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Abstract
Neurogenic stunned myocardium is a form of stress cardiomyopathy. The disorder is sometimes referred to as atypical Takotsubo cardiomyopathy. The pathophysiology of neurogenic stunned myocardium is hypothesized to involve significant overdrive of the sympathetic nervous system after a brain injury. Treatment options for a patient with a brain injury who has progressed to cardiogenic shock remain controversial, with no consistent guidelines. A patient with subarachnoid hemorrhage who progresses to cardiogenic shock with concurrent cerebral vasospasm presents a special treatment challenge. Neurogenic stunned myocardium is reversible; however, it must be recognized immediately to avoid or manage potential complications, such as cardiogenic shock and pulmonary edema. A multifaceted treatment approach is needed for the patient with cardiogenic shock and concurrent vasospasm.
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Affiliation(s)
- Amy Stoddard
- Amy Stoddard is a graduate student, University of Tennessee Health Science Center, 920 Madison Ave, Memphis, TN 38163
| | - Donna Lynch-Smith
- Donna Lynch-Smith is Associate Professor, University of Tennessee Health Science Center, Memphis, Tennessee
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2
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Ortiz Garcia JG, Nathan S, Brorson JR. Neurologic complications of implantable devices. HANDBOOK OF CLINICAL NEUROLOGY 2021; 177:211-220. [PMID: 33632440 DOI: 10.1016/b978-0-12-819814-8.00019-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Technologies for repairing cardiac structures or sustaining cardiac function with implantable devices have helped patients with an ever-expanding array of cardiac conditions. Patients are surviving and thriving with cardiac conditions that would formerly have been disabling or fatal. With the implantation of devices in the heart, however, comes the inevitable risk of neurological complications. This chapter focuses on devices implanted in the chambers or valves of the heart itself, including prosthetic heart valves, closure devices for patent foramen ovale, atrial appendage occluder devices, short-term implantable circulatory assist devices, and long-term ventricular assist devices, but excluding coronary artery stents or extracardiac devices. Further, it considers the procedural and postprocedural risks of the devices, leaving the discussion of clinical effectiveness of the devices to other chapters of this book.
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Affiliation(s)
- Jorge G Ortiz Garcia
- Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, United States
| | - Sandeep Nathan
- Section of Cardiology, Department of Internal Medicine, University of Chicago, Chicago, IL, United States
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, IL, United States.
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3
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Bender M, Richter E, Schwarm FP, Kolodziej MA, Uhl E, Reinges MHT, Stein M. Transcranial Doppler Sonography Defined Vasospasm, Ischemic Brain Lesions, and Delayed Ischemic Neurological Deficit in Younger and Elderly Patients after Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2020; 138:e718-e724. [PMID: 32198122 DOI: 10.1016/j.wneu.2020.03.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/09/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Vasospasm, delayed ischemic neurologic deficit (DIND), and ischemic brain lesions after acute subarachnoid hemorrhage (SAH) are associated with increased morbidity and mortality. The purpose of this study was to analyze age cutoffs for vasospasm, DIND, and ischemic brain lesions after SAH. METHODS This study included 292 aneurysmal SAH patients from January 2005 to December 2015. Patients' data were extracted from a prospective database with measurements of transcranial Doppler sonography. Any vasospasm was defined as a maximum mean flow velocity (MMFV) >120 cm/sec. Severe vasospasms were defined as at least 2 measurements of MMFVs >200 cm/sec or an increase of MMFV >50 cm/sec/24 hours over 2 consecutive days or a new neurologic deficit. All MMFVs >120 cm/sec in absence of severe vasospasm criteria were defined as mild vasospasm. Age-related cutoff values were calculated using receiver operating curve analysis. RESULTS Any vasospasms occurred in 142 patients and thereof mild vasospasm in 86/142 (60.6%) patients and severe vasospasm in 56/142 patients (39.4%). Significantly higher incidences of any vasospasm (P = 0.005), severe vasospasm (P = 0.003), DIND (P = 0.031), and ischemic brain lesions (P = 0.04) were observed in patients aged <50 years. According to receiver operating curve analysis, the optimal age cutoff was 50 years for the presence of overall vasospasms, severe vasospasms, DIND, and ischemic brain lesions and 65 years for mild vasospasms. CONCLUSIONS Higher incidences of any vasospasms, severe vasospasms, DIND, and ischemic brain lesions were observed in younger SAH patients.
