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Belkhir JR, Pease M, McCarthy DJ, Legarretta A, Mittal AM, Crago EA, Gross BA, Lang MJ. Subarachnoid Hemorrhage Outcomes in an Endovascular Right of First Refusal Neurosurgical Environment. World Neurosurg 2024; 181:e524-e532. [PMID: 37879435 PMCID: PMC10842161 DOI: 10.1016/j.wneu.2023.10.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Randomized controlled trials demonstrate that endovascular techniques yield improved outcomes compared with microsurgical approaches. However, not all patients are suitable candidates for endovascular management. This study aimed to determine if healthy patients managed microsurgically could achieve functional outcomes comparable to patients managed endovascularly. METHODS Patients treated for ruptured aneurysmal subarachnoid hemorrhage at 2 level 1 stroke centers from January 2012 through December 2020 were retrospectively reviewed. All cases were evaluated in an endovascular right of first refusal neurosurgical environment. We collected relevant clinical and follow-up data and created a generalized linear model to identify differences between patients treated endovascularly versus microsurgically. A propensity score model accounting for these differences was used to predict patient outcomes. Functional outcomes were independently assessed using the modified Rankin Scale (mRS) with good functional outcome defined as modified Rankin Scale score <3. RESULTS The study included 588 patients (211 microsurgical, 377 endovascular); median age was 58 years (interquartile range: 40-86 years); in-hospital mortality was 13%. Age, aneurysm size, and aneurysm location significantly predicted treatment modality (all P < 0.05). After greedy-type matching (210 microsurgical, 210 endovascular), patients managed microsurgically were less likely to be discharged home (odds ratio = 0.6, 95% confidence interval 0.4-0.9, P = 0.01). Functional differences disappeared over time; patients in the 2 treatment arms had similar functional outcomes at 3 months (odds ratio = 1.1, 95% confidence interval 0.7-1.8, P = 0.66) and 1 year after subarachnoid hemorrhage (odds ratio = 1.3, 95% confidence interval 0.8-2.1, P = 0.38). CONCLUSIONS In an endovascular right of first refusal neurosurgical environment, practitioners can treat patients who are not good endovascular candidates microsurgically and achieve functional outcomes comparable to patients managed endovascularly.
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Affiliation(s)
- J Raouf Belkhir
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J McCarthy
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Legarretta
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Crago
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Heinsberg LW, Weeks DE, Alexander SA, Minster RL, Sherwood PR, Poloyac SM, Deslouches S, Crago EA, Conley YP. Iron homeostasis pathway DNA methylation trajectories reveal a role for STEAP3 metalloreductase in patient outcomes after aneurysmal subarachnoid hemorrhage. Epigenetics Commun 2021; 1:4. [PMID: 35083470 PMCID: PMC8788201 DOI: 10.1186/s43682-021-00003-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 08/25/2021] [Indexed: 11/10/2022]
Abstract
BACKGROUND Following aneurysmal subarachnoid hemorrhage (aSAH), the brain is susceptible to ferroptosis, a type of iron-dependent cell death. Therapeutic intervention targeting the iron homeostasis pathway shows promise for mitigating ferroptosis and improving recovery in animal models, but little work has been conducted in humans. DNA methylation (DNAm) plays a key role in gene expression and brain function, plasticity, and injury recovery, making it a potentially useful biomarker of outcomes or therapeutic target for intervention. Therefore, in this longitudinal, observational study, we examined the relationships between trajectories of DNAm in candidate genes related to iron homeostasis and acute (cerebral vasospasm and delayed cerebral ischemia) and long-term (Glasgow Outcome Scale [GOS, unfavorable = 1-3] and death) patient outcomes after aSAH. RESULTS Longitudinal, genome-wide DNAm data were generated from DNA extracted from post-aSAH cerebrospinal fluid (n = 260 participants). DNAm trajectories of 637 CpG sites in 36 candidate genes related to iron homeostasis were characterized over 13 days post-aSAH using group-based trajectory analysis, an unsupervised clustering method. Significant associations were identified between inferred DNAm trajectory groups at several CpG sites and acute and long-term outcomes. Among our results, cg25713625 in the STEAP3 metalloreductase gene (STEAP3) stood out. Specifically, in comparing the highest cg25713625 DNAm trajectory group with the lowest, we observed significant associations (i.e., based on p-values less than an empirical significance threshold) with unfavorable GOS at 3 and 12 months (OR = 11.7, p = 0.0006 and OR = 15.6, p = 0.0018, respectively) and death at 3 and 12 months (OR = 19.1, p = 0.0093 and OR = 12.8, p = 0.0041, respectively). These results were replicated in an independent sample (n = 100 participants) observing significant associations with GOS at 3 and 12 months (OR = 8.2, p = 0.001 and OR = 6.3, p = 0.0.0047, respectively) and death at 3 months (OR = 2.3, p = 0.008) and a suggestive association (i.e., p-value < 0.05 not meeting an empirical significance threshold) with death at 12 months (OR = 2.0, p = 0.0272). In both samples, an additive effect of the DNAm trajectory group was observed as the percentage of participants with unfavorable long-term outcomes increased substantially with higher DNAm trajectory groups. CONCLUSION Our results support a role for DNAm of cg25713625/STEAP3 in recovery following aSAH. Additional research is needed to further explore the role of DNAm of cg25713625/STEAP3 as a biomarker of unfavorable outcomes, or therapeutic target to improve outcomes, to translate these findings clinically.
