Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium

Neurocardiology: Major mechanisms and effects

Neurocardiology is a broad interdisciplinary specialty investigating how the cardiovascular and nervous systems interact. In this brief introductory review, we describe several key aspects of this interaction with specific attention to cardiovascular effects. The review introduces basic anatomy and discusses physiological mechanisms and effects that play crucial roles in the interaction of the cardiovascular and nervous systems, namely: the cardiac neuraxis, the taxonomy of the nervous system, integration of sensory input in the brainstem, influences of the autonomic nervous system (ANS) on heart and vasculature, the neural pathways and functioning of the arterial baroreflex, receptors and ANS effects in the walls of blood vessels, receptors and ANS effects in excitable cells in the heart, ANS effects on heart rate and sympathovagal balance, endo-epicardial inhomogeneity, ANS effects with a balanced vagal and sympathetic stimulation, sympathovagal interaction, arterial baroreflex, baroreflex sensitivity and heart rate variability, arrhythmias and the arterial baroreflex, the cardiopulmonary baroreflex, the exercise pressor reflex, exercise-recovery hysteresis, mental stress, cardiac-cardiac reflexes, the cardiac sympathetic afferent reflex (CSAR), and neuromodulation. Also, the potential role of the discussed mechanisms in cardiovascular disorders will be touched upon.

A prospective observational study of electrocardiographic and echocardiographic changes in traumatic brain injury - effect of surgical decompression

BACKGROUND

Traumatic brain injury (TBI) causes significant changes in myocardial function, which is represented by ECG and echocardiographic changes. We intended to study the effect of surgical decompression on these changes.

MATERIALS AND METHODS

We recruited adult TBI patients undergoing surgery within 48 h of injury. Preoperatively, the patient's demographic and clinical details were recorded. ECG and TTE were performed before surgery and 24 h later (first postoperative day [POD1]). ECG was analyzed for heart rate, PR, QRS, and QTc intervals, morphologic end-repolarization abnormalities (MERA), and ST-segment and T wave changes. TTE data included left ventricular ejection fraction (LVEF) and regional wall motion abnormalities (RWMA). Glasgow coma scale (GCS) at discharge was recorded. ECG and TTE changes before and after surgery were compared, and its association with discharge GCS was analyzed. Preoperative predictors of LV dysfunction were analyzed.

RESULTS

Of the 110 patients recruited, common ECG changes were prolonged QTc interval (42%) and MERA (47%). TTE showed poor LVEF (<50%) in 10% and RWMA in 10.8% of patients. Following surgery, both ECG and TTE changes improved. Preoperative LVEF <50% and/or RWMA were associated with a lower GCS score at discharge. Preoperative poor GCS motor score and prolonged QTc interval were independent predictors of LV dysfunction.

CONCLUSIONS

Poor LV function was associated with poor admission GCS and prolonged QTc interval. Patients with reduced LV function had lower GCS at discharge.

Correlation of head injury with ECG and echo changes

Background

Abnormal electrocardiogram (ECG) findings can be seen in traumatic brain injury (TBI) patients. ECG may be an inexpensive tool to identify patients at high risk for developing cardiac dysfunction after TBI. This study aimed to examine abnormal ECG findings after isolated TBI and their association with true cardiac dysfunction based on echocardiogram.

Methods

This prospective observational study examined the data from adult patients with isolated and non-operated TBI between 2020 and 2021. Patients aged <18 years and >65 years with and presence of extracranial injuries including orthopedic, chest, cardiac, abdominal, and pelvis, pre-existing cardiac disease, patients who have undergone cardiothoracic surgery, with inotrope drugs, acute hemorrhage, and brain death were excluded from the study.

Results

We examined data from 100 patients with isolated TBI who underwent ECG and echocardiographic evaluation. ECG changes among 53% of mild cases showed a heart rate of 60-100/min, and 2% of cases showed more than 100/min. Prolonged pulse rate (PR) interval was observed in 8%, 11%, and 16% of mild, moderate, and severe cases, while no changes in PR interval were observed in 65% of cases. A prolonged QRS pattern was observed in 5%, 7%, and 15% of mild, moderate, and severe cases. A normal QRS complex was observed in 71% of cases. Prolonged QTc was observed in 3%, 10%, and 15% of cases in mild, moderate, and severe cases, respectively.

Conclusion

Repolarization abnormalities, but not ischemic-like ECG changes, are associated with cardiac dysfunction after isolated TBI. 12-lead ECG may be an inexpensive screening tool to evaluate isolated TBI patients for cardiac dysfunction.

Case report: Naturally occurring neurogenic stunned myocardium in a dog secondary to status epilepticus

A 4-year-old male neutered Boston Terrier was presented with status epilepticus. He was diagnosed with idiopathic epilepsy and hospitalized with supportive care. During hospitalization, the patient developed both supraventricular and ventricular arrhythmias as well as focal left ventricular dyskinesis. Cardiac troponin I was significantly increased, which was supportive of myocardial damage. Neurogenic stunned myocardium was suspected, and the patient was treated and responded to esmolol. Follow-up echocardiography demonstrated the resolution of the ventricular dyskinesia. This report describes the clinical presentation, diagnostic findings, treatment, management, and outcome of the first reported case of naturally occurring neurogenic stunned myocardium in a dog. Electrocardiogram monitoring, cardiac troponin I, and echocardiography should be considered in patients presenting with seizure activity, especially when exhibiting cluster seizures or in status epilepticus.

The Heart Is at Risk: Understanding Stroke-Heart-Brain Interactions with Focus on Neurogenic Stress Cardiomyopathy-A Review

In recent years, it has been convincingly demonstrated that acute brain injury may cause severe cardiac complications-such as neurogenic stress cardiomyopathy (NSC), a specific form of takotsubo cardiomyopathy. The pathophysiology of these brain-heart interactions is complex and involves sympathetic hyperactivity, activation of the hypothalamic-pituitary-adrenal axis, as well as immune and inflammatory pathways. There have been great strides in our understanding of the axis from the brain to the heart in patients with isolated acute brain injury and more specifically in patients with stroke. On the other hand, in patients with NSC, research has mainly focused on hemodynamic dysfunction due to arrhythmias, regional wall motion abnormality, or left ventricular hypokinesia that leads to impaired cerebral perfusion pressure. Comparatively little is known about the underlying secondary and delayed cerebral complications. The aim of the present review is to describe the stroke-heart-brain axis and highlight the main pathophysiological mechanisms leading to secondary and delayed cerebral injury in patients with concurrent hemorrhagic or ischemic stroke and NSC as well as to identify further areas of research that could potentially improve outcomes in this specific patient population.