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Affiliation(s)
- Michael Bender
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany.
| | - Eva Richter
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - Frank P Schwarm
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | | | - Eberhard Uhl
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
| | - Marcus H T Reinges
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany; Department of Neurosurgery, Bremen-Mitte Hospital, Bremen, Bremen, Germany
| | - Marco Stein
- Department of Neurosurgery, Justus-Liebig-University Gießen, Gießen, Germany
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4
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Ibrahim MS, Samuel B, Mohamed W, Suchdev K. Cardiac Dysfunction in Neurocritical Care: An Autonomic Perspective. Neurocrit Care 2020; 30:508-521. [PMID: 30484009 DOI: 10.1007/s12028-018-0636-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A number of neurologic disorders can cause cardiac dysfunction by involving the conductive system and contractile apparatus of the heart. This is especially prominent in the neurocritical care setting where the spectrum of cardiac dysfunction due to acute neurologic injury ranges from trivial and isolated electrocardiographic changes to malignant arrhythmias and sudden death (Table 1). The mechanism of these cardiac complications is complex and not fully understood. An understanding of the neuroanatomical structures and pathways is of immense importance to comprehend the underlying pathophysiology that culminates as cardiac damage and dysregulation. Once the process is initiated, it can complicate and adversely affect the outcome of primary neurologic conditions commonly seen in the neurocritical care setting. Not only are these cardiac disorders under-recognized, there is a paucity of data to formulate evidence-based guidelines regarding early detection, acute management, and preventive strategies. However, certain details of clinical features and their course combined with location of primary neurologic lesion on neuroimaging and data obtained from laboratory investigations can be of great value to develop a strategy to appropriately manage these patients and to prevent adverse outcome from these cardiac complications. In this review, we highlight the mechanisms of cardiac dysfunction due to catastrophic neurologic conditions or due to stress of critical illness. We also address various clinical syndromes of cardiac dysfunction that occur as a result of the neurologic illness and in turn may complicate the course of the primary neurologic condition.
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Affiliation(s)
- Mohammad S Ibrahim
- Department of Neurology, Division of Neurocritical care, Wayne State University School of Medicine, Detroit, MI, USA
| | - Bennson Samuel
- Department of Neurology, Division of Neurocritical care, Wayne State University School of Medicine, Detroit, MI, USA
| | - Wazim Mohamed
- Department of Neurology, Division of Neurocritical care, Wayne State University School of Medicine, Detroit, MI, USA
| | - Kushak Suchdev
- Department of Neurology, Division of Neurocritical care, Wayne State University School of Medicine, Detroit, MI, USA.
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5
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6
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Morris NA, Manning N, Marshall RS, Connolly ES, Claassen J, Agarwal S, Roh DJ, Schmidt JM, Park S. Transcranial Doppler Waveforms During Intra-aortic Balloon Pump Counterpulsation for Vasospasm Detection After Subarachnoid Hemorrhage. Neurosurgery 2018; 83:416-421. [PMID: 28973669 DOI: 10.1093/neuros/nyx405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 06/20/2017] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Transcranial Doppler ultrasound is a standard screening tool for vasospasm after subarachnoid hemorrhage. Prevention of vasospasm-induced delayed cerebral ischemia after subarachnoid hemorrhage depends on optimization of cerebral perfusion pressure, which can be challenged by neurogenic stress cardiomyopathy. Intra-aortic balloon pumps have been utilized to augment cerebral perfusion, but they change the transcranial Doppler waveform, altering its interpretability for vasospasm screening. OBJECTIVE To assess the features of the transcranial Doppler waveform that correlate with vasospasm. METHODS We retrospectively reviewed cases of subarachnoid hemorrhage that underwent same-day transcranial Doppler ultrasound and angiography. Transcranial Doppler waveforms were assessed for mean velocity, peak systolic velocity, balloon pump-augmented diastolic velocity, and a novel feature, "delta velocity" (balloon pump-augmented velocity - systolic velocity). Relationship of flow velocity features to vasospasm was estimated by generalized estimating equation models using a Gaussian distribution and an exchangeable correlation structure. RESULTS There were 31 transcranial Doppler and angiography pairings (12 CT angiography/19 digital subtraction angiography) from 4 patients. Fourteen pairings had proximal vasospasm by angiography. Delta velocity was associated with proximal vasospasm (coefficient -6.8 [95% CI -9.8 to -3.8], P < .001). There was no significant correlation with proximal vasospasm for mean velocity (coefficient -13.0 [95% CI -29.3 to 3.4], P = .12), systolic velocity (coefficient -8.7 [95% CI -24.8 to 7.3], P = .29), or balloon pump-augmented velocity (coefficient -15.3 [95% CI -31.3 to 0.71], P = .06). CONCLUSION Delta velocity, a novel transcranial Doppler flow velocity feature, may reflect vasospasm in patients with subarachnoid hemorrhage and intra-aortic balloon pumps.