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Affiliation(s)
- Lacey W. Heinsberg
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Daniel E. Weeks
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Sheila A. Alexander
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ryan L. Minster
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
| | - Paula R. Sherwood
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Sandra Deslouches
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth A. Crago
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yvette P. Conley
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA 15261, USA
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Heinsberg LW, Arockiaraj AI, Crago EA, Ren D, Shaffer JR, Sherwood PR, Sereika SM, Weeks DE, Conley YP. Genetic Variability and Trajectories of DNA Methylation May Support a Role for HAMP in Patient Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 32:550-563. [PMID: 31346934 DOI: 10.1007/s12028-019-00787-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND/OBJECTIVE Preclinical evidence suggests that iron homeostasis is an important biological mechanism following aneurysmal subarachnoid hemorrhage (aSAH); however, this concept is underexplored in humans. This study examined the relationship between patient outcomes following aSAH and genetic variants and DNA methylation in the hepcidin gene (HAMP), a key regulator of iron homeostasis. METHODS In this exploratory, longitudinal observational study, participants with verified aSAH were monitored for acute outcomes including cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) and evaluated post-discharge at 3 and 12 months for long-term outcomes of death and functional status using the Modified Rankin Scale (mRS; poor = 3-6) and Glasgow Outcome Scale (GOS; poor = 1-3). Participants were genotyped for two genetic variants, and DNA methylation data were collected from serial cerebrospinal fluid over 14 days post-aSAH at eight methylation sites within HAMP. Participants were grouped based on their site-specific DNA methylation trajectory, with and without correcting for cell-type heterogeneity (CTH), and the associations between genetic variants and inferred DNA methylation trajectory groups and patient outcomes were tested. To correct for multiple testing, an empirical significance threshold was computed using permutation testing. RESULTS Genotype data for rs10421768 and rs7251432 were available for 241 and 371 participants, respectively, and serial DNA methylation data were available for 260 participants. Acute outcome prevalence included CV in 45% and DCI in 37.1% of the overall sample. Long-term outcome prevalence at 3 and 12 months included poor GOS in 23% and 21%, poor mRS in 31.6% and 27.3%, and mortality in 15.1% and 18.2%, respectively, in the overall sample. Being homozygous for the rs7251432 variant allele was significantly associated with death at 3 months (p = 0.003) and was the only association identified that passed adjustment for multiple testing mentioned above. Suggestive associations (defined as trending toward significance, p value < 0.05, but not meeting empirical significance thresholds) were identified between the homozygous variant allele for rs7251432 and poor GOS and mRS at 3 months (both p = 0.04) and death at 12 months (p = 0.02). For methylation trajectory groups, no associations remained significant after correction for multiple testing. However, for methylation trajectory groups not adjusted for CTH, suggestive associations were identified between cg18149657 and poor GOS and mRS at 3 months (p = 0.003 and p = 0.04, respectively) and death at 3 months (p = 0.04), and between cg26283059 and DCI (p = 0.01). For methylation trajectory groups adjusted for CTH, suggestive associations were identified between cg02131995 and good mRS at 12 months (p = 0.02), and between cg26283059 and DCI (p = 0.01). CONCLUSIONS This exploratory pilot study offers preliminary evidence that HAMP may play a role in patient outcomes after aSAH. Replication of this study and mechanistic investigation of the role of HAMP in patient outcomes after aSAH are needed.
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Affiliation(s)
- Lacey W Heinsberg
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA.
| | - Annie I Arockiaraj
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth A Crago
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Dianxu Ren
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - John R Shaffer
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Paula R Sherwood
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Susan M Sereika
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Weeks
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yvette P Conley
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Heinsberg LW, Alexander SA, Crago EA, Minster RL, Poloyac SM, Weeks DE, Conley YP. Genetic Variability in the Iron Homeostasis Pathway and Patient Outcomes After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 33:749-758. [PMID: 32246437 PMCID: PMC7541432 DOI: 10.1007/s12028-020-00961-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND/OBJECTIVE Iron can be detrimental to most tissues both in excess and in deficiency. The brain in particular is highly susceptible to the consequences of excessive iron, especially during blood brain barrier disruption after injury. Preliminary evidence suggests that iron homeostasis is important during recovery after neurologic injury; therefore, the exploration of genetic variability in genes involved in iron homeostasis is an important area of patient outcomes research. The purpose of this study was to examine the relationship between tagging single nucleotide polymorphisms (SNPs) in candidate genes related to iron homeostasis and acute and long-term patient outcomes after aneurysmal subarachnoid hemorrhage (aSAH). METHODS This study was a longitudinal, observational, candidate gene association study of participants with aSAH that used a two-tier design including tier 1 (discovery, n = 197) and tier 2 (replication, n = 277). Participants were followed during the acute outcome phase for development of cerebral vasospasm and delayed cerebral ischemia (DCI) and during the long-term outcome phase for death and gross functional outcome using the Glasgow Outcome Scale (GOS; poor = 1-3). Genetic association analyses were performed using a logistic regression model adjusted for age, sex, and Fisher grade. Approximate Bayes factors (ABF) and Bayesian false discovery probabilities (BFDP) were used to prioritize and interpret results. RESULTS In tier 1, 235 tagging SNPs in 28 candidate genes were available for analysis and 26 associations (20 unique SNPs in 12 genes) were nominated for replication in tier 2. In tier 2, we observed an increase in evidence of association for three associations in the ceruloplasmin (CP) and cubilin (CUBN) genes. We observed an association of rs17838831 (CP) with GOS at 3 months (tier 2 results, odds ratio [OR] = 2.10, 95% confidence interval [CI] = 1.14-3.86, p = 0.018, ABF = 0.52, and BFDP = 70.8%) and GOS at 12 months (tier 2 results, OR = 1.86, 95% CI 0.98-3.52, p = 0.058, ABF = 0.72, and BFDP = 77.3%) as well as rs10904850 (CUBN) with DCI (tier 2 results, OR = 0.70, 95% CI 0.48-1.02, p = 0.064, ABF = 0.59, and BFDP = 71.8%). CONCLUSIONS Among the genes examined, our findings support a role for CP and CUBN in patient outcomes after aSAH. In an effort to translate these findings into clinical utility and improve outcomes after aSAH, additional research is needed to examine the functional roles of these genes after aSAH.
