatment may improve outcome. It is, therefore, important to rule out SAH as soon as possible in all patients complaining of sudden onset of severe headache lasting for longer than an hour with no alternative explanation. The three main predictors of mortality and dependence are impaired level of consciousness on admission, advanced age, and a large volume of blood on initial cranial computed tomography. The major complications of SAH include re-bleeding, cerebral vasospasm leading to immediate and delayed cerebral ischaemia, hydrocephalus, cardiopulmonary dysfunction, and electrolyte disturbances. Prophylaxis and therapy of cerebral vasospasm include maintenance of cerebral perfusion pressure (CPP) and normovolaemia, administration of nimodipine, triple-H therapy, balloon angioplasty, and intra-arterial papaverine. Occlusion of the aneurysm after SAH is usually attempted surgically ('clipping') or endovascularly by detachable coils ('coiling'). The need for an adequate CPP (for the prevention of cerebral ischaemia and cerebral vasospasm) must be balanced against the need for a low transmural pressure gradient of the aneurysm (for the prevention of rupture of the aneurysm). Effective measures to prevent or attenuate increases in intracranial pressure, brain swelling, and cerebral vasospasm throughout all phases of anaesthesia are prerequisite for optimal outcome.

Mechanisms in neurogenic stress cardiomyopathy after aneurysmal subarachnoid hemorrhage

Cardiac dysfunction after aneurysmal subarachnoid hemorrhage (SAH) is often referred to as "neurogenic stunned myocardium," which does not accurately reflect the suspected pathophysiology. We propose an alternative terminology, "neurogenic stress cardiomyopathy," as a more appropriate label based on our review of the current literature. This article will review the distinctive characteristics of SAH-induced cardiac dysfunction, hypotheses to explain the pathophysiology, and the supporting clinical and animal studies. Recognition of the unique features associated with SAH-induced cardiac complications allows optimal management of patients with SAH. We will also discuss the clinical and theoretical overlap of SAH-induced cardiac dysfunction with a syndrome known as tako-tsubo cardiomyopathy and explore therapeutic opportunities.

Neurocardiogenic injury in neurovascular disorders

cardiac injury occurs frequently after stroke; and the most widely investigated form of neurocardiogenic injury is aneurysmal subarachnoid hemorrhage. Echocardiography and screening for elevated troponin and B-type natriuretic peptide levels may help prognosticate and guide treatment of stroke. Cardiac catheterization is not routinely recommended in subarachnoid hemorrhage patients with left ventricular dysfunction and elevated troponin. The priority should be treatment of the underlying neurologic condition, even in patients with left ventricular dysfunction. Cardiac injury that occurs after subarachnoid hemorrhage appears to be reversible. In contrast to subarachnoid hemorrhage patients, patients with ischemic stroke are more likely to have concomitant significant heart disease. For patients who develop brain death, cardiac evaluation under optimal conditions may help increase the organ donor pool.

Cardiac complications after aneurysmal subarachnoid hemorrhage

BACKGROUND

Cardiac complications are frequently encountered by neurointensivists caring for patients with SAH. Our aim was to better characterize the natural history of various cardiac abnormalities in this population. We sought to determine the risk factors for cardiac abnormalities, patient outcome, and impact of treatment type on cardiac abnormalities.

METHODS

We performed a single center retrospective review of admissions of patients with aneurysmal SAH to the neurosurgical ICU in a large university hospital. Patient demographics, pertinent history, cardiac tests, hospital LOS, intervention type, and discharge outcome were collected.

RESULTS

Data from 266 patients were available for analysis. Of these patients, 50% (n = 133) demonstrated cardiac abnormalities as indicated by abnormal EKG, ECHO, or troponin I. Only age was determined to be an independent statistically significant predictor of cardiac abnormality (P = .01). There was no difference in mortality between the cardiac abnormality and control groups (P = .33). However, there was increased morbidity in the cardiac abnormality group as demonstrated by worse discharge disposition, in addition to increased length of hospital stay (22.6 vs 17.1 days, P < .01). The incidence of cardiac abnormalities was the same among surgical and endovascular treatment groups.