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Affiliation(s)
- Nicholas A Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland
| | - Nathan Manning
- Department of Neurosurgery, Columbia University Medical Center, New York, New York.,Department of Radiology, Columbia University Medical Center, New York, New York.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Randolph S Marshall
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - Jan Claassen
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Sachin Agarwal
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - David J Roh
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - J Michael Schmidt
- Department of Neurology, Columbia University Medical Center, New York, New York
| | - Soojin Park
- Department of Neurology, Columbia University Medical Center, New York, New York
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7
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Ruptured Mycotic Aneurysm and Cerebral Vasospasm in the Setting of Endocarditis and Heart Failure Requiring Cardiothoracic Surgery: Case Report and Literature Review. World Neurosurg 2017; 100:711.e13-711.e18. [DOI: 10.1016/j.wneu.2017.01.076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 01/17/2017] [Accepted: 01/19/2017] [Indexed: 11/20/2022]
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8
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Neurogenic stunned myocardium in subarachnoid hemorrhage. J Crit Care 2016; 38:27-34. [PMID: 27837689 DOI: 10.1016/j.jcrc.2016.10.010] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 10/13/2016] [Accepted: 10/15/2016] [Indexed: 02/07/2023]
Abstract
"Stunned myocardium," characterized by reversible left ventricular dysfunction, was first described via animal models using transient coronary artery occlusion. However, this phenomenon has also been noted with neurologic pathologies and collectively been labeled "neurogenic stunned myocardium" (NSM). Neurogenic stunned myocardium resulting from subarachnoid hemorrhage (SAH) is a challenging pathology due to its diagnostic uncertainty. Traditional diagnostic criteria for NSM after SAH focus on electrocardiographic and echocardiographic abnormalities and troponemia. However, tremendous heterogeneity still exists. Traditional pathophysiological mechanisms for NSM encompassed hypothalamic and myocardial perivascular lesions. More recently, research on pathophysiology has centered on myocardial microvascular dysfunction and genetic polymorphisms. Catecholamine surging as a mechanism has also gained attention with particular focus placed on the role of adrenergic blockade in both the prehospital and acute settings. Management remains largely supportive with case reports acknowledging the utility of inotropes such as dobutamine and milrinone and intra-aortic balloon pump when NSM is accompanied by cardiogenic shock. Neurogenic stunned myocardium that follows SAH can result in many complications such as arrhythmias, pulmonary edema, and prolonged intubation, which can negatively impact long-term recovery from SAH and increase morbidity and mortality. This necessitates the need to accurately diagnose and treat NSM.
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9
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de Oliveira Manoel AL, Goffi A, Marotta TR, Schweizer TA, Abrahamson S, Macdonald RL. The critical care management of poor-grade subarachnoid haemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:21. [PMID: 26801901 PMCID: PMC4724088 DOI: 10.1186/s13054-016-1193-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Aneurysmal subarachnoid haemorrhage is a neurological syndrome with complex systemic complications. The rupture of an intracranial aneurysm leads to the acute extravasation of arterial blood under high pressure into the subarachnoid space and often into the brain parenchyma and ventricles. The haemorrhage triggers a cascade of complex events, which ultimately can result in early brain injury, delayed cerebral ischaemia, and systemic complications. Although patients with poor-grade subarachnoid haemorrhage (World Federation of Neurosurgical Societies 4 and 5) are at higher risk of early brain injury, delayed cerebral ischaemia, and systemic complications, the early and aggressive treatment of this patient population has decreased overall mortality from more than 50% to 35% in the last four decades. These management strategies include (1) transfer to a high-volume centre, (2) neurological and systemic support in a dedicated neurological intensive care unit, (3) early aneurysm repair, (4) use of multimodal neuromonitoring, (5) control of intracranial pressure and the optimisation of cerebral oxygen delivery, (6) prevention and treatment of medical complications, and (7) prevention, monitoring, and aggressive treatment of delayed cerebral ischaemia. The aim of this article is to provide a summary of critical care management strategies applied to the subarachnoid haemorrhage population, especially for patients in poor neurological condition, on the basis of the modern concepts of early brain injury and delayed cerebral ischaemia.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada. .,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.