Troponin I New Biomarker in Traumatic Brain Injury

Mortality in traumatic brain injury (TBI) is thought to be pathology in the heart-brain axis but its effect on the prognosis of traumatic brain injury remains unclear. Our study aimed to investigate the relationship between cardiac troponin I (cTnI) level and prognosis in TBI patients. Between January 2017 and May 2021, 480 patients diagnosed with TBI, who applied to the emergency department, were retrospectively included in this multicentric study. The databases of the hospitals were examined comprehensively and the demographic, clinical, laboratory, radiological, and therapeutic data and results of the patients were obtained. The severity of trauma and clinical status was evaluated with AIS, Injury Severity Score (ISS), ASA physical status, and Glasgow Coma Scale (GCS). The severity of the trauma was evaluated with the ISS. The modified Rankin Scale (mRS) and the Glasgow Outcome Scale (GOS) at discharge were used to evaluate in-hospital clinical outcomes. cTnI levels were classified into three categories: normal (< 0.05 ng/ml), mildly elevated (0.05–0.99 ng/ml), and severely elevated (≥ 1 ng/ml). The mean age of the patients was 41.7 and 75.4% of them were men. It was observed that mortality among patients over 65 years (13.9%) increased. High cTnI was detected in 284 (59.1%) patients. Although it was not statistically significant regarding the elevation of cTnI in patients under 65 years of age (P = 0.62), the difference was significant for cTnI in patients over 65 years of age (P < 0.001). The relationship between cTnI elevation was found to be statistically significant (P < 0.001) as the severity of the trauma increased and when severe additional traumas (thoracic, abdominal, or pelvic) occurred. A high cTnI level is associated with poor prognosis in TBI patients. cTnI measurement is a useful tool for early risk stratification and accelerated care; however, further prospective studies are needed.

Targeting hydrogen sulfide and nitric oxide to repair cardiovascular injury after trauma

The systemic cardiovascular effects of major trauma, especially neurotrauma, contribute to death and permanent disability in trauma patients and treatments are needed to improve outcomes. In some trauma patients, dysfunction of the autonomic nervous system produces a state of adrenergic overstimulation, causing either a sustained elevation in catecholamines (sympathetic storm) or oscillating bursts of paroxysmal sympathetic hyperactivity. Trauma can also activate innate immune responses that release cytokines and damage-associated molecular patterns into the circulation. This combination of altered autonomic nervous system function and widespread systemic inflammation produces secondary cardiovascular injury, including hypertension, damage to cardiac tissue, vascular endothelial dysfunction, coagulopathy and multiorgan failure. The gasotransmitters nitric oxide (NO) and hydrogen sulfide (H2S) are small gaseous molecules with potent effects on vascular tone regulation. Exogenous NO (inhaled) has potential therapeutic benefit in cardio-cerebrovascular diseases, but limited data suggests potential efficacy in traumatic brain injury (TBI). H2S is a modulator of NO signaling and autonomic nervous system function that has also been used as a drug for cardio-cerebrovascular diseases. The inhaled gases NO and H2S are potential treatments to restore cardio-cerebrovascular function in the post-trauma period.

Takotsubo cardiomyopathy in the setting of severe hyponatremia and beer potomania: A case report

Takotsubo cardiomyopathy (TC), an acute cardiac event is often associated with acute emotional stress, usually in the setting of cardiovascular risk factors. This case report attempts to review one of the triggers of TC beer potomania-induce hyponatremia with imaging findings that shows the link between severe hyponatremia and TC.

Assessment of cardiac function in rat endovascular perforation model of subarachnoid hemorrhage; A model of subarachnoid hemorrhage-induced cardiac dysfunction

Although the association between cardiac dysfunction and subarachnoid hemorrhage (SAH) has been recognized, its precise underlying mechanism remains unknown. Furthermore, no suitable animal models are available to study this association. Here, we established an appropriate animal model of SAH-induced cardiac dysfunction and elucidated its mechanism. In this rat model, contrast-enhanced computed tomography of the brain confirmed successful induction of SAH. Electrocardiography detected abnormalities in 55% of the experimental animals, while echocardiography indicated cardiac dysfunction in 30% of them. Further evaluation of left ventriculography confirmed cardiac dysfunction, which was transient and recovered over time. Additionally, in this SAH model, the expression of the acute phase reaction protein, proto-oncogene c-Fos increased in the paraventricular hypothalamic nucleus (PVN), the sympathetic nerve center of the brain. Polymerase chain reaction analysis revealed that the SAH model with cardiac dysfunction had higher levels of the macrophage-associated chemokine (C-X-C motif) ligand 1 (CXCL-1) and chemokine (C-C motif) ligand 2 (CCL-2) than the SAH model without cardiac dysfunction. Our results suggested that SAH caused inflammation and macrophage activation in the PVN, leading to sympathetic hyperexcitability that might cause cardiac dysfunction directly and indirectly. This animal model may represent a powerful tool to investigate the mechanisms of the brain-heart pathway.

Cardiac cephalalgia: a case series of four patients and updated literature review

Background

Cardiac damage is common in patients with acute brain injury; however, little is known regarding cardiac-induced neurological symptoms. In the International Classification of Headache, Third Edition (ICHD-III), cardiac cephalalgia is classified as a headache caused by impaired homeostasis.

Methods

This report presents four patients with acute myocardial infarction (AMI) who presented with headache that fulfilled the ICHD-III diagnostic criteria for cardiac cephalalgia. A systematic review of cardiac cephalalgia using the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines is also presented.

Results

Case 1: A 69-year-old man with a history of percutaneous coronary intervention (PCI) developed sudden severe occipital pain, nausea, and cold sweating. Coronary angiography (CAG) revealed occlusion of the right coronary artery (RCA). Case 2: A 66-year-old woman complained of increasing occipitalgia and chest discomfort while riding a bicycle. CAG demonstrated 99% stenosis of the left anterior descending artery. Case 3: A 54-year-old man presented with faintness, cold sweating, and occipitalgia after eating lunch. CAG detected occlusion of the RCA. Case 4: A 72-year-old man went into shock after complaining of a sudden severe headache and nausea. Vasopressors were initiated and emergency CAG was performed, which detected three-vessel disease. In all four, electrocardiography (ECG) showed ST segment elevation or depression and echocardiography revealed a left ventricular wall motion abnormality. All patients underwent PCI, which resulted in headache resolution after successful coronary reperfusion. A total of 59 cases of cardiac cephalalgia were reviewed, including the four reported here. Although the typical manifestation of cardiac cephalalgia is migraine-like pain on exertion, it may present with thunderclap headache without a trigger or chest symptoms, mimicking subarachnoid hemorrhage. ECG may not always show an abnormality. Headaches resolve after successful coronary reperfusion.

Conclusions

Cardiac cephalalgia resulting from AMI can present with or without chest discomfort and even mimic the classic thunderclap headache associated with SAH. It should be recognized as a neurological emergency and treated without delay.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12245-022-00436-2.

