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Zhang X, Lei Y, Nan L, Dong S, Liu Y, Yu J, Xu K, Hou K, Ma H. QTc prolongation after aneurysmal subarachnoid hemorrhage might be associated with worse neurologic outcome in patients receiving microsurgical clipping or embolization of the intracranial aneurysms: a retrospective observational study. BMC Neurol 2024; 24:170. [PMID: 38783204 PMCID: PMC11112891 DOI: 10.1186/s12883-024-03679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 05/17/2024] [Indexed: 05/25/2024] Open
Abstract
PURPOSE QT interval prolongation is one of the most common electrocardiographic (ECG) abnormalities in patients with aneurysmal subarachnoid hemorrhage (aSAH). Whether corrected QT interval (QTc) prolongation is associated with perioperative cardiac events and dismal neurological outcome in mid to long-term follow-up in patients after aSAH is insufficiently studied and remains controversial. METHODS We retrospectively studied the adult (≥ 18 years) patients admitted to our institution between Jan 2018 and Dec 2020 for aSAH who underwent intracranial aneurysm clipping or embolization. The patients were divided into 2 groups (normal and QTc prolongation groups) according to their QTc. To minimize the confounding bias, a propensity score matching (PSM) analysis was performed to compare the neurologic outcomes between patients with normal QTc and QTc prolongation. RESULTS After screening, 908 patients were finally included. The patients were divided into 2 groups: normal QTc groups (n = 714) and long QTc group (n = 194). Female sex, hypokalemia, posterior circulation aneurysm, and higher Hunt-Hess grade were associated with QTc prolongation. In multiple regression analysis, older age, higher hemoglobin level, posterior circulation aneurysm, and higher Hunt-Hess grade were identified to be associated with worse outcome during 1-year follow-up. Before PSM, patients with QTc prolongation had higher rate of perioperative cardiac arrest or ventricular arrhythmias. After PSM, there was no statistical difference between normal and QTc prolongation groups in perioperative cardiac events. However, patients in the QTc prolongation group still had worse neurologic outcome during 1-year follow-up. CONCLUSIONS QTc prolongation is associated with worse outcome in patients following SAH, which is independent of perioperative cardiac events.
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Affiliation(s)
- Xinmin Zhang
- Department of Anesthesiology, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Yang Lei
- Department of Anesthesiology, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Ling Nan
- Department of Anesthesiology, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Su Dong
- Department of Anesthesiology, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Yadong Liu
- Department of Anesthesiology, Liaoyuan Hospital of Traditional Chinese Medicine, Liaoyuan, China
| | - Jinlu Yu
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Kan Xu
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China
| | - Kun Hou
- Department of Neurosurgery, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China.
| | - Haichun Ma
- Department of Anesthesiology, First Hospital of Jilin University, 1 Xinmin Avenue, Changchun, 130021, China.
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Yücetas SC, Kaya H, Kafadar S, Kafadar H, Tibilli H, Akcay A. Evaluation of index of cardiac-electrophysiological balance in patients with subarachnoid hemorrhage. BMC Cardiovasc Disord 2022; 22:477. [PMID: 36357852 PMCID: PMC9650786 DOI: 10.1186/s12872-022-02924-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 09/30/2022] [Indexed: 11/12/2022] Open
Abstract
Background Various electrocardiographic (ECG) changes occur after subarachnoid hemorrhage (SAH). Prolonged QT and corrected QT (QTc) intervals are notable changes. QT, QTc, T peak-to-end T(p-e) intervals, and Tp-e/QTc ratio are used as ventricular arrhythmia indices. In recent publications, the cardiac electrophysiological balance index (ICEB), which provides more information than other ECG parameters (QT, QTc, etc.), is recommended in predicting the risk of ventricular arrhythmia. This study aims to assess ICEB in aneurysmal SAH patients. Methods The study included 50 patients diagnosed with aneurysmal SAH and 50 patients diagnosed with hypertension without end-organ damage as the control group. All patients’ Fisher scores and Glasgow Coma Scale (GCS) scores were recorded. Both groups were given 12-lead ECGs. QT, QTc, Tp-e intervals, QRS duration, ICEB (QT/QRS), ICEBc (QTc/QRS), and T(p-e)/QTc values were calculated and analyzed between groups. Results Compared to the control group; QT (426,64 ± 14,62 vs. 348,84 ± 12,24 ms, p < 0,001), QTc (456,24 ± 28,84 vs. 392,48 ± 14,36 ms, p < 0,001), Tp-e (84,32 ± 3,46 vs. 70,12 ± 3,12, p < 0,001), Tp-e/QTc (0,185 ± 0,08 vs. 0,178 ± 0,02, p < 0,001), ICEB (4,53 ± 0,78 vs. 3,74 ± 0,28, p < 0,001) and ICEBc (4,86 ± 0,86 vs. 4,21 ± 0,24, p < 0,001) were significantly higher in patients with aneurysmal SAH. QT, QTc and Tp-e interval, Tp-e/QTc ratio, ICEB (QT/QRS) and ICEBc (QTc/QRS) were positively correlated with the Fisher score and were negatively correlated with the GCS. According to linear regression analyses, the ICEBc (QTc/QRS) found to be independently associated with the Fisher score. Conclusion The values of the ICEB and ICEBc were significantly increased in patients with aneurysmal SAH. The severity of SAH was positively correlated with the ICEB and ICEBc. The ICEBc (QTc/QRS) independently associated with the Fisher score. This may that SAH suggest may predispose to malignant ventricular arrhythmias.
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Deenen S, Ramnarain D, Pouwels S. Subarachnoidal hemorrhage related cardiomyopathy: an overview of Tako-Tsubo cardiomyopathy and related cardiac syndromes. Expert Rev Cardiovasc Ther 2022; 20:733-745. [PMID: 36124824 DOI: 10.1080/14779072.2022.2125871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
INTRODUCTION Subarachnoid hemorrhage (SAH) is caused by a ruptured intracranial aneurysm leading to acute extravasation of blood into the subarachnoid space. SAH has an incidence of 6.3 per 100,000 persons per year in Europe and accounts for 5% of all strokes. SAH occurs at a relatively young age and has poor clinical outcomes and high mortality rates. Cardiac syndromes are regularly seen in patients with acute neurologic disease including SAH. These cardiac complications of SAH are associated with increased morbidity and mortality and present in a large variety and severity. AREAS COVERED The main goal of this review is to describe the SAH-related cardiac syndromes. Secondly, we will provide an overview of the underlying pathophysiology regarding the development of cardiac syndromes. Thirdly, we will describe the impact of cardiac syndromes on patient outcome. EXPERT OPINION Of all neurology patients, SAH patients have the highest risk of developing takotsubo syndrome (TTS), occurring in about 0.8-30% of patients. Both TTS and neurogenic stunned myocardium have many similarities on echocardiographic evaluation. In European Cardiology consensus, SAH is recognized as a primary cause of TTS.