| | - Alberto Goffi
- Toronto Western Hospital MSNICU, 2nd Floor McLaughlin Room 411-H, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Tom R Marotta
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Tom A Schweizer
- Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - Simon Abrahamson
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
| | - R Loch Macdonald
- St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada.,Keenan Research Centre for Biomedical Science of St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1 W8, Canada
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10
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Taccone FS, Citerio G. Advanced monitoring of systemic hemodynamics in critically ill patients with acute brain injury. Neurocrit Care 2015; 21 Suppl 2:S38-63. [PMID: 25208672 DOI: 10.1007/s12028-014-0033-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Hemodynamic monitoring is widely used in critical care; however, the impact of such intervention in patients with acute brain injury (ABI) remains unclear. Using PubMed, a systematic review was performed (1966-August 2013), and 118 studies were included. Data were extracted using the PICO approach. The evidence was classified, and recommendations were developed according to the GRADE system. Electrocardiography and invasive monitoring of arterial blood pressure should be the minimal hemodynamic monitoring required in unstable or at-risk patients in the intensive care unit. Advanced hemodynamic monitoring (i.e., assessment of preload, afterload, cardiac output, and global systemic perfusion) could help establish goals that take into account cerebral blood flow and oxygenation, which vary depending on diagnosis and disease stage. Choice of techniques for assessing preload, afterload, cardiac output, and global systemic perfusion should be guided by specific evidence and local expertise. Hemodynamic monitoring is important and has specific indications among ABI patients. Further data are necessary to understand its potential for therapeutic interventions and prognostication.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care, Erasmus Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium,
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11
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Mittal M, Radhakrishnan M, UmamaheswaraRao GS. Management of catecholamine-induced stunned myocardium--a case report. J Clin Anesth 2015; 27:527-30. [PMID: 26160709 DOI: 10.1016/j.jclinane.2015.05.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 02/03/2015] [Accepted: 05/21/2015] [Indexed: 11/26/2022]
Abstract
Hypertensive, hypervolumic, and hemodilution therapy (triple-H therapy) is administered to patients with symptomatic cerebral vasospasm after intracranial aneurysm clipping. This therapy can sometimes result in cardiac dysfunction because of pharmacologically induced hyperadrenergic state. The diagnosis may be missed if blood pressure alone is monitored to guide triple-H therapy. In this report, we describe one such patient who developed cardiac failure after triple-H therapy. This was diagnosed by using a bioreactance noninvasive cardiac output monitoring. Continuous cardiac output monitoring by this technique facilitated treatment of cardiac failure with milrinone and dobutamine. At discharge, the patient had no neurologic deficits.
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Affiliation(s)
- Mohit Mittal
- Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - M Radhakrishnan
- Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore, India.
| | - G S UmamaheswaraRao
- Department of Neuroanaesthesia, National Institute of Mental Health and Neurosciences, Bangalore, India
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12
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Dabus G, Nogueira RG. Current options for the management of aneurysmal subarachnoid hemorrhage-induced cerebral vasospasm: a comprehensive review of the literature. INTERVENTIONAL NEUROLOGY 2014; 2:30-51. [PMID: 25187783 DOI: 10.1159/000354755] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVES Cerebral vasospasm is one of the leading causes of morbi-mortality following aneurysmal subarachnoid hemorrhage. The aim of this article is to discuss the current status of vasospasm therapy with emphasis on endovascular treatment. METHODS A comprehensive review of the literature obtained by a PubMed search. The most relevant articles related to medical, endovascular and alternative therapies were selected for discussion. RESULTS Current accepted medical options include the oral nimodipine and 'triple-H' therapy (hypertension, hypervolemia and hemodilution). Nimodipine remains the only modality proven to reduce the incidence of infarction. Although widely used, 'triple-H' therapy has not been demonstrated to significantly change overall outcome after cerebral vasospasm. Indeed, both induced hypervolemia and hemodilution may have deleterious effects, and more recent physiologic data favor normovolemia with induced hypertension or optimization of cardiac output. Endovascular options include percutaneous transluminal balloon angioplasty (PTA) and intra-arterial (IA) infusion of vasodilators. Multiple case reports and case series have been encountered in the literature using different drug regimens with diverse mechanisms of action. Compared with PTA, IA drug infusion has the advantages of distal penetration and a better safety profile. Its main disadvantages are the more frequent need for repeat treatments and its systemic hemodynamic repercussions. Alternative options using intraventricular/cisternal drug therapy and flow augmentation strategies have also shown possible benefits; however, their use is not yet as well established. CONCLUSION Blood pressure or cardiac output optimization should be the mainstay of hyperdynamic therapy. Endovascular treatment appears to have a positive impact on neurological outcome compared with the natural history of the disease. The role of intraventricular therapy and flow augmentation strategies in association with medical and endovascular treatment may, in the future, play a growing role in the management of patients with severe refractory vasospasm.