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Affiliation(s)
- Lacey W Heinsberg
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA.
| | - Sheila A Alexander
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Elizabeth A Crago
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ryan L Minster
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Daniel E Weeks
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yvette P Conley
- Department of Health Promotion and Development, School of Nursing, University of Pittsburgh, 440 Victoria Building, 3500 Victoria Street, Pittsburgh, PA, 15261, USA
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
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Arockiaraj AI, Liu D, Shaffer JR, Koleck TA, Crago EA, Weeks DE, Conley YP. Methylation Data Processing Protocol and Comparison of Blood and Cerebral Spinal Fluid Following Aneurysmal Subarachnoid Hemorrhage. Front Genet 2020; 11:671. [PMID: 32670358 PMCID: PMC7332758 DOI: 10.3389/fgene.2020.00671] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/02/2020] [Indexed: 11/13/2022] Open
Abstract
One challenge in conducting DNA methylation-based epigenome-wide association study (EWAS) is the appropriate cleaning and quality-checking of data to minimize biases and experimental artifacts, while simultaneously retaining potential biological signals. These issues are compounded in studies that include multiple tissue types, and/or tissues for which reference data are unavailable to assist in adjusting for cell-type mixture, for example cerebral spinal fluid (CSF). For our study that evaluated blood and CSF taken from aneurysmal subarachnoid hemorrhage (aSAH) patients, we developed a protocol to clean and quality-check genome-wide methylation levels and compared the methylomic profiles of the two tissues to determine whether blood is a suitable surrogate for CSF. CSF samples were collected from 279 aSAH patients longitudinally during the first 14 days of hospitalization, and a subset of 88 of these patients also provided blood samples within the first 2 days. Quality control (QC) procedures included identification and exclusion of poor performing samples and low-quality probes, functional normalization, and correction for cell-type heterogeneity via surrogate variable analysis (SVA). Significant differences in rates of poor sample performance was observed between blood (1.1% failing QC) and CSF (9.12% failing QC; p = 0.003). Functional normalization increased the concordance of methylation values among technical replicates in both CSF and blood. SVA improved the asymptotic behavior of the test of association in a simulated EWAS under the null hypothesis. To determine the suitability of blood as a surrogate for CSF, we calculated the correlations of adjusted methylation values at each CpG between blood and CSF globally and by genomic regions. Overall, mean within-CpG correlation was low (r < 0.26), suggesting that blood is not a suitable surrogate for global methylation in CSF. However, differences in the magnitude of the correlation were observed by genomic region (CpG island, shore, shelf, open sea; p < 0.001 for all) and orientation with respect to nearby genes (3' UTR, transcription start site, exon, body, 5' UTR; p < 0.01 for all). In conclusion, the correlation analysis and QC pipelines indicated that DNA extracted from blood was not, overall, a suitable surrogate for DNA from CSF in aSAH methylomic studies.
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Affiliation(s)
- Annie I Arockiaraj
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Dongjing Liu
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - John R Shaffer
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Center for Craniofacial and Dental Genetics, Department of Oral Biology, School of Dental Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Theresa A Koleck
- School of Nursing, Columbia University, New York, NY, United States
| | - Elizabeth A Crago
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States
| | - Daniel E Weeks
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Yvette P Conley
- Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States.,School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States
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Kagiyama N, Sugahara M, Crago EA, Qi Z, Lagattuta TF, Yousef KM, Friedlander RM, Hravnak MT, Gorcsan J. Neurocardiac Injury Assessed by Strain Imaging Is Associated With In-Hospital Mortality in Patients With Subarachnoid Hemorrhage. JACC Cardiovasc Imaging 2020; 13:535-546. [DOI: 10.1016/j.jcmg.2019.02.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 01/29/2019] [Accepted: 02/06/2019] [Indexed: 11/25/2022]
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Kagiyama N, Soyama Y, Crago EA, Sugahara M, Hasselberg NE, Lagattuta T, Yousef KM, Hravnak M, Gorcsan J. QUANTIFICATION OF REVERSE TAKOTSUBO PATTERN IN PATIENTS WITH SUBARACHNOID HEMORRHAGE BY LONGITUDINAL STRAIN. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32005-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Kagiyama N, Soyama Y, Crago EA, Sugahara M, Hasselberg NE, Lagattuta T, Yousef KM, Hravnak MT, Gorcsan J. PROGNOSTIC VALUE OF PERSISTENTLY ABNORMAL LEFT VENTRICULAR GLOBAL LONGITUDINAL STRAIN IN PATIENTS WITH SUBARACHNOID HEMORRHAGE. J Am Coll Cardiol 2018. [DOI: 10.1016/s0735-1097(18)32255-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is a sudden debilitating condition affecting individuals during the most productive times of their lives. Treatment advances have reduced mortality rates but increased the number of survivors facing deficits in physical and neuropsychological function. OBJECTIVE This study examined associations between neuropsychological function and work productivity after aSAH. METHODS Fifty-two patients with aSAH, employed before hemorrhage, were recruited from an ongoing National Institutes of Health study. Work Limitations Questionnaire (WLQ), neuropsychological tests (executive function, psychomotor speed, attention and mental flexibility, memory), and Patient Assessment of Own Function were completed at 3 and 12 months after aSAH. RESULTS Subjects in this analysis reported some level of difficulty in work productivity at 3 and 12 months (35% and 30%, respectively) after hemorrhage. Lower WLQ scores in time management and mental/interpersonal subscales were associated with poorer performance in psychomotor function (r = .5, p = .04 and r = .42, p = .09). Poorer mental flexibility and working memory correlated with time management difficulty at 3 months (r = -.4, p = .09 and r = .54, p = .02). Patients performing poorly on story recall tests were more likely to report difficulty with job physical performance (r = -.42, p = .09) and completing work effectively (r = .61, p = .009). Poorer working memory performance was associated with lower scores on mental/interpersonal WLQ subscales (r = .45, p = .05) and overall health-related work productivity loss (r = .47, p = .04). WLQ areas also correlated with participants' perception of their neuropsychological function after aSAH. CONCLUSIONS These results suggest that neuropsychological deficits impact work quality after hemorrhage and provide strong impetus for future studies so that domain-specific interventions can be implemented to improve outcomes that affect quality of life including work productivity.