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Affiliation(s)
- Susan Deenen
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - Dharmanand Ramnarain
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of Intensive Care Medicine, Saxenburgh Medical Center, Hardenberg, The Netherlands
| | - Sjaak Pouwels
- Department of Intensive Care Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.,Department of General, Abdominal and Minimally Invasive Surgery, Helios Klinikum, Krefeld, Germany
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Geraghty JR, Cheng T, Hirsch Y, Saini NS, Nazir NT, Testai FD. Elevated Serum Leukocytes are Predictive of Cardiac Injury Following Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106423. [PMID: 35255288 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 01/24/2022] [Accepted: 02/17/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Aneurysmal subarachnoid hemorrhage (aSAH) accounts for 5% of strokes but results in significant morbidity and mortality. In addition to systemic inflammation, up to half of patients develop cardiac injury; however, the relationship between systemic inflammation and cardiac injury after aSAH is unknown. We investigated changes in leukocyte counts in relation to cardiac dysfunction MATERIALS AND METHODS: We reviewed the records of consecutive patients with SAH at our large academic medical referral center. The inclusion criteria were aSAH and available cardiac troponin I (cTnI) levels within 48 h of admission. The primary outcome was cardiac injury, defined as cTnI ≥0.04 ng/mL (lab reference range 0.01-0.03 ng/mL). We compared baseline characteristics, including serum leukocyte counts and performed univariable and multivariable logistic regression analysis to determine whether changes in leukocyte subpopulations predict cardiac injury. RESULTS Of 288 SAH patients, 250 met inclusion criteria. Of these, 116 (46.4%) had elevated cTnI. In univariable analysis, total leukocyte count (p < 0.001), absolute neutrophil count (ANC, p < 0.001), and absolute monocyte count (p = 0.013), were associated with elevated cTnI. in multivariable analysis, total leukocyte count (OR=1.079, p = 0.037) and ANC (OR=1.081, p = 0.044) remained predictors of elevated cTnI. Adjusted ANC distinguishes between aSAH patients with normal and elevated TnI (area under the curve=0.766, p < 0.001) with specificity of 89.2%. CONCLUSIONS Elevated total leukocytes and ANC are independently associated with cardiac injury in aSAH. Systemic inflammatory responses after aSAH may play a role in cardiac dysfunction, warranting additional studies to further characterize how cardiac inflammation after aSAH drives subsequent morbidity and mortality.
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Affiliation(s)
- Joseph R Geraghty
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, 912 S. Wood St. Suite 174N, Chicago, IL 60612, United States.
| | - Tiffany Cheng
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, 912 S. Wood St. Suite 174N, Chicago, IL 60612, United States; Department of Psychiatry, Washington University School of Medicine in St. Louis, St. Louis, MO, United States
| | - Yonatan Hirsch
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, 912 S. Wood St. Suite 174N, Chicago, IL 60612, United States
| | - Neil S Saini
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, 912 S. Wood St. Suite 174N, Chicago, IL 60612, United States
| | - Noreen T Nazir
- Division of Cardiology, Department of Medicine, University of Illinois at Chicago College of Medicine, Chicago, IL, United States
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago College of Medicine, 912 S. Wood St. Suite 174N, Chicago, IL 60612, United States
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Carotid and Intracranial Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00021-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Comparison of Two Algorithms Analysing the Intracranial Pressure Curve in Terms of the Accuracy of Their Start-Point Detection and Resistance to Artefacts. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839852 DOI: 10.1007/978-3-030-59436-7_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
OBJECTIVES For further insight into the possibly predictive quality of the intracranial pressure (ICP) waveform morphology a definite and reliable identification of its components is a prerequisite but presents the problem of artefacts in physiological signals. METHODS ICP and electrocardiogram (ECG) data were recorded to depict not only their numerical value but also their respective waveforms and were analysed by two algorithms, which were then compared for their artefact resistance.The algorithms in question identify the start point of every ICP wave, one (AR[SA]) by scale analysis, the other (AR[ECG]) by analysing the ICP wave linked to the ECG. RESULTS Start-point identification accuracy in rhythmic patients showed sensitivity of 95.14% for AR[SA] and 99.99% for AR[ECG], with a positive predictive value (ppv) of 98.30% for AR[SA] and 99.76% for AR[ECG].In arrhythmic patients sensitivity was 98.05% for AR[SA] and 99.73% for AR[ECG], with a ppv of 100% for AR[SA] and 99.78% for AR[ECG]. CONCLUSIONS AR[ECG] has proven to be more resistant to artefacts than AR[SA], even in cases such as cardiac arrhythmia. It facilitates reliable, three-dimensional visualisation of long-term changes in ICP-wave morphology and is thus suited for analysis in cases of more complex or irregular vital parameters.
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Gherasim L. Takotsubo Syndrome versus Neurogenic Stunned Myocardium. MAEDICA 2020; 15:288-296. [PMID: 33312241 PMCID: PMC7726496 DOI: 10.26574/maedica.2020.15.3.288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
- Leonida Gherasim
- Professor, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania Cardiology, University Hospital of Bucharest, Romania
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Thoracic sympathetic nuclei ischemia: Effects on lower heart rates following experimentally induced spinal subarachnoid hemorrhage. Neurochirurgie 2020; 66:155-161. [PMID: 32387429 DOI: 10.1016/j.neuchi.2019.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 12/09/2019] [Accepted: 12/26/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND The neuropathological mechanism of heart rhythm disorders, following spinal cord pathologies, to our knowledge, has not yet been adequately investigated. In this study, the effect of the ischemic neurodegeneration of the thoracic sympathetic nuclei (TSN) on the heart rate (HR) was examined following a spinal subarachnoid hemorrhage (SSAH). METHODS This study was conducted on 22 rabbits. Five rabbits were used as a control group, five as SHAM, and twelve as a study group. The animals' HRs were recorded via monitoring devices on the first day, and those results were accepted as baseline values. The HRs were remeasured after injecting 0.5 cc of isotonic saline for SHAM and 0.5 cc of autolog arterial blood into the thoracic spinal subarachnoid space at T4-T5 for the study group. After a three-week follow-up with continuous monitoring of their HRs, the rabbit's thoracic spinal cords and stellate ganglia were extracted. The specimens were evaluated by histopathological methods. The densities of degenerated neurons in the TSN and stellate ganglia were compared with the HRs. RESULTS The mean HRs and mean degenerated neuron density of the TSN and stellate ganglia in control group were 251±18/min, 5±2/mm3, and 3±1/mm3, respectively. The mean HRs and the mean degenerated neuron density of the TSN and stellate ganglia were detected as 242±13/min, 6±2/mm3, and 4±2/mm3 in SHAM (P>0.05 vs. control); 176±19/min, 94±12/mm3, and 28±6/mm3 in the study group (P<0.0001 vs. control and P<0.005 vs. SHAM), respectively. CONCLUSIONS SAH induced TSN neurodegeneration may have been responsible for low HRs following SSAH. To date this has not been mentioned in the literature.
