Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes

Younger age at intracranial aneurysms rupture among patients with opioid use disorders

BACKGROUND

Association between opioid abuse and intracranial aneurysms rupture has been suggested in recent studies. However, these observations are limited to single center studies and could be benefited from validation in larger cohorts. Hence, we aimed to study the association between age at aneurysmal subarachnoid hemorrhage (aSAH) and opioid use disorders (OUD) using a large, national database.

METHODS

This study was conducted using the 2016 and 2017 National Inpatient Sample (NIS) with ICD-10 codes. Cohorts were categorized as "Non-users", "OUD", and "Multi-drug users". Linear regression models were used to examine the association between OUD and multi-drug users with age at aneurysm rupture, and multiple logistic regression models were used for the association between in-hospital mortality and drug abuse.

RESULTS

A total of 17,391 patients with aSAH were captured in the 2016 and 2017 NIS database. Out of these patients, 235 (1.4%) were included in the OUD group and 59 (0.3%) in the multi-drug users' group. Adjusted linear regression showed an unstandardized coefficient (UC) = -12.3 [95%CI = -14.4/-10.1, p < 0.001] for OUD patients and an UC = -16.8 [95%CI = -21.1/-12.5, p < 0.001] for multi-drug users, compared to non-users. The risk of in-hospital mortality was significantly increased in drug user, OR = 1.47 [95%CI: 1.1-2.01, p = 0.017] for OUD patients, and OR = 2.35 [95%CI: 1.35-4.11, p = 0.003] for multi-drug users.

CONCLUSIONS

This is the first national study to examine the association between age at intracranial aneurysms rupture and opioid abuse. aSAH patients with history of OUD were 12 years younger compared to non-users, when OUD was combined with other drugs, the age at aneurysms rupture was 17 years younger. Further elucidation regarding the mechanisms by which opioids triggers aneurysms rupture and predispose to worsen outcomes following aSAH is required, as well as appropriate prevention, and management strategies for aSAH patients with OUD.

Effects of Various Therapeutic Agents on Vasospasm and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage-Results of a Network Meta-Analysis

BACKGROUND

Vasospasm and delayed ischemic neurologic deficits are the leading causes of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). Several therapeutic agents have been assessed in randomized controlled trials for their efficacy in reducing the incidence of vasospasm and improving functional outcome. The aim of this network meta-analysis is to compare all these therapeutic agents for their effect on functional outcome and other parameters after aSAH.

METHODS

A comprehensive search of different databases was performed to retrieve randomized controlled trials describing the effect of various therapeutic approaches on functional outcome and other parameters after aSAH.

RESULTS

Ninety-two articles were selected for full text review and 57 articles were selected for the final analysis. Nicardipine prolonged-release implants were found to be the best treatment in terms of favorable outcome (odds ratio [OR], 8.55; 95% credible interval [CrI], 1.63-56.71), decreasing mortality (OR, 0.08; 95% CrI, 0-0.82), and preventing angiographic vasospasm (OR, 0.018; 95% CrI, 0.00057-0.16). Cilostazol was found to be the second-best treatment in improving favorable outcomes (OR, 3.58; 95% CrI, 1.97-6.57) and decreasing mortality (OR, 0.41; 95% CrI, 0.12-1.15). Fasudil (OR, 0.16; 95% CrI, 0.03-0.78) was found to be the best treatment in decreasing increased vessel velocity and enoxaparin (OR, 0.25; 95% CrI, 0.057-1.0) in preventing delayed ischemic neurologic deficits.

CONCLUSIONS

Our analysis showed that nicardipine prolonged-release implants and cilostazol were associated with the best chance of improving favorable outcome and mortality in patients with aSAH. However, larger multicentric studies from other parts of the world are required to confirm these findings.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.