Left Ventricular Function in the Initial Period After Severe Traumatic Brain Injury in Swine

BACKGROUND

Cardiac dysfunction is common in the days after severe traumatic brain injury (TBI) and may contribute to hypotension episodes, leading to worse outcomes. Little is known about cardiac function in the minutes and hours immediately following TBI. By using fluid percussion TBI in a swine model, we aimed to characterize the immediate post injury cardiac function.

METHODS

Intubated, anesthetized immature (25.8 ± 1.5 kg) female swine were subjected to severe fluid percussion TBI (4.2 ± 0.2 atm). Beginning at 45 min, simulating hospital arrival, all animals were resuscitated with normal saline (NS), mannitol, and phenylephrine as needed to maintain a cerebral perfusion pressure more than 60 mm Hg and intracranial pressure (ICP) less than 20 mm Hg. Primary outcomes of cardiac function were cardiac output measured by thermodilution and transesophageal echo measurements of cardiac function recorded at prespecified time points and tested for trends over time using linear regression with spline at the time of resuscitation onset. Secondary outcomes included hemodynamic measurements, ICP, and cerebral perfusion pressure.

RESULTS

Eighteen animals were included. Post-TBI hemodynamic changes demonstrated an early decrease in mean arterial pressure and cerebral perfusion pressure with a corresponding increase in heart rate and ICP. Immediately after injury, there was a significant decrease in both left atrial area and tissue Doppler imaging e' of the LV lateral wall. In addition, there was a simultaneous increase in LV end diastolic diameter and increase in E/e' ratio of the lateral mitral annulus. All other transesophageal echo measurements demonstrated no significant changes throughout the duration of the experiment.

CONCLUSIONS

Traumatic brain injury is associated with cardiac dysfunction and increased mortality, however there is still a limited understanding of the hemodynamic and echocardiographic response associated with TBI. In this study we demonstrate the hemodynamic and echocardiographic changes in the early stages of TBI in swine. The authors hope that these results may help better understanding on the management of patients with severe head injury.

Pediatric takotsubo syndrome caused by hydrocephalus after posterior fossa tumor surgery

Takotsubo syndrome (TTS) can develop after intense physical or emotional stress and is uncommon in children. We report a 2-year-old girl who developed TTS caused by acute hydrocephalus after posterior fossa tumor resection and required mechanical ventilation and administration of vasopressor/inotropic agents. Her cardiac function gradually recovered over the course of 2 weeks. Hydrocephalus after posterior fossa surgery can cause compression of the medulla oblongata, resulting in solitary nucleus dysfunction and TTS, a potentially life-threatening complication.

Prospective Analysis of Role of hsTnT and NT-proBNP in Prediction of Neurogenic Stress Cardiomyopathy in Patients with Aneurysmal Subarachnoid Haemorrhage

Background

Neurogenic stress cardiomyopathy (NSC), also known as stress-induced cardiomyopathy (SIC), is a significant complication of aneurysmal subarachnoid hemorrhage and an important contributor to morbidity mortality.

Objective

This prospective observational study assessed whether the high sensitive troponin T (hsTnT) and N-terminal pro-B-type natriuretic peptide (NTproBNP) helps in the prediction of NSC after SAH.

Methods

The consecutive patients with aSAH without any cardiac history were included prospectively over 12 months. Neurological assessment for the grade of SAH (Hunt & Hess and WFNS grade), electrocardiogram, and echocardiography done at admission. The serial measurements of serum hsTnT and NTproBNP for consecutive 7 days done. The NSC is defined as transient hypokinesia of the ventricular wall on echocardiography.

Results

The study included 69 patients, and 7 (10.1%) were diagnosed with NSC. The NSC had a positive correlation with Hunt and Hess grade (P = 0.010), and the serum levels of hsTnT and NTproBNP were higher in patients with NSC in comparison to without NSC over all 7 days. The peak levels of hsTnT and NTproBNP were significantly higher in patients with cardiomyopathy (P = 0.000 and 0.032, respectively). The best cut-off level of peak hsTnT was 0.032 pg/dl to predict cardiomyopathy with sensitivity and specificity of 100% and 80%, respectively, and NTproBNP was 430.6 ng/dL with sensitivity and specificity of 86% and 73%, respectively.

Conclusion

The peak levels of hsTnT and NTproBNP with abnormal ECG and echocardiography at admission help identify NSC in the early phase of aSAH.

Systemic and local cardiac inflammation after experimental long bone fracture, traumatic brain injury and combined trauma in mice

Background

Trauma is the leading cause of death and disability worldwide, especially in the young population. Cardiac injuries are an independent predictor for a poor overall outcome after trauma. The aim of the present study was to analyze systemic inflammation as well as local cardiac inflammation after experimental limb-, neuro- and combined trauma in mice.

Methods

Male C57BL/6 mice received either a closed tibia fracture (Fx), isolated traumatic brain injury (TBI) or a combination of both (Fx ​+ ​TBI). Control animals underwent sham procedure. After 6 and 24 ​h, systemic levels of inflammatory mediators were analyzed, respectively. Locally, cardiac inflammation and cardiac structural alterations were investigated in left ventricular tissue of mice 6 and 24 ​h after trauma.

Results

Mice showed enhanced systemic inflammation after combined trauma, which was manifested by increased levels of KC, MCP-1 and G-CSF. Locally, mice exhibited increased expression of inflammatory cytokines (IL-1β, TNF) in heart tissue, which was probably mediated via toll-like receptor (TLR) signaling. Furthermore, mice demonstrated a redistribution of connexin 43 in cardiac tissue, which appeared predominantly after combined trauma. Besides inflammation and structural cardiac alterations, expression of glucose transporter 4 (GLUT4) mRNA was increased in the heart early after TBI and after combination of TBI and limb fracture, indicating a modification of energy metabolism. Early after combination of TBI and tibia fracture, nitrosative stress was increased, manifested by elevation of nitrotyrosine in cardiac tissue. Finally, mice showed a trend of increased systemic levels of cardiac troponin I and heart-fatty acid binding protein (HFABP) after combined trauma, which was associated with a significant decrease of troponin I and HFABP mRNA expression in cardiac tissue after TBI and combination of TBI and limb fracture.

Conclusion

Mice exhibited early cardiac alterations as well as alterations in cardiac glucose transporter expression, indicating a modification of energy metabolism, which might be linked to increased systemic- and local cardiac inflammation after limb-, neuro- and combined trauma. These cardiac alterations might predispose individuals for secondary cardiac damage after trauma that might compromise cardiac function after TBI and long bone fracture.

Translational potential statement

Injuries to the head and extremities frequently occur after severe trauma. In our study, we analyzed the effects of closed tibia fracture, isolated TBI, and the combination of both injuries with regard to the development of post-traumatic secondary cardiac injuries.