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Affiliation(s)
- Guilherme Dabus
- Department of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Fla., USA
| | - Raul G Nogueira
- Departments of Neurology, Neurosurgery and Radiology, Emory University School of Medicine, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, Ga., USA
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13
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Manto A, De Gennaro A, Manzo G, Serino A, Quaranta G, Cancella C. Early endovascular treatment of aneurysmal subarachnoid hemorrhage complicated by neurogenic pulmonary edema and Takotsubo-like cardiomyopathy. Neuroradiol J 2014; 27:356-60. [PMID: 24976204 DOI: 10.15274/nrj-2014-10035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2013] [Accepted: 03/04/2014] [Indexed: 12/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) may be associated with acute cardiopulmonary complications, like neurogenic pulmonary edema (NPE) and Takotsubo-like cardiomyopathy (TCM). These dysfunctions seem to result from a neurogenically induced overstimulation of the sympathetic nervous system through the brain-heart connection and often complicate poor grade aneurysmal SAH. The optimal treatment modality and timing of intervention in this clinical setting have not been established yet. Early endovascular therapy seems to be the fitting treatment in this particular group of patients, in which surgical clipping is often contraindicated due to the added risk of craniotomy. Herein we describe the case of a woman admitted to the emergency department with aneurysmal SAH complicated by NPE-TCM, in which early endovascular coiling was successfully performed. Our case, characterized by a favorable outcome, further supports the evidence that early endovascular treatment should be preferred in this peculiar clinical scenario.
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Affiliation(s)
- Andrea Manto
- Neuroradiology Unit, Umberto I Hospital; Nocera Inferiore, Salerno, Italy -
| | - Angela De Gennaro
- Department of Biomorphological and Functional Sciences, Federico II University; Naples, Italy
| | - Gaetana Manzo
- Department of Biomorphological and Functional Sciences, Federico II University; Naples, Italy
| | - Antonietta Serino
- Neuroradiology Unit, Umberto I Hospital; Nocera Inferiore, Salerno, Italy
| | - Gaetano Quaranta
- Cardiology Unit, Umberto I Hospital; Nocera Inferiore, Salerno, Italy
| | - Claudia Cancella
- Anesthesia and Reanimation Unit, Umberto I Hospital; Nocera Inferiore, Salerno, Italy
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14
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Behrouz R, Sullebarger JT, Malek AR. Cardiac manifestations of subarachnoid hemorrhage. Expert Rev Cardiovasc Ther 2014; 9:303-7. [DOI: 10.1586/erc.10.189] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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15
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Rahal JP, Malek AM, Heilman CB. Intra-Aortic Balloon Pump Counterpulsation in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2013; 80:e203-7. [DOI: 10.1016/j.wneu.2012.11.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Accepted: 11/09/2012] [Indexed: 10/27/2022]
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16
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Ducruet AF, Albuquerque FC, Crowley RW, Williamson R, Forseth J, McDougall CG. Balloon-Pump Counterpulsation for Management of Severe Cardiac Dysfunction After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2013; 80:e347-52. [DOI: 10.1016/j.wneu.2012.05.029] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2012] [Accepted: 05/23/2012] [Indexed: 10/27/2022]
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17
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Taccone FS, Brasseur A, Vincent JL, De Backer D. Levosimendan for the treatment of subarachnoid hemorrhage-related cardiogenic shock. Intensive Care Med 2013; 39:1497-8. [PMID: 23673402 DOI: 10.1007/s00134-013-2945-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2013] [Indexed: 12/01/2022]
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18
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Bruder N, Rabinstein A. Cardiovascular and Pulmonary Complications of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2011; 15:257-69. [DOI: 10.1007/s12028-011-9598-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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19
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Wachter D, Hans F, Kreitschmann-Andermahr I, Rohde V. Lower Incidence of Transcranial Doppler and Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage and Aneurysm Clipping in the Elderly Patient? Neurosurgery 2011; 69:261-6; discussion 266-7. [DOI: 10.1227/neu.0b013e31821d2b49] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Abstract
BACKGROUND:
Vasospasm is the major cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage. It is well known that the vasoreactivity decreases with advancing age, but it is not well investigated in a large patient cohort whether, as a consequence, the incidence of vasospasm is lower in elderly patients.