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Affiliation(s)
- Elizabeth A Crago
- Thomas J. Price, BS, former graduate student, School of Nursing, University of Pittsburgh, Pittsburgh, PA; and medical student, Virginia Commonwealth School of Osteopathic Medicine, Greenville, SC. Catherine M. Bender, RN PhD, FAAN, Professor and Director of PhD program, School of Nursing, University of Pittsburgh, Pittsburgh, PA. Dianxu Ren, PhD, Associate Professor, School of Nursing, University of Pittsburgh, Pittsburgh, PA. Samuel M. Poloyac, PharmD PhD, Professor and Associate Dean of Graduate Studies, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Paula R. Sherwood, RN PhD, FAAN, Professor, School of Nursing, University of Pittsburgh, Pittsburgh, PA
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McAteer A, Hravnak M, Chang Y, Crago EA, Gallek MJ, Yousef KM. The Relationships Between BNP and Neurocardiac Injury Severity, Noninvasive Cardiac Output, and Outcomes After Aneurysmal Subarachnoid Hemorrhage. Biol Res Nurs 2017. [PMID: 28627225 DOI: 10.1177/1099800417711584] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Neurocardiac injury, a type of myocardial dysfunction associated with neurological insult to the brain, occurs in 31-48% of aneurysmal subarachnoid hemorrhage (aSAH) patients. Cardiac troponin I (cTnI) is commonly used to diagnose neurocardiac injury. Brain natriuretic peptide (BNP), another cardiac marker, is more often used to evaluate degree of heart failure. The purpose of this study was to examine the relationships between BNP and (a) neurocardiac injury severity according to cTnI, (b) noninvasive continuous cardiac output (NCCO), and (c) outcomes in aSAH patients. METHOD This descriptive longitudinal study enrolled 30 adult aSAH patients. Data collected included BNP and cTnI levels and NCCO parameters for 14 days and outcomes (modified Rankin Scale [mRS] and mortality) at discharge and 3 months. Generalized estimating equations were used to evaluate associations between BNP and cTnI, NCCO, and outcomes. RESULTS BNP was significantly associated with cTnI. For every 1 unit increase in log BNP, cTnI increased by 0.05 ng/ml ( p = .001). Among NCCO parameters, BNP was significantly associated with thoracic fluid content ( p = .0003). On multivariable analyses, significant associations were found between BNP and poor mRS. For every 1 unit increase in log BNP, patients were 3.16 times more likely to have a poor mRS at discharge ( p = .021) and 5.40 times more likely at 3 months ( p < .0001). CONCLUSION There were significant relationships between BNP and cTnI and poor outcomes after aSAH. BNP may have utility as a marker of neurocardiac injury and outcomes after aSAH.
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Affiliation(s)
- Amber McAteer
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marilyn Hravnak
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yuefang Chang
- 2 Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Elizabeth A Crago
- 1 Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
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Qi Z, Sugahara M, Crago EA, Chang Y, Lagattuta TF, Yousef K, Friedlander RM, Hravnak MT, Gorcsan J. NEUROCARDIAC INJURY IN PATIENTS WITH SUBARACHNOID HEMORRHAGE IS ASSOCIATED WITH REGIONAL LEFT VENTRICULAR DISCOORDINATION. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31461-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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12
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Qi Z, Sugahara M, Crago EA, Chang Y, Lagattuta TF, Yousef K, Friedlander RM, Hravnak MT, Gorcsan J. ASSOCIATION OF GLOBAL LONGITUDINAL STRAIN WITH SEVERITY OF NEUROCARDIAC INJURY IN PATIENTS WITH SUBARACHNOID HEMORRHAGE. J Am Coll Cardiol 2016. [DOI: 10.1016/s0735-1097(16)31611-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Al-Zaiti SS, Crago EA, Hravnak M, Kozik TM, Pelter MM, Carey MG. ECG Changes During Neurologic Injury. Am J Crit Care 2015; 24:453-4. [PMID: 26330440 DOI: 10.4037/ajcc2015618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Salah S Al-Zaiti
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
| | - Elizabeth A Crago
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
| | - Marilyn Hravnak
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
| | - Teri M Kozik
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
| | - Michele M Pelter
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
| | - Mary G Carey
- Salah S. Al-Zaiti is an assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh, Pennsylvania. Elizabeth A. Crago is a research assistant professor at the Department of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Marilyn Hravnak is a professor of Acute and Tertiary Care Nursing, University of Pittsburgh. Pennsylvania. Teri M. Kozik is a nurse researcher at St. Joseph's Medical Center, Stockton, California. Mary G. Carey is associate director for clinical nursing research, Strong Memorial Hospital, Rochester, New York. Michele M. Pelter is an assistant professor at the the Department of Physiological Nursing at University of California, San Francisco, California
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Donnelly MK, Crago EA, Conley YP, Balzer JR, Ren D, Ducruet AF, Kochanek PM, Sherwood PR, Poloyac SM. 20-HETE is associated with unfavorable outcomes in subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2015; 35:1515-22. [PMID: 25920956 PMCID: PMC4640341 DOI: 10.1038/jcbfm.2015.75] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Revised: 03/06/2015] [Accepted: 03/23/2015] [Indexed: 12/25/2022]
Abstract
Emerging evidence has suggested that patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) develop vascular dysregulation as a potential contributor to poor outcomes. Preclinical studies have implicated the novel microvascular constrictor, 20-hydroxyeicosatetraenoic acid (20-HETE) in aSAH pathogenesis, yet the translational relevance of 20-HETE in patients with aSAH is largely unknown. The goal of this research was to determine the relationship between 20-HETE cerebrospinal fluid (CSF) levels, gene variants in 20-HETE synthesis, and acute/long-term aSAH outcomes. In all, 363 adult patients (age 18 to 75) with aSAH were prospectively recruited from the University of Pittsburgh Medical Center neurovascular Intensive Care Unit. Patients were genotyped for polymorphic variants and cytochrome P450 (CYP)-eicosanoid CSF levels were measured over 14 days. Outcomes included delayed cerebral ischemia (DCI), clinical neurologic deterioration (CND), and modified Rankin Scores (MRS) at 3 and 12 months. Patients with CND and unfavorable 3-month MRS had 2.2- and 2.7-fold higher mean 20-HETE CSF levels, respectively. Patients in high/moderate 20-HETE trajectory groups (35.7%) were 2.5-, 2.1-, 3.1-, 3.3-, and 2.1-fold more likely to have unfavorable MRS at 3 months, unfavorable MRS at 12 months, mortality at 3 months, mortality at 12 months, and CND, respectively. These results showed that 20-HETE is associated with acute and long-term outcomes and suggest that 20-HETE may be a novel target in aSAH.