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Assessment of the ECG T-Wave in Patients With Subarachnoid Hemorrhage. J Neurosurg Anesthesiol 2019; 33:58-64. [PMID: 31290770 DOI: 10.1097/ana.0000000000000624] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Vanga SR, Korlakunta H, Duthuluru S, Bommana S, Narotam P, Ryschon K, Mohiuddin SM, Porter C, Dawn B, Lakkireddy D. Partial Brain Tissue Oxygen Levels Predict Arrhythmia and Prognosis in Patients With Brain Injury. Am J Ther 2017; 23:e1781-e1787. [PMID: 27219536 DOI: 10.1097/mjt.0b013e31822831b3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The objective of this study was to examine the clinical determinants of incidence and prognosis of arrhythmias in the setting of acute brain injury. Acute brain injury is known to cause electrocardiographic abnormalities and cardiac arrhythmias. The relation between partial brain tissue oxygen (PBTO) and intracranial pressure (ICP) with arrhythmia incidence and prognosis remains unknown. Consecutive patients with acute brain injury and intracranial bleed admitted to the neurosurgical intensive care unit were enrolled in the study. Baseline characteristics [demographics, medical history, etiology of brain injury, Glasgow Coma Scale (GCS) score, blood pressure, and respiratory rate] were documented. Patient's telemetry recordings were reviewed for daily mean heart rates and arrhythmias. If arrhythmia was noted, PBTO levels at the beginning of arrhythmia, ICP, brain tissue temperature, and outcomes were recorded. A total of 106 subjects (53% men, age 39 ± 18 years, 65 traumatic and 41 nontraumatic brain injuries) were studied. Overall, 62% of subjects developed a total of 241 arrhythmia episodes. Ventricular arrhythmias were associated with significantly higher daily mean heart rates, low PBTO levels, and low GCS scores, whereas atrial arrhythmias were associated with lower daily mean heart rates, normal PBTO levels, and higher GCS and ICP. Three or more episodes of arrhythmia predicted worse outcomes, including mortality (P = 0.001). In patients with acute brain injury, poor PBTO levels are associated with higher incidence of ventricular tachyarrhythmias. In contrast, atrial tachyarrhythmias occur in patients with normal PBTO levels and higher ICP. Incidence of ventricular arrhythmia in those with poor PBTO is associated with increased mortality.
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Affiliation(s)
- Subba Reddy Vanga
- 1Division of Cardiovascular Diseases and the Cardiovascular Research Institute, University of Kansas Medical Center and Hospital, Kansas City, KS; 2Cardiovascular Consultants PC, Texas Health, Denton, TX; 3Department of Pulmonary and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS; 4Union Hospital Neuroscience, Terre Haute, IN; and 5Creighton University Medical Center, Omaha, NE
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Zhang L, Qi S. Electrocardiographic Abnormalities Predict Adverse Clinical Outcomes in Patients with Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2016; 25:2653-2659. [PMID: 27476337 DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Revised: 06/13/2016] [Accepted: 07/02/2016] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND We conducted a retrospective cohort study of a large sample to assess whether electrocardiographic (ECG) abnormalities are independently associated with the occurrence of neurogenic pulmonary edema (NPE), delayed cerebral ischemia (DCI), and in-hospital death after nontraumatic subarachnoid hemorrhage (SAH). METHODS In this retrospective observational study, patients who were admitted within 72 hours of SAH symptom onset between 2013 and 2015 were enrolled. Twelve-lead ECG findings obtained within 72 hours after SAH and the presence of NPE, DCI, and in-hospital death were collected based on the results reported in the medical records. RESULTS We included 834 patients. NPE occurred in 192 patients (23%). The median delay from SAH onset to NPE was 3 days (interquartile range [IQR]: 5 days). DCI occurred in 223 patients (27%; median delay to DCI, 4 days; IQR: 5 days). In total, 141 patients (17%) died in the hospital (median time to death, 12 days; IQR: 18 days). The frequency of ECG abnormalities for all enrolled patients was 65%. Corrected QT prolongation had an adjusted risk ratio (RR) of 1.5 (1.1-2.2) for NPE and 1.8 (1.3-2.4) for DCI. ST depression had an adjusted RR of 3.0 (1.2-7.5) for in-hospital death. NSSTTCs (nonspecific ST- or T-wave changes) had an adjusted RR of 2.7 (1.8-4.2) for NPE, 2.8 (1.9-4.3) for DCI, and 2.2 (1.3-3.5) for in-hospital death. All RRs were adjusted for age and Hunt-Hess scores. CONCLUSIONS ECG abnormalities assessed within 72 hours after SAH using a standard 12-lead ECG are independently associated with an increased risk of adverse clinical outcomes in patients with nontraumatic SAH.
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Affiliation(s)
- Limin Zhang
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, China
| | - Sihua Qi
- Department of Anaesthesiology, The Fourth Affiliated Hospital, Harbin Medical University, Harbin, China.
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Arab D, Yahia AM, Qureshi AI. Cardiovascular Manifestations of Acute Intracranial Lesions: Pathophysiology, Manifestations, and Treatment. J Intensive Care Med 2016; 18:119-29. [PMID: 14984630 DOI: 10.1177/0885066603251202] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this article was to review the effects of acute intracranial lesions on myocardial function. The authors reviewed scientific and clinical literature retrieved from a computerized MEDLINE search from January 1965 through January 2002. Pertinent literature was referenced, including clinical and laboratory investigations, to demonstrate the effects of acute intracranial lesions on the cardiovascular system. The literature was reviewed to summarize the mechanisms of cardiac damage and clinical manifestations and treatment of cardiovascular dysfunction caused by acute intracranial lesions. Myocardial damage and rhythm disturbances were shown to occur with acute intracranial neurological disease. The subgroup of patients used in this study formed a substantial pool of cardiac donors for cardiac transplantation. The pathophysiology of myocardial dysfunction and the optimal management continues to be a source of debate. In this article, the authors will review the anatomy, the available evidence of the pathophysiology, and the management of this complex group of patients. They will also discuss areas that need to be further investigated. Cardiovascular effects of acute intracranial lesions are common and contribute to increased morbidity and mortality.