CONCLUSIONS

Cardiac abnormalities, including those that meet ACC criteria for MI, are common among patients with SAH. However, in contrast to cardiac events outside the context of SAH, these abnormalities do not increase mortality. They do, however, adversely affect discharge disposition and prolong hospital LOS. The type of aneurysm treatment does not affect the incidence or outcome of cardiac abnormalities.

Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction

OBJECT

Neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage (SAH) is associated with a wide spectrum of reversible left ventricular wall motion abnormalities and includes a subset of patients with a pattern of apical akinesia and concomitant sparing of basal segments called "tako-tsubo cardiomyopathy".

METHODS

After obtaining institutional review board approval, the authors retrospectively identified among all patients admitted to the Mayo Clinic's Neurological Intensive Care Unit between January 1990 and January 2005 those with aneurysmal SAH who had met the echocardiographic criteria for tako-tsubo cardiomyopathy. Among 24 patients with SAH-induced reversible cardiac dysfunction, the authors identified eight with SAH-induced tako-tsubo cardiomyopathy. All eight patients were women with a mean age of 55.5 years (range 38.6-71.1). Seven patients presented with a poor-grade SAH, reflected by a Hunt and Hess grade of III or IV. Four patients underwent aneurysm clip application, and four underwent endovascular coil occlusion. The initial mean ejection fraction (EF) was 38% (range 25-55%), and the mean EF at recovery was 55% (range 40-68%). Cerebral vasospasm developed in six patients, but cerebral infarction developed in only three patients.

CONCLUSIONS

The authors describe the largest cohort with aneurysmal SAH-induced tako-tsubo cardiomyopathy. In the SAH population, tako-tsubo cardiomyopathy predominates in postmenopausal women and is often associated with pulmonary edema, prolonged intubation, and cerebral vasospasm. Additional studies are warranted to understand the complex mechanism involved in tako-tsubo cardiomyopathy and its intriguing relationship to neurogenic stunned myocardium.

NO LONG-TERM EXCESS MORTALITY IN 280 PATIENTS WITH RUPTURED DISTAL ANTERIORCEREBRAL ARTERY ANEURYSMS

OBJECTIVE

The aim of this study was to assess the long-term excess mortality after the rupture of distal anterior cerebral artery (DACA) aneurysms compared with that of a matched general Finnish population in an unselected, population-based series.

METHODS

We identified 280 consecutive patients (119 men, 161 women) treated for ruptured DACA aneurysms (clipped, 262; coiled, 10; no intervention, 8) at two neurosurgical centers serving solely the southern and eastern parts of Finland from 1976 to 2003. All patients were followed from subarachnoid hemorrhage until death or the end of 2004. No patients were lost to follow-up. Long-term excess mortality was estimated using the annual relative survival ratio compared with the general Finnish population matched by age, sex, and calendar time.

RESULTS

The median follow-up period was 9.6 years (range, 0.1-29 yr). The 3-year cumulative relative survival ratio was 0.84 (95% confidence interval, 0.78-0.88), implying 16% excess mortality in the patient group during the first 3 years after subarachnoid hemorrhage. The annual relative survival ratio attained 1.0 at the fourth year of follow-up, indicating no excess mortality thereafter. There were four episodes of recurrent subarachnoid hemorrhage and only one from a treated DACA aneurysm, with a 10-year cumulative risk of 1.4% (95% confidence interval, 0.0-3.0). Cardiovascular disease and cancer were the leading causes of death after 10 years of follow-up.

CONCLUSION

After surviving 3 years after the rupture of a DACA aneurysm, the patients' long-term survival became similar to that of the matched general population. Rebleeding of treated DACA aneurysm was rare.