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Affiliation(s)
- Mark K Donnelly
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Crago
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yvette P Conley
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.,Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeffery R Balzer
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Dianxu Ren
- Department of Health and Community Systems, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Andrew F Ducruet
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Paula R Sherwood
- Department of Acute and Tertiary Care, School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Samuel M Poloyac
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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15
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Crago EA, Sherwood PR, Bender C, Balzer J, Ren D, Poloyac SM. Plasma Estrogen Levels Are Associated With Severity of Injury and Outcomes After Aneurysmal Subarachnoid Hemorrhage. Biol Res Nurs 2014; 17:558-66. [PMID: 25548393 DOI: 10.1177/1099800414561632] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Biochemical mediators alter cerebral perfusion and have been implicated in delayed cerebral ischemia (DCI) and poor outcomes after aneurysmal subarachnoid hemorrhage (aSAH). Estrogens (estrone [E1] and estradiol [E2]) are mediators with neuroprotective properties that could play a role in DCI. This study explored associations between plasma estrogen levels and outcomes following aSAH. METHODS Plasma samples from 1-4, 4-6, and 7-10 days after hemorrhage from 99 adult aSAH patients were analyzed for estrogen levels using liquid chromatography tandem mass spectrometry. DCI was operationalized as radiographic/ultrasonic evidence of impaired cerebral blood flow accompanied by neurological deterioration. Outcomes were assessed using the Modified Rankin Scale at 3 and 12 months after hemorrhage. Statistical analysis included correlation, regression, and group-based trajectory. RESULTS Higher E1 and E2 levels were associated with higher Hunt and Hess grade (E1, p = .01; E2, p = .03), the presence of DCI (E1, p = .02; E2, p = .02), and poor 3-month outcomes (E1, p = .002; E2, p = .002). Trajectory analysis identified distinct populations over time for E1 (61% E1 high) and E2 (68% E2 high). Patients in higher trajectory groups had higher Fisher grades (E1, p = .008; E2, p = .01), more frequent DCI (E1, p = .04; E2, p = .08), and worse 3-month outcomes (E1, p = .01; E2, p = .004) than low groups. CONCLUSIONS These results provide the first clinical evidence that plasma E1 and E2 concentrations are associated with severity of injury and outcomes after aSAH.
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Affiliation(s)
| | - Paula R Sherwood
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Catherine Bender
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Jeffrey Balzer
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dianxu Ren
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Samuel M Poloyac
- School of Pharmaceutical Sciences, University of Pittsburgh, Pittsburgh, PA, USA
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Yousef KM, Balzer JR, Crago EA, Poloyac SM, Sherwood PR. Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: a correlational study. Intensive Crit Care Nurs 2014; 30:346-52. [PMID: 24933608 DOI: 10.1016/j.iccn.2014.05.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 05/04/2014] [Accepted: 05/06/2014] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH). RESEARCH METHODOLOGY Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6). RESULTS DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%. CONCLUSIONS These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study.
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Affiliation(s)
- Khalil M Yousef
- University of Jordan, Faculty of Nursing, Queen Rania Al Abdullah Street, Amman 11942, Jordan.