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Affiliation(s)
- Dinesh Arab
- Department of Medicine, Division of Cardiology, Toshiba Stroke Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo 14209-1194, USA
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Chen I, Mitchell P. Serum potassium and sodium levels after subarachnoid haemorrhage. Br J Neurosurg 2016; 30:554-9. [DOI: 10.1080/02688697.2016.1181151] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Takeuchi S, Nagatani K, Otani N, Wada K, Mori K. Electrocardiograph abnormalities in intracerebral hemorrhage. J Clin Neurosci 2015; 22:1959-62. [DOI: 10.1016/j.jocn.2015.04.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Revised: 04/14/2015] [Accepted: 04/18/2015] [Indexed: 10/23/2022]
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Pinnamaneni S, Dutta T, Melcer J, Aronow WS. Neurogenic stress cardiomyopathy associated with subarachnoid hemorrhage. Future Cardiol 2015; 11:77-87. [PMID: 25606704 DOI: 10.2217/fca.14.73] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Cardiac manifestations are recognized complications of subarachnoid hemorrhage. Neurogenic stress cardiomyopathy is one complication that is seen in acute subarachnoid hemorrhage. It can present as transient diffuse left ventricular dysfunction or as transient regional wall motion abnormalities. It occurs more frequently with neurologically severe-grade subarachnoid hemorrhage and is associated with increased morbidity and poor clinical outcomes. Managing this subset of patients is challenging. Early identification followed by a multidisciplinary team approach can potentially improve outcomes.
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Relationship of Troponin T and Age- and Sex-Adjusted BNP Elevation Following Subarachnoid Hemorrhage with 30-Day Mortality. Neurocrit Care 2015; 23:59-65. [DOI: 10.1007/s12028-014-0105-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Park JH, Kim YR, Kim SH, Nam GB. Admission B-type natriuretic peptide levels are associated with in-hospital cardiac events in patients with intracranial hemorrhage. Acta Neurochir (Wien) 2015; 157:21-7. [PMID: 25338533 DOI: 10.1007/s00701-014-2260-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 10/09/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is often associated with cardiac events. Twelve-lead electrocardiography (ECG) and transthoracic echocardiography are essential diagnostic tools for preoperative risk assessment. B-type natriuretic peptide (BNP) is a well-known predictor of cardiac outcome in various clinical settings. This study examined whether BNP levels on admission are associated with in-hospital cardiac events among ICH patients. METHOD This prospective study enrolled 77 ICH patients who were admitted to this hospital for emergency neurosurgery. On admission, BNP levels, 12-lead ECG and transthoracic echocardiography were carried out for all patients. These patients were divided into two groups: Group I included 19 patients (10 men and 9 women) having 24 in-hospital cardiac events (mean age of 57 ± 15 years); Group II included 57 patients (29 men, mean age of 71 ± 11 years) without cardiac events. RESULTS Admission BNP levels of Group I patients were significantly higher than those of Group II patients (683.8 ± 1,043.8 pg/ml vs 168.5 ± 173.5 pg/ml, p = 0.001). In multivariate analysis, BNP levels and T-wave inversion are independent predictors of in-hospital cardiac events. A cutoff value of BNP levels (156.6 pg/ml) predicted in-hospital cardiac events in ICH patients with 80 % sensitivity and 66 % specificity. CONCLUSIONS Serum BNP levels and electrocardiographic T-wave inversion on admission are independent predictors of in-hospital cardiac events in patients with ICH who undergo emergency neurosurgery.
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Affiliation(s)
- Jae Hong Park
- Department of Cardiology, Incheon-Naun Hospital, Incheon, Korea
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21
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Silberstein SD, Lipton RB, Dodick DW. Operational Diagnostic Criteria for Chronic Migraine: Expert Opinion. Headache 2014; 54:1258-66. [DOI: 10.1111/head.12407] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2014] [Indexed: 02/06/2023]
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22
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Ybanez N, Agrawal V, Tranmer BI, Gennari FJ. Severe Hypokalemia in a Patient With Subarachnoid Hemorrhage. Am J Kidney Dis 2014; 63:530-5. [DOI: 10.1053/j.ajkd.2013.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2013] [Accepted: 07/02/2013] [Indexed: 11/11/2022]
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23
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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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Dombrowski K, Laskowitz D. Cardiovascular manifestations of neurologic disease. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:3-17. [PMID: 24365284 DOI: 10.1016/b978-0-7020-4086-3.00001-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Cardiac manifestations of neurologic diseases are common in clinical practice. There are numerous anatomic and pathophysiologic links between the normal and abnormal function of both systems. There are a number of brain-heart interactions which affect the care of patients as well as help guide therapeutic development. This is exemplified in the area of vascular neurology where knowledge of the brain-heart connection is essential not only for bedside management but where collaborative efforts between neurology and cardiology are key in developing new strategies for ischemic stroke prevention and treatment, atrial fibrillation, and interventional techniques. This chapter will focus on cardiac manifestations of neurologic disease, with special emphasis on vascular and intensive care neurology, epilepsy, and neurodegenerative and peripheral nervous system diseases.
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Affiliation(s)
- Keith Dombrowski
- Department of Medicine (Neurology), Duke University Medical Center, Durham, NC, USA.
| | - Daniel Laskowitz
- Department of Medicine (Neurology), Duke University Medical Center, Durham, NC, USA; Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Gemmete JJ, Elias AE, Chaudhary N, Pandey AS. Endovascular methods for the treatment of intracranial cerebral aneurysms. Neuroimaging Clin N Am 2013; 23:563-91. [PMID: 24156851 DOI: 10.1016/j.nic.2013.03.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This article briefly discusses the clinical features, natural history, and epidemiology of intracranial cerebral aneurysms, along with current diagnostic imaging techniques for their detection. The main focus is on the basic techniques used in endovascular coiling of ruptured and nonruptured saccular intracranial cerebral aneurysms. After a discussion of each technique, a short review of the results of each form of treatment is given, concentrating on reported large case series. Specific complications related to the endovascular treatment of saccular intracranial aneurysms are then discussed.