Positive troponin-T in noncompaction is associated with neuromuscular disorders and poor outcome

OBJECTIVES

Though cardiac troponin-T may be positive in hypertrophic and dilated cardiomyopathy, it is not known how often troponin-T is positive in left ventricular hypertrabeculation/ noncompaction (LVHT), an unclassified cardiomyopathy. This retrospective study aimed to assess how often troponin-T is positive in LVHT, is associated with elevated CK, is attributable to cardiac or extra-cardiac causes, in particular neuromuscular disorders (NMDs), or if it is a predictor of poor survival.

RESULTS

Among 100 patients, detected over a period of 11 years, troponin-T was determined at least once in 71 (71%) of them. Troponin-T was determined once in 36 patients, twice in 8 cases, three times in 11 patients, and more than three times in 16 cases. Troponin- T was positive at least once in 12 patients (17%). Forty-five of the 71 patients suffered from a NMD (63%). Troponin-T positivity was associated with elevated CK in 6 cases. Troponin-T-positivity was attributable to acute myocardial ischemia in a single case, to chronic renal failure in 5 cases, to dilated cardiomyopathy in 4 cases, to atrial fibrillation in 3 cases, to heart failure in 4 cases, and to NMD in 10 cases. Troponin-T positivity in LVHT patients with NMD was assumed to be due to cardiac involvement in the disease. Among the 22 patients who died during the observational period troponin was determined in 16 and was positive in 4 (25%).

CONCLUSIONS

Troponin-T is positive in 17% of the patients with LVHT. Most of these patients suffer from a NMD. Troponin-T positivity in LVHT predicts the presence of NMD and poor survival.

Prehospital Hypoxia Affects Outcome in Patients With Traumatic Brain Injury: A Prospective Multicenter Study

BACKGROUND

The goals of this study were to determine the incidence and duration of hypotension and hypoxia in the prehospital setting in patients with potentially survivable brain injuries, and to prospectively examine the association of these secondary insults with mortality and disability at hospital discharge.

METHODS

Trauma patients with suspected brain injuries underwent continuous blood pressure and pulse oximetry monitoring during helicopter transport. Postadmission inclusion criteria were (1) diagnosis of acute traumatic brain injury (TBI) confirmed by computed tomography (CT) scan, operative findings, or autopsy findings; and (2) Head Abbreviated Injury Scale (AIS) score of > or = 3 or Glasgow Coma Scale (GCS) score of < or = 12 within the first 24 hours of admission. Patients were excluded with (1) no abnormal intracranial findings on the patient's CT scan; (2) determination of a nonsurvivable injury (based on an AIS score of 6 for any body region; or, (3) death in less than 12 hours after injury. Primary outcome measures included mortality and Disability Rating Scale score at discharge.

RESULTS

We enrolled 150 patients into the study. Fifty-seven patients had at least one secondary insult; 37 had only hypoxic episodes, 14 had only hypotensive episodes, and 6 patients had both. Demographics and injury characteristics did not differ between those with and those without secondary insults. The mortality for patients without secondary insults was 20%, compared with 37% for patients with hypoxic episodes, 8% for patients with hypotensive episodes, and 24% for patients with both. The Disability Rating Scale score at discharge was significantly higher in patients with secondary insults. Using multivariate analysis, the calculated odds ratio of mortality caused by prehospital hypoxia after head injury was 2.66 (p < 0.05).

CONCLUSIONS

Secondary insults after TBI are common, and these insults are associated with disability. Hypoxia in the prehospital setting significantly increases the odds of mortality after brain injury controlled for multiple variables.

Medical complications after subarachnoid hemorrhage: new strategies for prevention and management

PURPOSE OF REVIEW

To summarize new concepts regarding the occurrence, prevention, and management of medical complications following subarachnoid hemorrhage.