| | - Jeffrey R Balzer
- Neurological Surgery Department, University of Pittsburgh Medical Center-Presbyterian, Suite B-400, 200 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Elizabeth A Crago
- University of Pittsburgh, School of Nursing Acute and Tertiary Care, 320B Victoria Building, 3500 Victoria St., Pittsburgh, PA 15261, USA
| | - Samuel M Poloyac
- University of Pittsburgh, School of Pharmacy, 807 Salk Hall, Pittsburgh, PA 15213, USA
| | - Paula R Sherwood
- Acute and Tertiary Care Department, School of Nursing, Department of Neurological Surgery, School of Medicine, University of Pittsburgh, 336 Victoria Building, 3500 Victoria St., Pittsburgh, PA 15261, USA; University of Pittsburgh, School of Nursing Acute and Tertiary Care, 320B Victoria Building, 3500 Victoria St., Pittsburgh, PA 15261, USA
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17
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Thampatty BP, Sherwood PR, Gallek MJ, Crago EA, Ren D, Hricik AJ, Kuo CWJ, Klamerus MM, Alexander SA, Bender CM, Hoffman LA, Horowitz MB, Kassam AB, Poloyac SM. Role of endothelin-1 in human aneurysmal subarachnoid hemorrhage: associations with vasospasm and delayed cerebral ischemia. Neurocrit Care 2011; 15:19-27. [PMID: 21286855 PMCID: PMC3134137 DOI: 10.1007/s12028-011-9508-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endothelin-1 (ET-1) is a potent vasoconstrictor implicated in the pathogenesis of vasospasm and delayed cerebral ischemia (DCI) in aneurysmal subarachnoid hemorrhage (aSAH) patients. The aim of this study was to investigate the relationship between cerebrospinal fluid (CSF) ET-1 levels and angiographic vasospasm and DCI. METHODS Patients with aSAH were consented (n = 106). Cerebral vasospasm was determined by angiography. DCI was determined by transcranial Doppler (TCD) results and/or angiogram results with corresponding clinical deterioration. CSF ET-1 levels over 14 days after the initial insult was quantified by ELISA. ET-1 analysis included a group-based trajectory analysis and ET-1 exposure rate during 24, 48, and 72 h prior to, as well as 72 h post angiography, or clinical deterioration. RESULTS Trajectory analysis revealed two distinct groups of subjects with 56% of patients in the low ET-1 trajectory group (mean at day 1 = 0.31 pg/ml; SE = 0.04; mean at day 14 = 0.41 pg/ml; SE = 0.15) and 44% of patients in the high ET-1 trajectory group (mean at day 1 = 0.65 pg/ml; SE = 0.08; mean at day 14 = 0.61 pg/ml; SE = 0.06). Furthermore, we observed that ET-1 exposure rate 72 h before angiography and clinical spasm was a significant predictor of both angiographic vasospasm and DCI, whereas, ET-1 exposure after angiography and clinical spasm was not associated with either angiographic vasospasm or DCI. CONCLUSION Based on these results we conclude that ET-1 concentrations are elevated in a sub-group of patients and that the acute (72 h prior to angiography and clinical neurological deterioration), but not chronic, elevations in CSF ET-1 concentrations are indicative of the pathogenic alterations of vasospasm and DCI in aSAH patients.
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Crago EA, Thampatty BP, Sherwood PR, Kuo CWJ, Bender C, Balzer J, Horowitz M, Poloyac SM. Cerebrospinal fluid 20-HETE is associated with delayed cerebral ischemia and poor outcomes after aneurysmal subarachnoid hemorrhage. Stroke 2011; 42:1872-7. [PMID: 21617146 DOI: 10.1161/strokeaha.110.605816] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Delayed cerebral ischemia (DCI) is a major complication after aneurysmal subarachnoid hemorrhage (aSAH); it is manifested by changes in cerebral blood flow accompanied by neurological decline, and it results in long-term functional and neuropsychological impairment. Preclinical evidence has demonstrated that the arachidonic acid metabolite, 20-hydroxyeicosatetraenoic acid (20-HETE), affects cerebral microvascular tone and cerebral blood flow after aSAH. The purpose of this study was to determine whether cerebrospinal fluid 20-HETE levels were associated with DCI and long-term neuropsychological outcomes in aSAH patients. METHODS Cerebrospinal fluid samples were collected twice daily through 14 days after hemorrhage on 108 acute, adult, aSAH patients. Samples were analyzed for 20-HETE via HPLC MSQ single quadrupole mass spectrometry. DCI was defined as the presence of impaired cerebral blood flow (angiographic vasospasm, elevated transcranial Dopplers, abnormal computed tomography or magnetic resonance perfusion scans) accompanied by neurological deterioration. Outcomes, including death and neuropsychological testing, were completed at 3 months after hemorrhage. RESULTS Detectable 20-HETE levels were observed in 31% of patient samples and were associated with severity of hemorrhage (Hunt & Hess [HH], P=0.04; Fisher, P=0.05). Detection of 20-HETE was not associated with angiographic vasospasm (P=0.34); however, detectable 20-HETE was significantly associated with DCI (P=0.016). Our data also suggest that detectable 20-HETE was associated with decreased performance in 5 neuropsychological domains. CONCLUSIONS These results provide the first clinical evidence that cerebrospinal fluid 20-HETE concentrations are associated with DCI and poor outcomes, and this provides impetus for future studies to elucidate the clinical utility of inhibiting 20-HETE formation as a novel therapeutic intervention in patients with aSAH.
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Affiliation(s)
- Elizabeth A Crago
- School of Pharmacy, University of Pittsburgh, 807 Salk Hall, Pittsburgh, PA 15261, USA
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19
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Miketic JK, Hravnak M, Sereika SM, Crago EA. Elevated cardiac troponin I and functional recovery and disability in patients after aneurysmal subarachnoid hemorrhage. Am J Crit Care 2010; 19:522-8; quiz 529. [PMID: 20107235 DOI: 10.4037/ajcc2010156] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid hemorrhage experience myocardial injury at the time of rupture, but its effect on functional recovery and disability is unclear. OBJECTIVE To describe the prevalence of myocardial injury, as indicated by high serum levels of cardiac troponin I (≥0.3 ng/mL), within the first 5 days after aneurysmal subarachnoid hemorrhage and the effect of the injury on 3-month functional recovery and disability. METHODS In a prospective longitudinal study, 239 patients with Hunt/Hess grade 3 or greater and/or Fisher grade 2 or greater at admission had serum level of troponin I measured on days 0 to 5. Patients were interviewed at 3 months to evaluate functional recovery (Glasgow Outcome Scale) and functional disability (Modified Rankin Scale). Statistics included χ² analysis, t tests, and binary logistic regression. RESULTS Troponin values were elevated in 33.5% of the patients, and few patients in either group had a history of coronary artery disease (7.4% with troponin levels ≥0.3 ng/mL vs 2.7% with levels <0.3 ng/mL, P = .12). Higher troponin levels were significantly related to age and Hunt/Hess and Fisher grades, but not race, and were significantly associated with poorer functional recovery (P < .001) and more functional disability (P < .001). Even after controls for age, race, and more severe Hunt/Hess grades, higher levels remained a significant predictor of poorer functional recovery (P = .04) and disability (P = .01). CONCLUSION Elevated levels of cardiac troponin I after aneurysmal subarachnoid hemorrhage are common in patients with no cardiac history, are associated with severity of the hemorrhage, and are independently predictive of poorer functional recovery and increased disability.