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Affiliation(s)
- Joseph J Gemmete
- Division of Interventional Neuroradiology and Cranial Base Surgery, Departments of Radiology, Neurosurgery, and Otolaryngology, University of Michigan Health System, UH B1D 328, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5030, USA.
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Zaroff JG, Leong J, Kim H, Young WL, Cullen SP, Rao VA, Sorel M, Quesenberry CP, Sidney S. Cardiovascular predictors of long-term outcomes after non-traumatic subarachnoid hemorrhage. Neurocrit Care 2013; 17:374-81. [PMID: 21769457 DOI: 10.1007/s12028-011-9592-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac injury is common after subarachnoid hemorrhage (SAH) and is associated with adverse early outcomes, but long-term effects are unknown. The first aim of this study was to compare the long-term rates of death, stroke, and cardiac events in SAH survivors versus a matched population without SAH. The second aim was to quantify the effects of cardiac injury on the outcome rates. METHODS This was a retrospective cohort study of patients with and without non-traumatic SAH. For aim #1, the predictor variable was SAH and the outcome variables were all-cause and cerebrovascular mortality, stroke, cardiac mortality, acute coronary syndrome (ACS), and heart failure (HF) admission. A multivariable Cox proportional hazards analysis was performed. For aim #2, the predictor variables were cardiac injury (elevated serum cardiac enzymes or a diagnosis code for ACS) and dysfunction (pulmonary edema on X-Ray or a diagnosis code for HF). RESULTS Compared with 4,695 members without SAH, the 910 SAH patients had higher rates of all-cause mortality (hazard ratio [HR 2.6], 95% confidence intervals [CI] 2.0-3.4), cerebrovascular mortality (HR 30.6, CI 13.5-69.4), and stroke (HR 10.2, CI 7.5-13.8). Compared with the non-SAH group, the SAH patients with cardiac injury had increased rates of all-cause mortality (HR 5.3, CI 3.0-9.3), cardiac mortality (HR 7.3, CI 1.7-31.6), and heart failure (HR 4.3, CI 1.53-11.88). CONCLUSIONS SAH survivors have increased long-term mortality and stroke rates compared with a matched non-SAH population. SAH-induced cardiac injury is associated with an increased risk of death and heart failure hospitalization.
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Affiliation(s)
- Jonathan G Zaroff
- Kaiser Northern California Division of Research, San Francisco, CA, 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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Wira CR, Rivers E, Martinez-Capolino C, Silver B, Iyer G, Sherwin R, Lewandowski C. Cardiac complications in acute ischemic stroke. West J Emerg Med 2012; 12:414-20. [PMID: 22224130 PMCID: PMC3236132 DOI: 10.5811/westjem.2011.2.1765] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 08/02/2010] [Accepted: 02/04/2011] [Indexed: 01/27/2023] Open
Abstract
Introduction To characterize cardiac complications in acute ischemic stroke (AIS) patients admitted from an urban emergency department (ED). Methods Retrospective cross-sectional study evaluating AIS patients admitted from the ED within 24 hours of symptom onset who also had an echocardiogram performed within 72 hours of admission. Results Two hundred AIS patients were identified with an overall in-hospital mortality rate of 8% (n = 16). In our cohort, 57 (28.5%) of 200 had an ejection fraction less than 50%, 35 (20.4%) of 171 had ischemic changes on electrocardiogram (ECG), 18 (10.5%) of 171 presented in active atrial fibrillation, 21 (13.0%) of 161 had serum troponin elevation, and 2 (1.1%) of 184 survivors had potentially lethal arrhythmias on telemetry monitoring. Subgroup analysis revealed higher in-hospital mortality rates among those with systolic dysfunction (15.8% versus 4.9%; P = 0.0180), troponin elevation (38.1% versus 3.4%; P < 0.0001), atrial fibrillation on ECG (33.3% versus 3.8%; P = 0.0003), and ischemic changes on ECG (17.1% versus 6.1%; P = 0.0398) compared with those without. Conclusion A proportion of AIS patients may have cardiac complications. Systolic dysfunction, troponin elevation, atrial fibrillation, or ischemic changes on ECG may be associated with higher in-hospital mortality rates. These findings support the adjunctive role of cardiac-monitoring strategies in the acute presentation of AIS.
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Affiliation(s)
- Charles R Wira
- Yale School of Medicine, Department of Emergency Medicine and Acute Stroke Service, New Haven, Connecticut
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Jeong YS, Kim HD. Clinically significant cardiac arrhythmia in patients with aneurysmal subarachnoid hemorrhage. J Cerebrovasc Endovasc Neurosurg 2012; 14:90-4. [PMID: 23210034 PMCID: PMC3471254 DOI: 10.7461/jcen.2012.14.2.90] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 03/28/2012] [Accepted: 04/18/2012] [Indexed: 11/30/2022] Open
Abstract
Objective Many previous studies have shown that electrocardiographic (ECG) changes occur patients with subarachnoid hemorrhage (SAH). This study was designed to identify the frequency, influencing factors, and outcome of clinically significant cardiac arrhythmias after SAH. Methods We retrospectively analyzed clinical data of 122 patients including ECG finding, age, sex, the Hunt-Hess grade, the Fisher's grade, the history of hypertension, peak blood pressure and heart rate, location of aneurysm, Glasgow Outcome Scale (GOS) score, the days of admission to the intensive care unit, the presence of symptomatic vasospasm. Results Of 122 SAH patients, 50% (n = 61) had a verified clinically significant arrhythmia. There were no statistically significant independent factors associated with clinically significant arrhythmia in multivariate analysis. Although adjustments for the effects of age, Hunt-Hess grade, and the presence of symptomatic vasospasm on death were made, clinically significant arrhythmias were still independently predictive of death (no arrhythmia versus arrhythmia, 11.5% versus 27.9%, adjusted odds ratio [OR] 3.524, 95% confidence interval [CI] 1.229-10.100, p = 0.019) and poor outcome (GOS ≤ 2, 13.1% versus 29.5%, adjusted OR 3.202, 95% CI 1.174-8.732, p= 0.023). Conclusion Clinically significant arrhythmias after SAH are associated with a high mortality rate, and serious cardiac and neurological comorbidity. Patients with an abnormal ECG on admission should undergo close cardiac monitoring, and the presence of rhythm disturbances should prompt aggressive measures to treat myocardial infarction (MI), maintain a normal cardiac rhythm, and minimize the presence of autonomic stress.