RECENT FINDINGS

Data regarding the impact of common medical complications after subarachnoid hemorrhage on delayed cerebral ischemia and neurological outcome after subarachnoid hemorrhage are available from recent outcomes studies. Fever, anemia requiring transfusion, hyperglycemia, electrolyte abnormalities, pneumonia, hypertension, and neurogenic stunned myocardium and pulmonary edema occur frequently after subarachnoid hemorrhage. Fever, anemia, hyperglycemia, and acute hypoxia and hypotension related to neurogenic stunned myocardium have the greatest impact on mortality and functional outcome after subarachnoid hemorrhage. Potential treatment interventions for these complications include the development of acute resuscitation strategies to optimize cerebral perfusion in poor-grade patients, maintaining normothermia with systemic cooling devices, administration of erythropoietin to prevent severe anemia, preserving normoglycemia with continuous insulin infusions, and goal-directed hemodynamic support guided by brain tissue oxygenation.

SUMMARY

Clinical trials to investigate interventions targeted at preventing or treating common medical complications after subarachnoid hemorrhage are needed.

Dosage des isoformes cardiaques des troponines T ou I : intérêt en cardiologie et en anesthésie–réanimation

Measurement of cardiac troponin I or T in serum (highly specific for the myocardium) have replaced classical markers, such as creatine kinase MB. Cardiac troponins are preferred markers because of their high specificity and sensitivity. This had led to modifications of the original World Health Organization criteria for acute myocardial infarction. Furthermore, the place of the troponins as superior markers of subsequent cardiac risk in acute coronary syndrome has now become firmly established, for both diagnostic and risk stratification purposes. The use of C-reactive protein and/or other inflammatory biomarkers may add independent information in this context. After non cardiac surgery, the total cardiospecificity of cardiac troponins explains why other biomarkers of necrosis should no longer be used. Recent studies suggest that any elevation of troponin in the postoperative period is indicative of increased risk of long-term cardiac complications. This prognostic value has been previously demonstrated in other clinical settings such as invasive coronary intervention (surgical myocardial revascularization and percutaneous coronary intervention) and after heart valve surgery. Increases of troponin indicate cardiac damage, whatever the mechanism (ischemic or not). Other causes of cardiac injury include: pulmonary embolism, myocarditis, pericarditis, congestive heart failure, septic shock, myocardial contusion. In most cases, elevation of troponins has been shown to be associated with a bad outcome.

Two cases of transient left ventricular apical ballooning syndrome associated with subarachnoid hemorrhage

Electrocardiogram (ECG) abnormalities secondary to subarachnoid hemorrhage are well known, but the etiology remains unclear. Transient left ventricular apical ballooning syndrome is characterized by acute onset myocardial infarction-like symptoms, transient (reversible) cardiac dysfunction, and shapes resembling ampulla on left ventriculography. We managed general anesthesia for two patients with transient left ventricular apical ballooning and ECG abnormalities associated with subarachnoid hemorrhage. During anesthesia, their hemodynamic status was almost stable although their cardiac performance analyzed by transthoracic echocardiography and transesophageal cardiography was poor. Anesthetic management of this syndrome may be simplified if less cardiosuppressive anesthetic management is used. We recommend evaluating cardiac function with transthoracic echocardiography or transesophageal cardiography when an subarachnoid hemorrhage patient has ECG abnormalities.

Hypotension and transient renal impairment induced by lumbar puncture

INTRODUCTION

Raised intracranial pressure (ICP) may induce hypertension through sympathetic mechanisms.

METHODS

Case report.

RESULTS

A 55-year-old man was admitted with a symptomatic intracerebral mass and new refractory arterial hypertension. Several antihypertensive medications were necessary to control his blood pressure. A lumbar puncture was performed for diagnostic purposes and raised opening pressure (42 cm H2O) denoted raised ICP. After cerebrospinal fluid extraction, the closing pressure dropped to normal level. Shortly after the lumbar puncture, a sudden and pronounced drop in blood pressure was noted. Over the next day, the patient's serum creatinine rose from 0.9 to 1.9 mg/dL. Blood pressure normalized after discontinuation of all antihypertensive drugs and administration of intravenous fluids. Renal function also completely recovered within 2 days. The patient remained spontaneously normotensive thereafter.