Takotsubo Syndrome in Neurologic Disease

Transient cardiac dysfunction, or Takotsubo cardiomyopathy, is a well-known complication among patients presenting with neurologic insult, who are described as having takotsubo syndrome. This condition is commonly associated with aneurysmal subarachnoid hemorrhage but has also been described in patients after cerebral surgery or in those with ischemic stroke, seizure, and traumatic brain injury. Current evidence suggests that cardiac dysfunction in these patients is a result of increases in catecholamines that are induced by supraphysiologic levels of sympathetic activity. The cardiac injury is typically reversible and carries a good prognosis, but secondary complications may arise if the diagnosis is not recognized early.

Atrial Fibrillation and Stroke

Atrial fibrillation (AF) is the most common cardiac arrythmia and a major cause of stroke, heart failure, sudden death, and cardiovascular morbidity. AF increases risk of thromboembolic stroke via stasis in the left atrium and subsequent embolization to the brain. In patients with acute ischemic stroke, it is essential that clinicians undertake careful investigation to search for AF. In these patients, up to 23.7% eventually are found to have underlying AF. Oral anticoagulation is effective in prevention of strokes secondary to AF, reducing overall stroke numbers by approximately 64%. Left atrial appendage occlusion is promising for prevention of stroke in AF.

Trauma, a Matter of the Heart-Molecular Mechanism of Post-Traumatic Cardiac Dysfunction

Trauma remains a leading global cause of mortality, particularly in the young population. In the United States, approximately 30,000 patients with blunt cardiac trauma were recorded annually. Cardiac damage is a predictor for poor outcome after multiple trauma, with a poor prognosis and prolonged in-hospitalization. Systemic elevation of cardiac troponins was correlated with survival, injury severity score, and catecholamine consumption of patients after multiple trauma. The clinical features of the so-called "commotio cordis" are dysrhythmias, including ventricular fibrillation and sudden cardiac arrest as well as wall motion disorders. In trauma patients with inappropriate hypotension and inadequate response to fluid resuscitation, cardiac injury should be considered. Therefore, a combination of echocardiography (ECG) measurements, echocardiography, and systemic appearance of cardiomyocyte damage markers such as troponin appears to be an appropriate diagnostic approach to detect cardiac dysfunction after trauma. However, the mechanisms of post-traumatic cardiac dysfunction are still actively being investigated. This review aims to discuss cardiac damage following trauma, focusing on mechanisms of post-traumatic cardiac dysfunction associated with inflammation and complement activation. Herein, a causal relationship of cardiac dysfunction to traumatic brain injury, blunt chest trauma, multiple trauma, burn injury, psychosocial stress, fracture, and hemorrhagic shock are illustrated and therapeutic options are discussed.

The Association of Early Electrocardiographic Abnormalities With Brain Injury Severity and Outcome in Severe Traumatic Brain Injury

The aim of this study was to evaluate the frequency of electrocardiographic (ECG) abnormalities in the acute phase of severe traumatic brain injury (TBI) and the association with brain injury severity and outcome. In contrast to neurovascular diseases, sparse information is available on this issue. Data of adult patients with severe TBI admitted to the Intensive Care Unit (ICU) for intracranial pressure monitoring of a level-1 trauma center from 2002 till 2018 were analyzed. Patients with a cardiac history were excluded. An ECG recording was obtained within 24 h after ICU admission. Admission brain computerized tomography (CT)-scans were categorized by Marshall-criteria (diffuse vs. mass lesions) and for location of traumatic lesions. CT-characteristics and maximum Therapy Intensity Level (TILmax) were used as indicators for brain injury severity. We analyzed data of 198 patients, mean (SD) age of 40 ± 19 years, median GCS score 3 [interquartile range (IQR) 3–6], and 105 patients (53%) had thoracic injury. In-hospital mortality was 30%, with sudden death by cardiac arrest in four patients. The incidence of ECG abnormalities was 88% comprising ventricular repolarization disorders (57%) mostly with ST-segment abnormalities, conduction disorders (45%) mostly with QTc-prolongation, and arrhythmias (38%) mostly of supraventricular origin. More cardiac arrhythmias were observed with increased grading of diffuse brain injury (p = 0.042) or in patients treated with hyperosmolar therapy (TILmax) (65%, p = 0.022). No association was found between ECG abnormalities and location of brain lesions nor with thoracic injury. Multivariate analysis with baseline outcome predictors showed that cardiac arrhythmias were not independently associated with in-hospital mortality (p = 0.097). Only hypotension (p = 0.029) and diffuse brain injury (p = 0.017) were associated with in-hospital mortality. In conclusion, a high incidence of ECG abnormalities was observed in patients with severe TBI in the acute phase after injury. No association between ECG abnormalities and location of brain lesions or presence of thoracic injury was present. Cardiac arrhythmias were indicative for brain injury severity but not independently associated with in-hospital mortality. Therefore, our findings likely suggest that ECG abnormalities should be considered as cardiac mimicry representing the secondary effect of traumatic brain injury allowing for a more rationale use of neuroprotective measures.

Early Serum Biomarkers for Intensive Care Unit Treatment within the First 24 Hours in Patients with Intracerebral Hemorrhage

BACKGROUND

 The prognostic significance of serum biomarkers in patients with intracerebral hemorrhage (ICH) is not well investigated concerning inhospital mortality (IHM) and cardiopulmonary events within the first 24 hours of intensive care unit (ICU) treatment. The influence of troponin I (TNI) value and cortisol value (CV) on cardiopulmonary events within the first 24 hours of ICU treatment was reported in subarachnoid hemorrhage patients, but not in ICH patients up to now. The aim of this study was to investigate the role of early serum biomarkers on IHM and TNI value and CV on cardiopulmonary events within the first 24 hours of ICU treatment.

PATIENTS AND METHODS

 A total of 329 patients with spontaneous ICH were retrospectively analyzed. Blood samples were taken on admission to measure serum biomarkers. The TNI value and CV were defined as biomarkers for cardiopulmonary stress. Demographic data, cardiopulmonary parameters, including norepinephrine application rate (NAR) in microgram per kilogram per minute and inspiratory oxygen fraction (FiO₂) within the first 24 hours, and treatment regime were analyzed concerning their impact on ICU treatment and in hospital outcome. Binary logistic analysis was used to identify independent prognostic factors for IHM.

RESULTS

 Patients with initially nonelevated CVs required higher NAR (p = 0.01) and FiO₂ (p = 0.046) within the first 24 hours of ICU treatment. Lower cholinesterase level (p = 0.004), higher NAR (p = 0.002), advanced age (p < 0.0001), larger ICH volume (p < 0.0001), presence of intraventricular hemorrhage (p = 0.007) and hydrocephalus (p = 0.009), raised level of C-reactive protein (p = 0.024), serum lactate (p = 0.003), and blood glucose (p = 0.05) on admission were significantly associated with IHM. In a multivariate model, age (odds ratio [OR]: 1.055; 95% confidence interval [CI]: 1.026-1.085; p < 0.0001), ICH volume (OR: 1.016; CI: 1.008-1.025; p < 0.0001), and Glasgow Coma Scale (GCS) score (OR: 0.680; CI: 0.605-0.764; p < 0.0001) on admission as well as requiring NAR (OR: 1.171; CI: 1.026-1.337; p = 0.02) and FiO₂ (OR: 0.951; CI: 0.921-0.983, p = 0.003) within the first 24 hours were independent predictors of IHM.