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Affiliation(s)
- Yeon-Seong Jeong
- Department of Neurosurgery, College of Medicine, Dong-A University, Busan, Korea
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30
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The 12-lead electrocardiogram in patients with subarachnoid hemorrhage: early risk prognostication. Am J Emerg Med 2012; 30:732-6. [DOI: 10.1016/j.ajem.2011.05.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Revised: 05/05/2011] [Accepted: 05/07/2011] [Indexed: 01/04/2023] Open
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Abstract
The emergence of dedicated neurologic-neurosurgical intensive care units, advancements in endovascular therapies, and aggressive brain resuscitation and monitoring have contributed to overall improved outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) over the past 20 to 30 years. Still, this feared neurologic emergency is associated with substantial mortality and morbidity. Emergency care for patients with aSAH focuses on stabilization, treatment of the aneurysm, controlling intracranial hypertension to optimize cerebral perfusion, and limiting secondary brain injury. This complex disorder can be associated with many neurologic complications such as acute hydrocephalus, rebleeding, global cerebral edema, seizures, vasospasm, and delayed cerebral ischemia in addition to systemic complications such as electrolyte imbalances, cardiopulmonary injury, and infections. Background routine intensive care practices such as avoidance of hyperthermia, venous thromboembolism prophylaxis, and avoidance of severe blood glucose derangements are additional important elements of care.
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Abstract
Successful critical care management of patients with aneurysmal subarachnoid hemorrhage (SAH) requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal SAH and strategies for disease management in the acute setting, including available tools for monitoring brain function. Intensive care management of patients with SAH focuses on prevention of further neurologic injury. Aneurysmal rebleeding, hydrocephalus, seizures, and delayed ischemic injury represent major threats. There is increasing awareness of extracerebral complications, including electrolyte disturbances (eg, cerebral salt wasting) and cardiac dysfunction. Prompt recognition and treatment of these disorders maximizes the odds of a good functional outcome. Technologic advances hold the promise of improved detection and treatment of secondary neurologic insults.
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Affiliation(s)
- Joshua M Levine
- Joshua M. Levine, MD Neurocritical Care Program, Hospital of the University of Pennsylvania, 3 West Gates Building, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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Temes RE, Tessitore E, Schmidt JM, Naidech AM, Fernandez A, Ostapkovich ND, Frontera JA, Wartenberg KE, Di Tullio MR, Badjatia N, Connolly ES, Mayer SA, Parra A. Left ventricular dysfunction and cerebral infarction from vasospasm after subarachnoid hemorrhage. Neurocrit Care 2011; 13:359-65. [PMID: 20945116 DOI: 10.1007/s12028-010-9447-x] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Although neurogenic stunned myocardium (NSM) after aneurysmal subarachnoid hemorrhage (SAH) is well described, its clinical significance remains poorly defined. We investigated the influence of left ventricular (LV) dysfunction and cerebral vasospasm on cerebral infarction, serious cardiovascular events, and functional outcome after SAH. METHODS Of the 481 patients enrolled in the University Columbia SAH Outcomes Project between 10/96 and 05/02, we analyzed a subset of 119 patients with at least one echocardiogram, serial transcranial Doppler (TCD) data, and with no prior history of cardiac disease. LV dysfunction was defined as an ejection fraction <40% on echocardiography. Infarction from vasospasm was adjudicated by the study team after comprehensive review of all clinical and imaging data. Functional outcome was assessed at 15 and 90 days with the modified Rankin Scale (mRS). RESULTS Eleven percent of patients had LV dysfunction (N = 13). Younger age, hydrocephalus, and complete filling of the quadrigeminal and fourth ventricles were associated with LV dysfunction (all P < 0.05). Despite a similar frequency of pre-existing hypertension, 0% of patients with LV dysfunction reported taking antihypertensive medication, compared to 35% of those without (P = 0.009). There was a significant association between LV dysfunction and infarction from vasospasm after adjusting for clinical grade, age, and peak TCD flow velocity (P = 0.03). Patients with LV dysfunction also had higher rates of hypotension requiring vasopressors (P = 0.001) and pulmonary edema (P = 0.002). However, there was no association between LV dysfunction and outcome at 14 days after adjustment for established prognostic variables. CONCLUSIONS LV dysfunction after SAH increases the risk of cerebral infarction from vasospasm, hypotension, and pulmonary edema, but with aggressive ICU support does not affect short-term survival or functional outcome. Antihypertensive medication may confer cardioprotection and reduce the risk of catecholamine-mediated injury after SAH.
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Affiliation(s)
- Richard E Temes
- Neurological Intensive Care Unit, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Wu B, Wang X, Zhang JH. Cardiac damage after subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 110:215-218. [PMID: 21116942 DOI: 10.1007/978-3-7091-0353-1_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Patients who had no heart disease had T-wave inversion and prolongation of the QT interval in electrocardiogram after Subarachnoid hemorrhage (SAH), which was reported 70years before. Cardiac complications, including focal myocytolysis, electrocardiographic changes, arrhythmias and left ventricular wall motion abnormalities and pulmonary edema. The autonomic and cardiovascular effects of SAH, however, are modulated by concomitant factors such as pre-existent cardiac diseases, electrolyte disorders and, probably, by genetic alterations in the ionic control of myocyte repolarization. Although beta-blockers have been reported to prevent myocardial damage following SAH, adequate clinical trials are lacking, and the widespread use of these drugs in acute cerebrovascular disease is not supported by evidence. Cardiac injury occurs frequently after SAH, and the most widely investigated form of neurocardiogenic injury.
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Affiliation(s)
- Bihua Wu
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, 637007, People's Republic of China.
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35
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Rhoney DH, McAllen K, Liu-DeRyke X. Current and future treatment considerations in the management of aneurysmal subarachnoid hemorrhage. J Pharm Pract 2010; 23:408-24. [PMID: 21507846 DOI: 10.1177/0897190010372334] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a type of hemorrhagic stroke that can cause significant morbidity and mortality. Although guidelines have been published to help direct the care of these patients, there is insufficient quality literature regarding the medical and pharmacological management of patients with aSAH. Treatment is divided into 3 categories: supportive therapy, prevention of complications, and treatment of complications. There are numerous pharmacological therapies that are targeted at prevention and treatment of the neurological and medical complications that may arise. Rebleeding, hydrocephalus, cerebral vasospasm, and seizures are the most common neurological complications while the most common medical complications include hyponatremia, pulmonary edema, cardiac arrhythmias, neurogenic stunned myocardium, fever, anemia, infection, hyperglycemia, and venous thromboembolism. Risk factors, clinical presentation, diagnosis, pathophysiology, as well as initial management, prevention, and treatment of complications will be the focus of this discussion.
