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Geraghty JR, Saini NS, Deshpande A, Cheng T, Nazir N, Testai FD. The Role of Serum Monocytes and Tissue Macrophages in Driving Left Ventricular Systolic Dysfunction and Cardiac Inflammation Following Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:1127-1139. [PMID: 38062302 DOI: 10.1007/s12028-023-01891-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/06/2023] [Indexed: 06/05/2024]
Abstract
BACKGROUND Neurocardiogenic injury is common after aneurysmal subarachnoid hemorrhage (aSAH) despite low prevalence of preexisting cardiac disease. Potential mechanisms include autonomic dysregulation due to excess catecholamines as well as systemic inflammation. Understanding how inflammation contributes to cardiac dysfunction may aid in identifying novel therapeutic strategies. Here, we investigated serum leukocytes as predictors of left ventricular systolic dysfunction in patients with aSAH. We also investigated increased cardiac macrophages in an animal model of SAH and whether immunomodulatory treatment could attenuate this inflammatory response. METHODS We retrospectively analyzed 256 patients with aSAH admitted to University of Illinois Hospital between 2013 and 2019. Our inclusion criteria included patients with aSAH receiving an echocardiogram within 72 h of admission. Our primary outcome was echocardiographic evidence of systolic dysfunction. We performed multinomial regression and receiver operating curve analysis. We also used the endovascular perforation model of SAH in male Sprague-Dawley rats to assess for myocardial inflammation. Two days after surgery, hearts were collected and stained for the macrophage marker Iba-1. We compared the presence and morphology of macrophages in cardiac tissue isolated from SAH animals and sham controls treated with and without the immunomodulatory agent fingolimod. RESULTS Of 256 patients with aSAH, 233 (91.0%) underwent echocardiography within 72 h of admission. Of 233, 81 (34.7%) had systolic dysfunction. Patients had baseline differences in the presence of hypertension, alcohol use, and admission Glasgow Coma Scale and Hunt-Hess score. On multivariable analysis, total leukocytes (odds ratio 1.312, p < 0.001), neutrophils (odds ratio 1.242, p = 0.012), and monocytes (odds ratio 6.112, p = 0.008) were independent predictors of reduced systolic function, whereas only monocytes (odds ratio 28.014, p = 0.030) predicted hyperdynamic function. Within the rodent heart, there were increased macrophages after SAH relative to controls, and this was attenuated by fingolimod treatment (p < 0.0001). CONCLUSIONS Increased serum leukocytes are associated with abnormal left ventricular systolic function following aSAH. The strongest independent predictor of both reduced and hyperdynamic systolic function was increased monocytes. Increased cardiac macrophages after experimental SAH can also be targeted by using immunomodulatory drugs.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA.
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA, 19104, USA.
| | - Neil S Saini
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
| | - Ashwini Deshpande
- Division of Cardiology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Tiffany Cheng
- Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - Noreen Nazir
- Division of Cardiology, Department of Medicine, University of Illinois College of Medicine, Chicago, IL, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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Messina A, Longhitano Y, Zanza C, Calabrò L, Villa F, Cammarota G, Sanfilippo F, Cecconi M, Robba C. Cardiac dysfunction in patients affected by subarachnoid haemorrhage affects in-hospital mortality: A systematic review and metanalysis. Eur J Anaesthesiol 2023; 40:442-449. [PMID: 37052065 DOI: 10.1097/eja.0000000000001829] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
BACKGROUND Subarachnoid haemorrhage (SAH) is a life-threatening condition with associated brain damage. Moreover, SAH is associated with a massive release of catecholamines, which may promote cardiac injury and dysfunction, possibly leading to haemodynamic instability, which in turn may influence a patient's outcome. OBJECTIVES To study the prevalence of cardiac dysfunction (as assessed by echocardiography) in patients with SAH and its effect on clinical outcomes. DESIGN Systematic review of observational studies. DATA SOURCES We performed a systematic search over the last 20 years on MEDLINE and EMBASE databases. ELIGIBILITY CRITERIA Studies reporting echocardiography findings in adult patients with SAH admitted to intensive care. Primary outcomes were in-hospital mortality and poor neurological outcome according to the presence or absence of cardiac dysfunction. RESULTS We included a total of 23 studies (4 retrospective) enrolling 3511 patients. The cumulative frequency of cardiac dysfunction was 21% (725 patients), reported as regional wall motion abnormality in the vast majority of studies (63%). Due to the heterogeneity of clinical outcome data reporting, a quantitative analysis was carried out only for in-hospital mortality. Cardiac dysfunction was associated with a higher in-hospital mortality [odds ratio 2.69 (1.64 to 4.41); P < 0.001; I2 = 63%]. The GRADE of evidence assessment resulted in very low certainty of evidence. CONCLUSION About one in five patients with SAH develops cardiac dysfunction, which seems to be associated with higher in-hospital mortality. The consistency of cardiac and neurological data reporting is lacking, reducing the comparability of the studies in this field.