CONCLUSION

 Higher levels of C-reactive protein, serum lactate, blood glucose, and lower cholinesterase level on admission were significantly associated with IHM. Patients with initially nonelevated CVs required higher NAR and FiO₂ within the first 24 hours of ICU treatment. Furthermore, requiring an NAR > 0.5 µg/kg/min or an FiO₂ > 0.21 were identified as additional independent predictors for IHM. These results could be helpful to improve ICU treatment in ICH patients.

Non-coronarogenic causes of increased cardiac troponins in clinical practice

Cardiospecific isoforms of troponins are the most sensitive and specific biomarkers for the diagnosis of myocardial infarction. However, though elevated troponin levels indicate myocardial damage, they do not determine the cause and mechanism of the damage. With the new highly sensitive methods, very minor damages of the heart muscle can be detected. Myocardial damage can occur in many non-coronarogenic diseases. In this review, we discuss the mechanisms of elevation, the diagnostic value of cardiac troponins in the renal failure, tachyarrhythmias, endocarditis, myocarditis, pericarditis, sepsis, neurogenic pathologies (stroke), pulmonary embolism. In addition, we pay attention to the main reasons for a false-positive increase of the concentration of cardiac troponins: heterophilic antibodies, rheumatoid factor, alkaline phosphatase, cross-reactions with skeletal muscle troponins.

Heart Rate Variability as a Biomarker of Neurocardiogenic Injury After Subarachnoid Hemorrhage

BACKGROUND

The objective of this study was to examine whether heart rate variability (HRV) measures can be used to detect neurocardiogenic injury (NCI).

METHODS

Three hundred and twenty-six consecutive admissions with aneurysmal subarachnoid hemorrhage (SAH) met criteria for the study. Of 326 subjects, 56 (17.2%) developed NCI which we defined by wall motion abnormality with ventricular dysfunction on transthoracic echocardiogram or cardiac troponin-I > 0.3 ng/mL without electrocardiogram evidence of coronary artery insufficiency. HRV measures (in time and frequency domains, as well as nonlinear technique of detrended fluctuation analysis) were calculated over the first 48 h. We applied longitudinal multilevel linear regression to characterize the relationship of HRV measures with NCI and examine between-group differences at baseline and over time.

RESULTS

There was decreased vagal activity in NCI subjects with a between-group difference in low/high frequency ratio (β 3.42, SE 0.92, p = 0.0002), with sympathovagal balance in favor of sympathetic nervous activity. All time-domain measures were decreased in SAH subjects with NCI. An ensemble machine learning approach translated these measures into a classification tool that demonstrated good discrimination using the area under the receiver operating characteristic curve (AUROC 0.82), the area under precision recall curve (AUPRC 0.75), and a correct classification rate of 0.81.

CONCLUSIONS

HRV measures are significantly associated with our label of NCI and a machine learning approach using features derived from HRV measures can classify SAH patients that develop NCI.

Cardiac Dysfunction in Neurocritical Care: An Autonomic Perspective

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.

Cerebral Perfusion Pressure Directed-Therapy Modulates Cardiac Dysfunction After Traumatic Brain Injury to Influence Cerebral Autoregulation in Pigs

BACKGROUND

Traumatic brain injury (TBI) is an important contributor to morbidity and mortality. Low cerebral perfusion pressure (CPP, mean arterial pressure [MAP] minus intracranial pressure) after TBI is associated with cerebral ischemia, impaired cerebral autoregulation, and poor outcomes. Normalization of CPP and limitation of cerebral autoregulation impairment is a key therapeutic goal. However, some vasoactive agents used to elevate MAP such as phenylephrine (Phe) improve outcome in females but not male piglets after TBI while dopamine (DA) does so in both sexes. Clinical evidence has implicated neurological injuries as a cause of cardiac dysfunction, and we recently described cardiac dysfunction after TBI. Cardiac dysfunction may, in turn, influence brain health. One mechanism of myocyte injury may involve catecholamine excess. We therefore tested the hypothesis that TBI caused cardiac dysfunction and catecholamine excess which may reciprocally be modulated by vasoactive agent choice to normalize CPP and prevent impairment of cerebral autoregulation after injury.

METHODS

TBI was produced in anesthetized pigs equipped with a closed cranial window, and Phe or DA administered to normalize CPP.

RESULTS

Plasma cardiac enzymes troponin and creatine kinase and catecholamines epinephrine and norepinephrine were elevated by TBI, such release potentiated by Phe in males but blocked in female piglets and blocked in both sexes after DA. Cerebral autoregulation was impaired after TBI, worsened by Phe in males but protected in females and males treated with DA. Papaverine-induced dilation was unchanged by fluid percussion brain injury, DA, and Phe.

CONCLUSIONS

These data indicate that pressor choice in elevation of CPP is important in limiting cardiac dysfunction and suggest that DA protects cerebral autoregulation in both sexes via reduction of cardiac biomarkers of injury and catecholamines released after TBI.

Propranolol protects cerebral autoregulation and reduces hippocampal neuronal cell death through inhibition of interleukin-6 upregulation after traumatic brain injury in pigs

BACKGROUND

Traumatic brain injury (TBI) is associated with reduced cerebral blood flow and impaired autoregulation after TBI, which may lead to poor outcome. Clinical evidence has implicated neurological injuries and associated neuroinflammation as causes of cardiac dysfunction. Studies on newborn pigs show an association of elevated catecholamines with a sex-dependent impairment of cerebral autoregulation after TBI. One strategy to decrease sympathetic hyperactivity is pharmacological intervention with beta blockade. We tested the hypothesis that propranolol would prevent the impairment of cerebral autoregulation and tissue changes after TBI via inhibition of interleukin-6 (IL-6) upregulation.

METHODS

Using newborn pigs of both sexes equipped with a closed cranial window, TBI was induced via lateral fluid percussion injury. Propranolol was administered at 1 h post-TBI. Analyses included cerebral autoregulation (pial artery reactivity) before and 4 h post-TBI, CSF IL-6 analysed (enzyme-linked immunosorbent assay), and histopathology at 4 h post-TBI.

RESULTS

Propranolol administration prevented impairment of hypotensive dilation in both male and female newborn pigs after fluid percussion injury, which was paralleled by reduced upregulation of IL-6 in the CSF. Moreover, propranolol prevented neuronal cell death in cornu amonis (CA)1 and CA3 hippocampus equivalently in male and female pigs after TBI. Papaverine-induced dilation was unchanged by TBI and propranolol.

CONCLUSIONS

These data indicate that sympathetic hyperactivity noted after TBI can be limited by propranolol administration to result in improved brain outcome post-injury via block of IL-6 upregulation, and this effect is irrespective of sex.