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Affiliation(s)
- Denise H Rhoney
- Eugene Applebaum College of Pharmacy & Health Sciences, Wayne State University, Detroit, MI 48201, USA.
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Gueli N, Verrusio W, Linguanti A, Marchitto N, Longo G, Marigliano V, Cacciafesta M. Third degree of atrioventricular block: A rare geriatric complication that may cause sudden death. Arch Gerontol Geriatr 2010; 50:292-4. [DOI: 10.1016/j.archger.2009.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2008] [Revised: 02/05/2009] [Accepted: 02/11/2009] [Indexed: 10/20/2022]
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37
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Consolidating a Resilience Network to Boost Civilian Resilience during Emergencies. Prehosp Disaster Med 2010. [DOI: 10.1017/s1049023x00022482] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Apostolakis E, Parissis H, Dougenis D. Brain Death and Donor Heart Dysfunction: Implications in Cardiac Transplantation. J Card Surg 2010; 25:98-106. [DOI: 10.1111/j.1540-8191.2008.00790.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The aim of our study was to investigate P wave dispersion (Pwd), QT, corrected QT (QTc), QT dispersion (QTd) and corrected QT dispersion (QTcd) intervals in subarachnoid haemorrhage. Thirty-five subarachnoid haemorrhage patients (Group S) and 35 neurologically normal patients (Group C) were included in this retrospective study. The standard 12 derivations of the electrocardiograms of all patients were analysed and Pwd, QT and QTd intervals were measured. QTc and QTcd intervals were determined with the Bazett formula. There was no significant difference between the study groups according to demographic characteristics, hypertension and diabetes mellutus incidences (P >0.05). The Pwd, QT, QTc, QTd and QTcd durations of Group S were significantly longer than those of Group C (P <0.001). Subarachnoid haemorrhage patients may have a higher likelihood of arrhythmia during anaesthesia and in intensive care due to extended QTcd and Pwd durations.
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Marcì M, Savatteri P, Pizzuto A, Giammona G, Renda B, Lojacono F, Sanfilippo N. Acute cardiac injury after subarachnoid haemorrhage: two case reports. CASES JOURNAL 2009; 2:9293. [PMID: 20062617 PMCID: PMC2803957 DOI: 10.1186/1757-1626-2-9293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 12/09/2009] [Indexed: 11/25/2022]
Abstract
It is well known that cardiopulmonary complications are often associated to subarachnoid haemorrhage. For appropriate therapeutic managing it is very important to distinguish acute coronary syndrome from neurogenic myocardial injury, which is a reversible condition. Furthermore, because the hearts of brain dead patients may be utilized for therapeutic purpose, it has became of importance to rule out erroneous diagnosis of cardiac ischemia in order to avoid rejection of hearts potential suitable for transplantation. We present a report of two female patients affected by cardiac complications caused by aneurismal subarachnoid haemorrhage admitted to our neurosurgical intensive care department.
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Affiliation(s)
- Marcello Marcì
- Cardiology Department, Azienda Ospedaliera Villa Sofia, Palermo, Italy
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Abstract
Neurogenic stunned myocardium may be defined as myocardial injury and dysfunction occurring after diverse types of acute brain injury as a result of imbalance of the autonomic nervous system. The spectrum of observed cardiac abnormalities includes electrocardiographic changes, arrhythmia, myocardial necrosis, release of B-type natriuretic peptide, and both systolic and diastolic dysfunction of the left ventricle. These are reversible abnormalities, and although management should include careful cardiac monitoring, treatments should generally focus on the underlying neurologic process to maximize neurologic recovery.
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Affiliation(s)
- Hoang Nguyen
- Cardiology Department, Kaiser San Francisco Medical Center, San Francisco, CA 94115, USA
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Subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest: A prospective computed tomography study. Resuscitation 2009; 80:977-80. [DOI: 10.1016/j.resuscitation.2009.05.010] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2009] [Revised: 05/02/2009] [Accepted: 05/11/2009] [Indexed: 11/22/2022]
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Headache, cardiac arrest, and intracranial hemorrhage. J Headache Pain 2009; 10:357-60. [PMID: 19597939 PMCID: PMC3452091 DOI: 10.1007/s10194-009-0138-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Accepted: 06/17/2009] [Indexed: 01/12/2023] Open
Abstract
Headache is one of the most common manifestations of non-traumatic intracranial hemorrhage, which is an uncommon, but not rare, cause of cardiac arrest in adults. History of a sudden headache preceding collapse may be a helpful clue to estimate the cause of out-of-hospital cardiac arrest (OHCA). Medical records of witnessed OHCA patients were reviewed to identify those who complained of a sudden headache preceding collapse, and the incidence of intracranial hemorrhage among them as well as their clinical characteristics was investigated retrospectively. During the 12-month period, 124 patients who sustained a witnessed OHCA were treated. Among them, 74 (60%) collapsed without any pain complaint, and only 6 (5%) complained of a sudden headache preceding collapse. All of the six patients were resuscitated: four had a severe subarachnoid hemorrhage (SAH), while the other two had a massive cerebellar hemorrhage. By contrast, 39 of the 74 patients who collapsed without any pain were resuscitated. Among them, another six patients were found to harbor an SAH. Thus, a total of 12 among the 124 witnessed OHCA (10%) sustained a fatal intracranial hemorrhage. While OHCA patients who collapse complaining of a sudden headache are uncommonly seen in the emergency room, they have a high likelihood of harboring a severe intracranial hemorrhage. It should also be reminded that approximately half of patients whose cardiac arrest is due to an intracranial hemorrhage may collapse without complaining of a headache. The prognosis of those with cerebral origin of OHCA is invariably poor, although they may relatively easily be resuscitated temporarily. Focus needs to be directed to avoid sudden death from a potentially treatable cerebral lesion, and public education to promote the awareness for the symptoms of potentially lethal hemorrhagic stroke is warranted.
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[Elevated troponin and ECG alterations in acute ischemic stroke and subarachnoid hemorrhage]. DER NERVENARZT 2009; 79:1386, 1388-90, 1392-4, passim. [PMID: 18679640 DOI: 10.1007/s00115-008-2541-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Vascular diseases are the most common cause of death and disability in industrialised countries. Ischaemic heart disease and cerebrovascular disease frequently coexist in one patient. Therefore it is not surprising that raised troponin levels and ECG changes are detected comparatively often in acute stroke; however these changes do not always indicate myocardial infarction. Clinical and experimental data suggest that some kind of neurologically mediated myocardial injury exists--especially in subarachnoid hemorrhage--but not as a manifestation of concomitant ischaemic heart disease. This review summarises the frequency and possible pathophysiological mechanisms. In any case, raised troponin levels and ECG changes after acute stroke are of negative prognostic value, and a cardiological diagnostic work-up should be done.