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Affiliation(s)
- Antonio Messina
- From the IRCCS Humanitas Research Hospital, Rozzano (AM, LC, FV, MC), Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy (AM, MC), Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA (YL, CZ), IRCCS Ospedale Policlinico San Martino (CR), Dipartimento di Medicina E Chirurgia, Universita' Degli Studi di Perugia, Perugia (GC) and Department of Anaesthesia and Intensive Care, A.O.U. 'Policlinico-San Marco', Catania, Italy (FS)
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Baker C, Muse J, Taussky P. Takotsubo Syndrome in Neurologic Disease. World Neurosurg 2021; 149:26-31. [PMID: 33556594 DOI: 10.1016/j.wneu.2021.01.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/09/2023]
Abstract
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.
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Affiliation(s)
- Cordell Baker
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - John Muse
- Department of Neurosurgery, University of Vermont, Burlington, Vermont, USA
| | - Philipp Taussky
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.
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Zhang L, Zhang B, Qi S. Impact of echocardiographic wall motion abnormality and cardiac biomarker elevation on outcome after subarachnoid hemorrhage: a meta-analysis. Neurosurg Rev 2018; 43:59-68. [PMID: 29804158 DOI: 10.1007/s10143-018-0985-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/30/2018] [Accepted: 05/15/2018] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Limin Zhang
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China
| | - Bing Zhang
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China.
| | - Sihua Qi
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Yiyuan Street 37, Harbin, 150001, China.
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Long-Term Outcomes for Different Forms of Stress Cardiomyopathy After Surgical Treatment for Subarachnoid Hemorrhage. Anesth Analg 2016; 122:1594-602. [PMID: 27007075 DOI: 10.1213/ane.0000000000001231] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Stress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH. METHODS We studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission. RESULTS Among 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8-20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6-17.2). CONCLUSIONS SAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.
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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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Murthy SB, Shah S, Rao CPV, Bershad EM, Suarez JI. Neurogenic Stunned Myocardium Following Acute Subarachnoid Hemorrhage. J Intensive Care Med 2013; 30:318-25. [DOI: 10.1177/0885066613511054] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 09/03/2013] [Indexed: 01/01/2023]
Abstract
Neurogenic stunned myocardium (NSM) is a triad of transient left ventricular dysfunction, electrocardiogram changes, and elevation in cardiac enzymes, often mimicking a myocardial infarction. It has been described following acute brain injury. The purported mechanism is catecholamine excess resulting in cardiac dysfunction. From the clinical standpoint, the most frequently encountered electrocardiographic changes are QTc prolongation and ST-T changes, with modest elevations in troponin levels. Basal and mid-ventricular segments of the left ventricle are most commonly involved. NSM poses therapeutic challenges when it occurs secondary to aneurysmal subarachnoid hemorrhage, particularly in the setting of coexisting vasospasm. Overall, NSM carries good prognosis if recognized early, with appropriate management of hemodynamic and cardiopulmonary parameters.
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Affiliation(s)
- Santosh B. Murthy
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
| | - Shreyansh Shah
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
| | | | - Eric M. Bershad
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
| | - Jose I. Suarez
- Department of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA
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Cardiovascular Protection to Improve Clinical Outcomes After Subarachnoid Hemorrhage: Is There a Proven role? Neurocrit Care 2012; 18:271-84. [DOI: 10.1007/s12028-012-9804-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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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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