Assessment of the ECG T-Wave in Patients With Subarachnoid Hemorrhage

BACKGROUND

Prolongation of the interval from the peak to the end of the T wave (Tp-Te) on a 12-lead electrocardiogram (ECG) is associated with ventricular arrhythmias. The aim of this study was to clarify associations between Tp-Te, Tp-Te/QT, and Tp-Te/rate-corrected QT (QTc) with clinical severity of subarachnoid hemorrhage (SAH) and clinical outcomes.

METHODS

This retrospective study included 222 patients with acute SAH (group S) and 306 patients with unruptured cerebral aneurysms (group U). Tp-Te, Tp-Te/QT, and Tp-Te/QTc were manually measured in standard 12-lead ECG recordings on admission and comparisons made between patients in groups S and U. The relationships of these ECG parameters with Hunt and Hess grade and Glasgow outcome scale were analyzed using multiple logistic regression analysis after adjustment for confounding factors.

RESULTS

Tp-Te, Tp-Te/QT, and Tp-Te/QTc were significantly greater in group S than in group U (group S: 109±30, 0.26±0.07, and 0.24±0.06 ms; group U: 84±12, 0.22±0.03, and 0.21±0.03 ms, respectively; P < 0.0001). In addition, in the multiple logistic regression analyses these variables were positively correlated with the Hunt and Hess grade (Tp-Te odds ratio [95% confidence interval], 2.414 [1.375-4.238], P=0.002; Tp-Te/QT, 1.886 [1.085-3.277], P = 0.024; Tp-Te/QTc, 1.873 [1.07-3.278], P=0.028, and negatively correlated with Glasgow outcome scale Tp-Te odds ratio [95% confidence interval], 4.168 [2.409-7.209], P<0.001; Tp-Te/QT, 2.434 [1.413-4.192], P=0.001; Tp-Te/QTc 2.953 [1.703-5.123], P<0.001).

CONCLUSIONS

Tp-Te, Tp-Te/QT, and Tp-Te/QTc are associated with disease severity and clinical outcome in patients with SAH.

Improving Understanding and Outcomes of Traumatic Brain Injury Using Bidirectional Translational Research

Recent clinical trials in traumatic brain injury (TBI) have failed to demonstrate therapeutic effects even when there appears to be good evidence for efficacy in one or more appropriate pre-clinical models. While existing animal models mimic the injury, difficulties in translating promising therapeutics are exacerbated by the lack of alignment of discrete measures of the underlying injury pathology between the animal models and human subjects. To address this mismatch, we have incorporated reverse translation of bedside experience to inform pre-clinical studies in a large animal (pig) model of TBI that mirror practical clinical assessments. Cerebral autoregulation is impaired after TBI, contributing to poor outcome. Cerebral perfusion pressure (CPP) is often normalized by use of vasoactive agents to increase mean arterial pressure (MAP) and thereby limit impairment of cerebral autoregulation and neurological deficits. Vasoactive agents clinically used to elevate MAP to increase CPP after TBI, such as phenylephrine (Phe), dopamine (DA), norepinephrine (NE), and epinephrine (EPI), however, have not been compared sufficiently regarding effect on CPP, autoregulation, and survival after TBI, and clinically, current vasoactive agent use is variable. The cerebral effects of these clinically commonly used vasoactive agents are not known. This review will emphasize pediatric work and will describe bidirectional translational studies using a more human-like animal model of TBI to identify better therapeutic strategies to improve outcome post-injury. These studies in addition investigated the mechanism(s) involved in improvement of outcome in the setting of TBI.

Prognostic Value of Echocardiography for Left Ventricular Dysfunction After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

OBJECTIVE

Cardiac dysfunction may worsen outcomes after aneurysmal subarachnoid hemorrhage (SAH). This study quantitatively assessed the prognostic value of left ventricular dysfunction with respect to functional outcomes and mortality in patients with aneurysmal SAH.

METHODS

We searched MEDLINE and EMBASE databases to retrieve relevant studies evaluating echocardiographic left ventricular dysfunction following aneurysmal SAH. Fourteen relevant observational studies evaluating 2234 patients were finally included in this study.

RESULTS

Echocardiographic regional wall motion abnormalities (RWMA) and neurogenic cardiomyopathy (NCM) of the left ventricle occurring after SAH were significantly related to an increase of in-hospital mortality (in 8 studies for RWMA, odds ratio [OR] 2.37; 95% confidence interval [CI] 1.74-3.25 and in 5 studies for NCM, OR 2.82; 95% CI 1.2-6.6). Decreased ejection fraction on echocardiography was not associated with the increase of in-hospital mortality (in 4 studies, OR 1.76; 95% CI 0.86-3.61). The heterogeneities of decreased ejection fraction and NCM were significantly resolved by analyzing only the studies based on echocardiogram measurements obtained within 72 hours after admission.

CONCLUSIONS

The present meta-analysis suggests that the identification of echocardiographic left ventricular dysfunction identified by RWMA and NCM after SAH could provide better prognostic information for in-hospital mortality.

Serum Cortisol as an Early Biomarker of Cardiopulmonary Parameters Within the First 24 Hours After Aneurysmal Subarachnoid Hemorrhage in Intensive Care Unit Patients

OBJECTIVE

Cardiopulmonary complications/stress are well-known phenomena in patients after aneurysmal subarachnoid hemorrhage (aSAH) and might be associated with an elevated serum troponin I (TNI) level. Since the glucocorticoid hormone cortisol is released during stress situations, the present study was conducted to investigate the influence of serum cortisol (SC) on cardiac and pulmonary parameters in patients after aSAH within the first 24 hours of intensive care unit (ICU) treatment.

PATIENTS AND METHODS

We retrospectively analyzed a cohort of 104 patients with aSAH admitted to our emergency department between January 2008 and April 2017. Blood samples were taken to determine SC and TNI. Demographics, initial Glasgow Coma Scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) score, and Fisher grade were evaluated retrospectively. Mean norepinephrine application rate (NAR) in µg/kg/min and mean inspiratory oxygen fraction (OF) within the first 24 hours were defined as cardiopulmonary parameters.

RESULTS

An elevated SC value was found in 44 (42%) patients, and 27 (26%) patients showed an increased TNI value. In patients with initially increased SC value, a significant higher NAR (P = .04) was needed. Furthermore, patients with initially elevated TNI value had a lower GCS score (P = .0013) and a higher WFNS score (P = .003) on admission and required a higher NAR (P = .02) as well as OF (P = .0008) within the first 24 hours of ICU treatment.

CONCLUSIONS

In the current study, initially elevated SC values were associated with a higher need of NAR within the first 24 hours of ICU treatment after aSAH. Moreover, patients with initially elevated TNI values required an increased NAR and a higher OF so that these biomarkers could be useful to improve ICU treatment.