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Ventricular arrhythmia risk after subarachnoid hemorrhage. Neurocrit Care 2009; 10:287-94. [PMID: 19184553 DOI: 10.1007/s12028-009-9188-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2008] [Accepted: 01/12/2009] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Cardiac morbidity and mortality after aneurysmal subarachnoid hemorrhage (SAH) are attributable to myocardial injury, decreased ventricular function, and ventricular arrhythmia (VA). Our objective was to test the relationships between QTc prolongation, VA, and survival after SAH. METHODS In 200 subjects with acute aneurysmal SAH, electrocardiograms, echocardiograms, and telemetry were evaluated. Serum electrolytes and troponin were also evaluated. RESULTS Initial QTc (mean 460 +/- 45 ms) was prolonged (> or = 470 ms) in 38% of subjects and decreased on follow-up (469 +/- 49 initial vs. 435 +/- 31 ms follow-up; N = 89; P < 0.0001). VA was present in 14% of subjects, 52% of subjects with VA had QTc > or = 470 ms, and initial QTc trended toward longer duration in subjects with VA (474 +/- 61 vs. 457 +/- 42 ms; P = 0.084). Multivariate analysis demonstrated significant predictors of VA after SAH were increasing age (OR 1.3/5 years; P = 0.025), increasing stroke severity (OR 1.8; P = 0.009), decreasing heart rate (OR 0.5/10 beats/min; P = 0.006), and the absence of angiotensin converting enzyme inhibitor or angiotensin II receptor antagonist use at SAH onset (OR 0.10; P = 0.027). All-cause mortality was 19% (25/135) at 3 months and subjects with VA had significantly higher mortality than those without VA (37% vs. 16%; P = 0.027). CONCLUSIONS These data demonstrate that QTc prolongation and arrhythmias are frequently noted after SAH, but arrhythmias are often not associated with QTc prolongation. In addition, the presence of VA identified subjects at greater risk of mortality following their SAH.
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Abstract
Successful critical care management of patients with aneurysmal subarachnoid hemorrhage requires a thorough understanding of the disease and its complications and a familiarity with modern multimodality neuromonitoring technology. This article reviews the natural history of aneurysmal subarachnoid hemorrhage and strategies for disease management in the acute setting. Available tools for monitoring brain function are discussed.
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Affiliation(s)
- Joshua M Levine
- Neurocritical Care Program, Hospital of the University of Pennsylvania, Philadelphia, PA 19103, USA.
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Frontera JA, Parra A, Shimbo D, Fernandez A, Schmidt JM, Peter P, Claassen J, Wartenberg KE, Rincon F, Badjatia N, Naidech A, Connolly ES, Mayer SA. Cardiac arrhythmias after subarachnoid hemorrhage: risk factors and impact on outcome. Cerebrovasc Dis 2008; 26:71-8. [PMID: 18525201 DOI: 10.1159/000135711] [Citation(s) in RCA: 85] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2007] [Accepted: 12/19/2007] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Serious cardiac arrhythmias have been described in approximately 5% of patients after subarachnoid hemorrhage (SAH). The aim of this study was to identify the frequency, risk factors and clinical impact of cardiac arrhythmia after SAH. METHODS We prospectively studied 580 spontaneous SAH patients and identified risk factors and complications associated with the development of clinically significant arrhythmia. Multiple logistic regression analysis was used to calculate adjusted odds ratios for the effect of arrhythmia on hospital complications and 3-month outcome, as measured by the modified Rankin Scale, after controlling for age, neurological grade, APACHE-2 physiologic subscore, brain herniation and aneurysm size. RESULTS Arrhythmia occurred in 4.3% (n = 25) of patients. Atrial fibrillation and flutter were the most common arrhythmias, occurring in 76% (n = 19) of these patients. Admission predictors of cardiac arrhythmia included older age, history of arrhythmia and abnormal admission electrocardiogram (all p < 0.05). After adjusting for length of stay, hospital complications associated with arrhythmia included myocardial ischemia, hyperglycemia, and herniation (all p < 0.05). Arrhythmia was associated with an excess ICU stay of 5 days (p = 0.002). After adjusting for other predictors of outcome, arrhythmia was associated with an increased risk of death (adjusted OR 8.0, 95% confidence interval 1.9-34.0, p = 0.005), and death or severe disability (adjusted OR 6.9, 95% confidence interval 1.5-32.0, p = 0.014). CONCLUSIONS Clinically important arrhythmias, most often atrial fibrillation or flutter, occurred in 4% of SAH patients. Arrhythmias are associated with an increased risk of cardiovascular comorbidity, prolonged hospital stay and poor outcome or death after SAH, after adjusting for other predictors of poor outcome.
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Affiliation(s)
- Jennifer A Frontera
- Neurological Intensive Care Unit, Department of Neurosurgery, Mount Sinai School of Medicine, New York, NY 10029, USA.
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Wippermann J, Bennink G, Wittwer T, Madershahian N, Ortmann C, Wahlers T. Reversal of Myocardial Dysfunction Due to Brain Injury. Asian Cardiovasc Thorac Ann 2008; 16:e30-1. [DOI: 10.1177/021849230801600326] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Severe myocardial dysfunction after blunt head injury is a rare but potentially lethal complication. We describe remarkable myocardial recovery after severe hemodynamic deterioration in a young man with brain injury, due to extracorporeal membrane oxygenation support. Because of the severity of brain damage, the patient succumbed after diagnosis of brain death. Postmortem histopathological examination of the heart showed severe myocardial necrosis.
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Edlow JA, Malek AM, Ogilvy CS. Aneurysmal Subarachnoid Hemorrhage: Update for Emergency Physicians. J Emerg Med 2008; 34:237-51. [DOI: 10.1016/j.jemermed.2007.10.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 08/13/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
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COLKESEN AYUCEL, SEN ORHAN, GIRAY SEMIH, ACIL TAYFUN, OZIN BULENT, MUDERRISOGLU HALDUN. Correlation Between QTc Interval and Clinical Severity of Subarachnoid Hemorrhage Depends on the QTc Formula Used. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2007; 30:1482-6. [DOI: 10.1111/j.1540-8159.2007.00895.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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