CONCLUSION

Sudden hypotension may occur after lumbar puncture in patients with raised ICP receiving treatment for arterial hypertension.

Abnormal ECG patterns during the acute phase of subarachnoid hemorrhage in patients without previous heart disease

Subarachnoid hemorrhage (SAH) occurs primarily during early to mid-adulthood; approximately 30% of individuals with SAH die within 2 weeks, and mortality is 30% to 45%. SAH happens suddenly, without patients being aware of previous heart abnormalities. Here, we performed a pilot single cohort (historical) study to examine the hypothesis that early abnormal electrocardiographic (ECG) changes may reveal unknown but “silent” heart pathologies in SAH patients without previous heart disease (PHD). Data were collected retrospectively on 56 consecutive patients during the acute phase of SAH (29 men, 27 women; mean age 49.0 ± 6.2 years) with different degrees of neurologic deficit (Hunt-Hess scale assessment) in a 2-year period single-cohort study. Repolarization abnormalities were most frequent (p<0.05) and were independent of a history of PHD, although it corresponded to a higher risk for such abnormalities (odds ratio OR=3.21; CI95%=1.01–10.22). ECG changes in patients without PHD were similar to those in PHD patients, confirming the hypothesis that SAH is associated with previously “silent” heart pathology. The increased frequency of ECG changes in PHD patients and their high incidence in no-PHD patients suggested a neurogenic form of myocardial dysfunction following SAH. Notably, repolarization changes were more frequent in patients with less severe deficit (p<0.05), whereas rhythm and conductive abnormalities were more frequent in patients with more severe neurologic deficit.

Aturdimiento miocárdico neurogénico

The existence of stunned myocardium and reversible myocardial dysfunction is widely described and accepted in patients suffering ischemic heart disease. However, it cannot be exclusive to coronary disease. Classically, the appearance of electrocardiographic changes in the critical neurological disease has been described. However, at present, it seems to be observed that some of these patients with critical neurological disease could have variable grades of myocardial dysfunction, which is generally reversible in the surviving patients. This myocardial dysfunction, which could affect critically ill neurological patients, has traits similar to stunned myocardium generated in coronary patients since: a) it is generally associated to electrocardiographic changes, b) it can be accompanied by segmental contractility disorders and even c) it may be accompanied by a certain increase of cardiac biomarkers. Although its etiopathogeny is unknown, it could be related with the severity of the primary neurological disease. Its prophylaxis and prognosis are also unknown. It could be related with neurogenic edema, with hemodynamic instability, and could also play a very important role in brain death and in organ donation.

Controversies in the management of aneurysmal subarachnoid hemorrhage*

BACKGROUND

The care of patients with aneurysmal subarachnoid hemorrhage has evolved significantly with the advent of new diagnostic and therapeutic modalities. Although it is believed that these advances have contributed to improved outcomes, considerable uncertainty persists regarding key areas of management.

OBJECTIVE

To review selected controversies in the management of aneurysmal subarachnoid hemorrhage, with a special emphasis on endovascular vs. surgical techniques for securing aneurysms, the diagnosis and therapy of cerebral vasospasm, neuroprotection, antithrombotic and anticonvulsant agents, cerebral salt wasting, and myocardial dysfunction, and to suggest venues for further clinical investigation.

DATA SOURCE

Search of MEDLINE and Cochrane databases and manual review of article bibliographies.

DATA SYNTHESIS AND CONCLUSIONS

Many aspects of care in patients with aneurysmal subarachnoid hemorrhage remain highly controversial and warrant further resolution with hypothesis-driven clinical or translational research. It is anticipated that the rigorous evaluation and implementation of such data will provide a basis for improvements in short- and long-term outcomes.

Extracerebral organ dysfunction in the acute stage after aneurysmal subarachnoid hemorrhage

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.