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Affiliation(s)
- Joyce K. Miketic
- Joyce K. Miketic is a graduate student researcher, Marilyn Hravnak is a professor, and Elizabeth A. Crago is a clinical coordinator in the Department of Acute and Tertiary Care at the University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania. Susan M. Sereika is an associate professor in the Department of Health and Community Systems in the School of Nursing and the Department of Biostatistics in the Graduate School of Public Health at the University of Pittsburgh
| | - Marilyn Hravnak
- Joyce K. Miketic is a graduate student researcher, Marilyn Hravnak is a professor, and Elizabeth A. Crago is a clinical coordinator in the Department of Acute and Tertiary Care at the University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania. Susan M. Sereika is an associate professor in the Department of Health and Community Systems in the School of Nursing and the Department of Biostatistics in the Graduate School of Public Health at the University of Pittsburgh
| | - Susan M. Sereika
- Joyce K. Miketic is a graduate student researcher, Marilyn Hravnak is a professor, and Elizabeth A. Crago is a clinical coordinator in the Department of Acute and Tertiary Care at the University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania. Susan M. Sereika is an associate professor in the Department of Health and Community Systems in the School of Nursing and the Department of Biostatistics in the Graduate School of Public Health at the University of Pittsburgh
| | - Elizabeth A. Crago
- Joyce K. Miketic is a graduate student researcher, Marilyn Hravnak is a professor, and Elizabeth A. Crago is a clinical coordinator in the Department of Acute and Tertiary Care at the University of Pittsburgh, School of Nursing, Pittsburgh, Pennsylvania. Susan M. Sereika is an associate professor in the Department of Health and Community Systems in the School of Nursing and the Department of Biostatistics in the Graduate School of Public Health at the University of Pittsburgh
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20
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Miller TM, Donnelly MK, Crago EA, Roman DM, Sherwood PR, Horowitz MB, Poloyac SM. Rapid, simultaneous quantitation of mono and dioxygenated metabolites of arachidonic acid in human CSF and rat brain. J Chromatogr B Analyt Technol Biomed Life Sci 2009; 877:3991-4000. [PMID: 19892608 DOI: 10.1016/j.jchromb.2009.10.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2009] [Revised: 08/31/2009] [Accepted: 10/07/2009] [Indexed: 11/16/2022]
Abstract
Currently, there are few biomarkers to predict the risk of symptomatic cerebral vasospasm (SV) in subarachnoid hemorrhage (SAH) patients. Mono and dioxygenated arachidonic acid metabolites, involved in the pathogenesis of ischemic injury, may serve as indicators of SV. This study developed a quantitative UPLC-MS/MS method to simultaneously measure hydroxyeicosatetraenoic acid (HETE), dihydroxyeicosatrienoic acid (DiHETrE), and epoxyeicosatrienoic acid (EET) metabolites of arachidonic acid in cerebrospinal fluid (CSF) samples of SAH patients. Additionally, we determined the recovery of these metabolites from polyvinylchloride (PVC) bags used for CSF collection. Linear calibration curves ranging from 0.208 to 33.3 ng/ml were validated. The inter-day and intra-day variance was less than 15% at most concentrations with extraction efficiency greater than 73%. The matrix did not affect the reproducibility and reliability of the assay. In CSF samples, peak concentrations of 8,9-DiHETrE, 20-HETE, 15-HETE, and 12-HETE ranged from 0.293 to 24.9 ng/ml. In rat brain cortical tissue samples, concentrations of 20-, 15-, 12-HETE, 8,9-EET, and 14,15-, 11,12-DiHETrE ranged from 0.57 to 23.99 pmol/g wet tissue. In rat cortical microsomal incubates, all 10 metabolites were measured with formation rates ranging from 0.03 to 7.77 pmol/mg/min. Furthermore, 12-HETE and EET metabolites were significantly altered by contact with PVC bags at all time points evaluated. These data demonstrate that the simultaneous measurement of these compounds in human CSF and rat brain can be achieved with a UPLC-MS/MS system and that this method is necessary for evaluation of these metabolites as potential quantitative biomarkers in future clinical trials.