Speckle tracking-vs conventional echocardiography for the detection of myocardial injury-A study on patients with subarachnoid haemorrhage

BACKGROUND

Myocardial injury with regional wall motion abnormalities (RWMA) is common in subarachnoid haemorrhage (SAH). We hypothesized that the diagnostic performance of left ventricular (LV) global and regional longitudinal strain (GLS and RLS, respectively), assessed with speckle tracking echocardiography is superior to standard echocardiography for the detection of myocardial injury in SAH.

METHODS

Seventy-one unselected patients with verified SAH were included. Echocardiography was performed within 48 hours after admission. hsTnT was followed daily up to 3 days post-admission. RWMA, LV ejection fraction (LVEF), GLS and RLS were analysed by two experienced echocardiographists, blinded to the information on plasma hsTnT. A reduced GLS was defined as >-15%. Two cut-off levels were used for the definition of RLS, ie when segmental strain was >-15% (liberal) or >-11% (conservative) in ≥2 adjacent segments. Myocardial injury was defined as a peak hsTnT ≥90 ng/L.

RESULTS

The incidence of myocardial injury was 25%. The hsTnT (median, 25% and 75% percentile) in patients with (a) reduced LV ejection fraction (LVEF <50%, n = 10) was 502 (175-718), (b) RWMA (n = 12) was 648 (337-750), (c) reduced GLS (n = 12) was 502 (132-750) and (d) reduced RLS (n = 42) was 40 (10-216), respectively. The specificity/sensitivity for LVEF, RWMA, GLS and RLS to detect myocardial injury 98%/50%, 100%/67%, 96%/56% and 54%/94%, respectively. The intra- and inter-observer variability for assessment of RLS was high.

CONCLUSION

The diagnostic performance of GLS by strain imaging is not superior to standard echocardiography for the detection of myocardial injury in SAH. RLS could not reliably detect regional myocardial injury.

Troponin I as an Early Biomarker of Cardiopulmonary Parameters Within the First 24 Hours After Nontraumatic Subarachnoid Hemorrhage in Intensive Care Unit Patients

OBJECTIVE

The elevation of serum cardiac troponin I (TNI) in patients with nontraumatic subarachnoid hemorrhage (ntSAH) is a well-known phenomenon. However, the relation between elevated TNI and different cardiopulmonary parameters (CPs) within the first 24 hours after ntSAH is unknown. The present study was conducted to investigate the association between TNI and different CP in patients with ntSAH within the first 24 hours of intensive care unit (ICU) treatment.

PATIENTS AND METHODS

We retrospectively analyzed a consecutive group of 117 patients with ntSAH admitted to our emergency department between January 2008 and February 2017. Blood samples were taken to determine TNI values on admission. Demographic data, baseline Glasgow Coma Scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) score, baseline Fisher grade (FG), norepinephrine application rate (NAR) in µg/kg/min, and inspiratory oxygen fraction (OF) were recorded within the first 24 hours.

RESULTS

An increased TNI value was found in 32 (27.4%) of 117 patients. There was a significant correlation between initial elevated TNI and a low WFNS score (P = .007), a low GCS score (P = .003) as well as a high OF (P = <.001). The FG (P = .27) and NAR (P = .08) within the first 24 hours of ICU treatment did not show any significant correlation.

CONCLUSIONS

In the present study, an increased TNI value was significantly associated with a low WFNS score and GCS score on admission. The TNI was a predictor of the need for a higher OF within the first 24 hours after ntSAH so that TNI could be an informative biomarker to improve ICU therapy.

Acute Cardiac Complications in Critical Brain Disease

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease. Effective prevention and treatment interventions are yet to be determined.

Acute Cardiac Complications in Critical Brain Disease

Acute cardiac complications in critical brain disease should be understood as a clinical condition representing an intense brain-heart crosstalk and might mimic ischemic heart disease. Two main entities (neurogenic stunned myocardium [NSM] and stress cardiomyopathy) have been better characterized in the neurocritically ill patients and they portend worse clinical outcomes in these cases. The pathophysiology of NSM remains elusive. However, significant progress has been made on the early identification of neurocardiac compromise following acute critical brain disease. Effective prevention and treatment interventions are yet to be determined.

Brain-Heart Interactions in Traumatic Brain Injury

The cardiovascular manifestations associated with nontraumatic head disorders are commonly known. Similar manifestations have been reported in patients with traumatic brain injury (TBI); however, the underlying mechanisms and impact on the patient's clinical outcomes are not well explored. The neurocardiac axis theory and neurogenic stunned myocardium phenomenon could partly explain the brain-heart link and interactions and can thus pave the way to a better understanding and management of TBI. Several observational retrospective studies have shown a promising role for beta-adrenergic blockers in patients with TBI in reducing the overall TBI-related mortality. However, several questions remain to be answered in clinical randomized-controlled trials, including population selection, beta blocker type, dosage, timing, and duration of therapy, while maintaining the optimal mean arterial pressure and cerebral perfusion pressure in patients with TBI.

Impact of echocardiographic wall motion abnormality and cardiac biomarker elevation on outcome after subarachnoid hemorrhage: a meta-analysis

Cardiac abnormalities (echocardiographic wall motion abnormality (WMA), biomarker elevation of cardiac troponin (cTn), B-type natriuretic peptide (BNP), or N-terminal prohormone of B-type natriuretic peptide (NT-proBNP)) frequently occur after subarachnoid hemorrhage (SAH). The clinical significance of cardiac abnormalities after SAH remains controversial. This meta-analysis was performed to assess the association between cardiac abnormalities and patient outcomes, including delayed cerebral ischemia (DCI), poor outcome, and death in SAH patients. PubMed and Embase were searched for observational studies reporting an association between cardiac abnormalities and outcome after SAH that were published before 31 December 2017. We extracted data regarding patient characteristics, cardiac abnormalities, and outcome measurements (DCI, poor outcome, or death). Risk ratios (RRs) and 95% confidence intervals (CIs) were calculated using a random-effects model. Twenty-six studies involving 3917 patients were included in our data analysis. WMA showed significant associations with higher rates of DCI (RR, 2.03; 95% CI, 0.99-4.15), poor outcome (RR, 1.45; 95% CI, 1.08-1.93), and death (RR, 2.54; 95% CI, 1.59-4.05). cTn elevation was associated with an increased risk of DCI (RR, 1.48; 95% CI, 1.23-1.79), poor outcome (RR, 1.85; 95% CI, 1.49-2.30), and death (RR, 2.68; 95% CI, 2.19-3.27). Elevation of BNP or NT-proBNT was significantly associated with higher rates of DCI (RR, 1.87; 95% CI, 1.16-3.02). WMA and elevation of cTn, BNP, and NT-proBNP in SAH patients are associated with an increased risk of DCI, poor outcome, and death after SAH.