Terson's Syndrome as the Initial Symptom of Subarachnoid Hemorrhage Caused by Ruptured Vertebral Artery Aneurysm-Case Report-

A 61-year-old male initially presented to the ophthalmology department complaining of sudden visual loss. Fundus photography and ultrasonography followed by computed tomography identified Terson's syndrome caused by subarachnoid hemorrhage (SAH). Cerebral angiography revealed a dissecting aneurysm of the left vertebral artery. Other than obtunded visual acuity, his neurological examination was normal and he denied any headache. He was treated conservatively with pain and blood pressure control. He complained of headache associated with rerupture of the aneurysm on day 5. The patient died of rerupture on day 14. The clinical course of this patient indicates that Terson's syndrome may occur without sudden increase of intracranial pressure. Terson's syndrome may occur as a rare initial clinical sign of SAH caused by ruptured cerebral aneurysm.

Transient left ventricular dysfunction under severe stress: brain-heart relationship revisited

PURPOSE

Transient left ventricular dysfunction in patients under emotional or physical stress, also known as tako-tsubo-like left ventricular dysfunction, has been recently been recognized as a distinct clinical entity. The aims of this review are to define this phenomenon and to explore its similarities to the left ventricular dysfunction seen in patients with acute brain injury.

METHODS

MEDLINE database, bibliographies of each citation for relevant articles, and consultation with clinical experts were used to examine the clinical picture of tako-tsubo-like left ventricular dysfunction.

RESULTS

We identified case series and a systematic review that report on patients with this syndrome. This phenomenon occurs predominantly in female patients, presenting with a variety of ST-T segment changes and mildly elevated cardiac enzymes that mimic an acute coronary syndrome. The left ventricular dysfunction, typically showing a hyperkinetic basal region and an akinetic apical half of the ventricle, occurs in the absence of obstructed epicardial coronary arteries. The ventricular dysfunction usually resolves within weeks with a generally favorable prognosis. This phenomenon has similarities to that seen in patients with acute brain injury with regard to clinical presentation, pathology, and its reversible nature.

CONCLUSIONS

Transient left ventricular dysfunction occurs in the absence of obstructive epicardial coronary artery disease. In its broadest sense, this phenomenon may encompass a range of disorders including left ventricular dysfunction after central nervous system injury.

Predictors of left ventricular regional wall motion abnormalities after subarachnoid hemorrhage

INTRODUCTION

Cardiac abnormalities that have been reported after subarachnoid hemorrhage (SAH) include the release of cardiac biomarkers, electrocardiographic changes, and left ventricular (LV) systolic dysfunction. The mechanisms of cardiac dysfunction after SAH remain controversial. The aim of this study was to determine the prevalence of LV regional wall motion abnormalities (RWMA) after SAH and to quantify the independent effects of specific demographic and clinical variables in predicting the development of RWMA.

METHODS

Three hundred patients hospitalized with SAH were prospectively studied with serial echocardiography. The primary outcome measure was the presence of RWMA. The predictor variables included the admission Hunt & Hess grade, age, gender, cardiac risk factors, aneurysm location, plasma catecholamine levels, cardiac troponin I (cTi) level, heart rate (HR), blood pressure, and phenylephrine dose. Univariate and multivariate logistic regression was performed with adjustment for serial measurements, reporting odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

In this study, 817 echocardiograms were analysed. RWMA were detected in 18% of those studied. The prevalence of RWMA in patients with Hunt & Hess grades 3 - 5 was 35%. Among patients with a peak cTi level greater than 1.0 m g/L, 65% had RWMA. Multivariate analysis demonstrated that high Hunt & Hess grade (OR 4.22 for grade 3 - 5 versus grade 1 - 2, p = 0.046), a cTi level greater than 1.0 microg/L (OR 10.47, p = 0.001), a history of prior cocaine or amphetamine use (OR 5.50, p = 0.037), and higher HR (OR 1.34 per 10 bpm increase, p = 0.024) were predictive of RWMA.

CONCLUSIONS

RWMA were frequent after SAH. High-grade SAH, an elevation in cTi levels, a history of prior stimulant drug use, and tachycardia are independent predictors of RWMA.