OBJECTIVE:
To investigate whether transcranial Doppler vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are less frequent in older patients.
METHODS:
Seven hundred fifty-eight patients who suffered from subarachnoid hemorrhage were included in this study. Clinical presentation, Hunt and Hess score, Fisher grade, incidence of vasospasm, neurological deficits and ischemic lesions on radiographic imaging, transcranial Doppler blood flow velocities, medical complications, and outcome were registered.
RESULTS:
Four hundred seventy-eight patients < 60 years of age and 280 patients ≥ 60 years of age were identified; 55.2% of the younger and 25.7% of the older age group developed post-hemorrhagic vasospasm (P < .001). Older patients developed less vasospasm (P = .00), fewer neurological deficits (P < .001), and fewer ischemic lesions on computed tomography imaging (P = .06). On the other hand, older patients had significantly worse outcomes than younger patients (P = .01) and more frequently died of medical complications (P = .01).
CONCLUSION:
Vasospasm, delayed ischemic neurological deficits, and vasospasm-associated ischemic lesions are more likely to occur in patients < 60 years of age than in older patients. The lower incidence of vasospasm and vasospasm-related ischemia in the elderly patient does not translate into better outcome because of the higher rate of fatal medical complications in patients ≥ 60 years of age.
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Affiliation(s)
- Dorothee Wachter
- Department of Neurosurgery, Georg-August-University Göttingen, Göttingen, Germany
| | - Franz Hans
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
| | | | - Veit Rohde
- Department of Neurosurgery, University Hospital RWTH Aachen, Aachen, Germany
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20
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YOKOTA H, SUGIURA S, IDA Y, ITOH H. Neurogenic Stress Cardiomyopathy Following Aneurysmal Subarachnoid Hemorrhage in a Very Elderly Patient -Case Report-. Neurol Med Chir (Tokyo) 2011; 51:842-6. [DOI: 10.2176/nmc.51.842] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | | | - Yuki IDA
- Department of Neurosurgery, Nabari City Hospital
| | - Hiroo ITOH
- Department of Cardiology, Nabari City Hospital
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Schmittinger CA, Wurzinger B, Deutinger M, Wohlmuth C, Knotzer H, Torgersen C, Dünser MW, Hasibeder WR. How to protect the heart in septic shock: a hypothesis on the pathophysiology and treatment of septic heart failure. Med Hypotheses 2009; 74:460-5. [PMID: 19889504 DOI: 10.1016/j.mehy.2009.10.012] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 10/04/2009] [Indexed: 01/29/2023]
Abstract
Heart failure is a well-recognized manifestation of organ failure in sepsis and septic shock. The pathophysiology of septic heart failure is complex and currently believed to involve several mechanisms. So far, the contributory role of high plasma catecholamine levels has not been investigated. In this manuscript, we present a hypothesis suggesting that excessive catecholamine production and exogenous administration of catecholamines may relevantly contribute to the development of heart failure and cardiovascular collapse in patients suffering from septic shock. Substantially elevated plasma catecholamine levels were measured during critical illness and sepsis or septic shock. There is a growing body of clinical and experimental evidence demonstrating that high catecholamine plasma levels exert direct toxic effects on the heart. The pathophysiologic mechanisms involved in catecholamine-induced cardiomyocyte toxicity may involve a combination of inflammation, oxidative stress, and abnormal calcium handling resulting in myocardial stunning, apoptosis and necrosis. Clinical signs of catecholamine-induced heart failure can present with a wide range of symptoms reaching from subtle histological changes with preserved myocardial pump function to severe heart failure exhibiting a distinctive echocardiographic pattern which became known as "Takotsubo"-like cardiomyopathy or the left ventricular apical ballooning syndrome. In a medical intensive care unit patient population, presence of sepsis was the only variable associated with the development of left ventricular apical ballooning. Since several therapeutic interventions influence catecholamine plasma levels in septic shock patients, treatment strategies aiming at the reduction of endogenous or exogenous catecholamine exposure may protect the heart during septic shock and could facilitate patient survival.
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Affiliation(s)
- Christian A Schmittinger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
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