Clinical Characteristics, Management, and Outcomes of Suspected Poststroke Acute Coronary Syndrome

Background

Acute coronary syndrome (ACS) can complicate acute ischemic stroke, causing significant morbidity and mortality. To date, literatures that describe poststroke acute coronary syndrome and its morbidity and mortality burden are lacking.

Methods

This is a single center, retrospective study where clinical characteristics, cardiac evaluation, and management of patients with suspected poststroke ACS were compared and analyzed for their association with inpatient mortality and 1-year all-cause mortality.

Results

Of the 82 patients, 32% had chest pain and 88% had ischemic ECG changes; mean peak troponin level was 18, and mean ejection fraction was 40%. The medical management group had older individuals (73 versus 67 years, p < 0.05), lower mean peak troponin levels (12 versus 49, p < 0.05), and lower mean length of stay (12 versus 25 days, p < 0.05) compared to those who underwent stent or CABG. Troponin levels were significantly associated with 1-year all-cause mortality.

Conclusion

Age and troponin level appear to play a role in the current clinical decision making for patient with suspected poststroke ACS. Troponin level appears to significantly correlate with 1-year all-cause mortality. In the management of poststroke acute coronary syndrome, optimal medical therapy had similar inpatient and all-cause mortality compared to PCI and/or CABG.

Acute Kidney Injury After Subarachnoid Hemorrhage

BACKGROUND

Acute kidney injury (AKI) is common in critically ill patients and may contribute to poor outcome. Few data are available on the incidence and impact of AKI in patients suffering from nontraumatic subarachnoid hemorrhage (SAH).

METHODS

We reviewed all patients admitted to our Department of Intensive Care with SAH over a 3-year period. Exclusion criteria were time from SAH symptoms to intensive care unit (ICU) admission >96 hours and ICU stay <48 hours. AKI was defined as sustained oligoanuria (urine output <0.5 mL/kg/h for 24 h) or an increase in plasma creatinine (≥0.3 mg/dL or a 1.5-fold increase from baseline level within 48 h). Neurological status was assessed at day 28 using the Glasgow Outcome Scale (GOS) (from 1=death to 5=good recovery; favorable outcome=GOS 4 to 5).

RESULTS

Of 243 patients admitted for SAH during the study period, 202 met the inclusion/exclusion criteria (median age 56 y, 78 male). Twenty-five patients (12%) developed AKI, a median of 8 (4 to 10) days after admission. Independent predictors of AKI were development of clinical vasospasm, and treatment with vancomycin. AKI was more frequent in ICU nonsurvivors than in survivors (11/50 vs. 14/152, P=0.03), and in patients with an unfavorable neurological outcome than in other patients (17/93 vs. 8/109, P=0.03). Nevertheless, in multivariable regression analysis, AKI was not an independent predictor of outcome.

CONCLUSIONS

AKI occurred in >10% of patients after SAH. These patients had more severe neurological impairment and needed more aggressive ICU therapy; AKI did not significantly influence outcome.

A Review of Neurogenic Stunned Myocardium

Neurologic stunned myocardium (NSM) is a phenomenon where neurologic events give rise to cardiac abnormalities. Neurologic events like stroke and seizures cause sympathetic storm and autonomic dysregulation that result in myocardial injury. The clinical presentation can involve troponin elevation, left ventricular dysfunction, and ECG changes. These findings are similar to Takotsubo cardiomyopathy and acute coronary syndrome. It is difficult to distinguish NSM from acute coronary syndrome based on clinical presentation alone. Because of this difficulty, a patient with NSM who is at high risk for coronary heart disease may undergo cardiac catheterization to rule out coronary artery disease. The objective of this review of literature is to enhance physician's awareness of NSM and its features to help tailor management according to the patient's clinical profile.

Impact of restrictive fluid protocol on hypoxemia after aneurysmal subarachnoid hemorrhage

PURPOSE

In patients with aneurysmal subarachnoid hemorrhage (aSAH), acute cardiac dysfunction and triple-H-therapy, can lead to hypoxemia. Our aim was to assess impact of a protocoled fluid restrictive approach on hypoxemia in these patients.

METHODS

We included prospectively ICU patients with aSAH admitted within 24h after the bleed. The study was divided into 2 phases. The first phase, from January to December 2012, was designated as control group (group C). The second phase, from February 2014 to January 2015, was designated as study group (group S). Between these periods, a protocoled fluid intake approach was implemented to maintain as low as possible the cumulative fluid balances.

RESULTS

Effective fluid restriction was obtained: at day 3 cumulative fluid balances were respectively for group C and group S, 1559±2402ml and 759±1855ml (p=0.04); and 2211±4918ml vs 529±2806ml (p=0.04) at day 7. We observed reduction in proportion of hypoxemic patient in group S compared to group C, at day 3 (22% vs 40%, p=0.047) and at day 7 (28% vs 57%, p=0.007).

CONCLUSIONS

Fluid restrictive management of patients with aSAH decreases number of hypoxemic patients at day 3 and day 7.

Acquired long QT syndrome in hospitalized patients

BACKGROUND

Acquired long QT syndrome (ALQTS) has long been overlooked in clinical practice. Recent studies reported that severe ALQTS (QTc ≥500 ms) in hospitalized patients is associated with increased all-cause mortality.

OBJECTIVE

The purpose of this study was to determine the role of ALQTS in the clinical outcomes of hospitalized patients.

METHODS

Electronic medical records were reviewed to identify severe ALQTS in hospitalized patients in a single study center from September 1, 2013, to February 28, 2014. Up to 1-year follow-up was conducted in the ALQTS subjects and compared with age-, gender-, and admitting diagnosis-matched hospitalized patients with a normal QT interval.

RESULTS

Severe ALQTS (QTc 529 ± 38 ms) was seen in 0.7% (293/41,649) of hospitalized patients, of whom 86% were treated in noncardiology departments. All-cause mortality was 32% in the ALQTS group vs 14% in the control group (P <.001) during follow-up of 255 ± 63 days. Syncope and life-threatening ventricular arrhythmia were more frequent in patients with severe ALQTS (6% vs 0.6%, P <.0001). Cerebral hemorrhage (odds ratio [OR] 6.405, 95% confidence interval [CI] 2.341-17.525), cancer (OR 5.937, 95% CI 2.658-13.260), infection (OR 2.207, 95% CI 1.124-4.333), and end-stage disease (OR 2.092, 95% CI 1.045-4.191) are the major contributors to all-cause mortality in ALQTS.

CONCLUSION

Severe ALQTS is not uncommon in hospitalized patients. It can be easily overlooked because the majority of patients with severe ALQTS are treated in noncardiology departments. The clinical outcome of severe ALQTS is poor. Removing QT-prolonging factors may reduce the risks of fatal arrhythmia and sudden death in patients with ALQTS.

Concurrent subarachnoid haemorrhage and ST elevation myocardial infarction

Rare case of concurrent subarachnoid haemorrhage and ST elevation myocardial infarction, highlighting the importance of detailed history in an emergency.

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

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