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Affiliation(s)
- Tricia M Miller
- Department of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA 15261, USA
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21
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Hravnak M, Frangiskakis JM, Crago EA, Chang Y, Tanabe M, Gorcsan J, Horowitz MB. Elevated cardiac troponin I and relationship to persistence of electrocardiographic and echocardiographic abnormalities after aneurysmal subarachnoid hemorrhage. Stroke 2009; 40:3478-84. [PMID: 19713541 DOI: 10.1161/strokeaha.109.556753] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac injury persistence after aneurysmal subarachnoid hemorrhage (aSAH) is not well described. We hypothesized that post-aSAH cardiac injury, detected by elevated cardiac troponin I (cTnI), is related to aSAH severity and associated with electrocardiographic and structural echocardiographic abnormalities that are persistent. METHODS Prospective longitudinal study was conducted of patients with aSAH with Fisher grade >or=2 and/or Hunt/Hess grade >or=3. Serum cTnI was collected on Days 1 to 5; cohort dichotomized into peak cTnI >or=0.3 ng/mL (elevated) or cTnI <0.3 ng/mL. Relationships among cTnI and aSAH severity, 12-lead electrocardiography early (<or=4 days) and late (>or=7 days), Holter monitoring on Days 1 to 5, and transthoracic echocardiogram (left ventricular ejection fraction and regional wall motion abnormalities) early (Days 0 to 5) and late (Days 5 to 12) were evaluated. RESULTS Of 204 subjects, 31% had cTnI >or=0.3 ng/mL. cTnI >or=0.3 ng/mL was incrementally related to aSAH severity by admission symptoms (Hunt/Hess P=0.001) and blood load (Fisher P=0.028). More patients with cTnI >or=0.3 ng/mL had prolonged QTc on early (63% versus 30%, P<0.0001) and late electrocardiography (24% versus 7%, P=0.024). On Holter monitoring, more patients with cTnI >or=0.3 ng/mL had ventricular tachycardia/fibrillation (22% versus 9%, P=0.018) but not atrial fibrillation/flutter (P=0.241). Cardiac troponin I >or=0.3 ng/mL was associated with both early ejection fraction <50% (44% versus 5%, P<0.0001) and regional wall motion abnormalities (44% versus 4%, P<0.0001). Regional wall motion abnormalities predominated in basal and midventricular segments and persisted to some degree in 73% of patients affected, whereas ejection fraction <50% persisted in 59% of patients affected. CONCLUSIONS Cardiac injury is incrementally worse with increasing aSAH severity and associated with persistent QTc prolongation and ventricular arrhythmias. Regional wall motion abnormalities and depressed ejection fraction persist to some degree in the majority of those affected.
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Affiliation(s)
- Marilyn Hravnak
- University of Pittsburgh Schools of Nursing, Pittsburgh, PA, USA.
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22
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Tanabe M, Crago EA, Suffoletto MS, Hravnak M, Frangiskakis JM, Kassam AB, Horowitz MB, Gorcsan J. Relation of elevation in cardiac troponin I to clinical severity, cardiac dysfunction, and pulmonary congestion in patients with subarachnoid hemorrhage. Am J Cardiol 2008; 102:1545-50. [PMID: 19026312 DOI: 10.1016/j.amjcard.2008.07.053] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Revised: 07/15/2008] [Accepted: 07/15/2008] [Indexed: 11/28/2022]
Abstract
An increase in cardiac troponin I (cTnI) occurs often after aneurysmal subarachnoid hemorrhage (SAH), but its significance is not well understood. One hundred three patients with SAH were prospectively evaluated in the SAHMII Study to determine the relations of cTnI to clinical severity, systolic and diastolic cardiac function, pulmonary congestion, and length of intensive care unit stay. Echocardiographic ejection fraction, wall motion score, mitral inflow early diastolic (E) and mitral annular early (E') velocities were assessed. Thirty patients (29%) had mildly positive cTnI (0.1 to 1.0 ng/ml), 24 (23%) had highly positive cTnI (>1.0 ng/ml), and 49 (48%) had negative cTnI (<0.1 ng/ml). Highly positive cTnI was associated with worse neurologic disease, longer intensive care unit stay, and slight depression of ejection fraction (51 +/- 11% [p <0.05] vs 59 +/- 8% and 63 +/- 6% in mildly positive or negative cTnI groups, respectively). Highly positive cTnI was also associated with abnormal wall motion acutely (>1.31 ng/ml; 76% sensitivity, 91% specificity), which typically resolved within 5 to 10 days. Both mildly or highly positive cTnI were associated with acute diastolic dysfunction, with E/E' of 17 +/- 6 and 16 +/- 6 (both p <0.05) vs 13 +/- 4 in patients with negative cTnI. Prevalences of pulmonary congestion were 79% (p <0.05) in patients with highly positive cTnI, 53% (p <0.05) in patients with mildly positive cTnI, and 29% in cTnI-negative patients. In conclusion, highly positive cTnI with SAH was associated with clinical neurologic severity, systolic and diastolic cardiac dysfunction, pulmonary congestion, and longer intensive care unit stay. Even mild increases in cTnI were associated with diastolic dysfunction and pulmonary congestion.
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Affiliation(s)
- Masaki Tanabe
- Division of Cardiology, University of Pittsburgh, Pittsburgh, PA, USA
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Abstract
OBJECTIVES To determine the impact of cardiac complications (CdCs) on outcomes in patients with acute subarachnoid hemorrhage (SAH). PATIENTS AND METHODS Eighty-one adult aneurysmal SAH patients with a fisher grade >1 and/or a Hunt and Hess grade >2 were recruited for this study. CdCs were defined as electrocardiogram (ECG) changes, myocardial necrosis, arrythmias, or pulmonary edema. Outcomes were assessed at 3, 6 and 12 months by telephone interview using the Modified Rankin Scale (MRS), Glasgow Outcome Scale (GOS), Barthel Index and Medical Outcome study Short Form-36 (SF-36). RESULTS The CdCs occurred in 33% of patients. The most common CdCs were arrythmias and pulmonary edema (30%). There was no significant difference in mortality between the two groups. At 3 months there was a significant difference in the Barthel (P = 0.007) and the SF-36 (P = 0.014) with trends in the GOS (P = 0.049) and the MRS (P = 0.063). At 6 months a significant difference remained in the SF-36 (P = 0.028) and a trend in the Barthel (P = 0.069). CONCLUSION Results show that CdCs may negatively impact outcomes in SAH patients up to 6 months following hemorrhage.
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Affiliation(s)
- E A Crago
- University of Pittsburgh School of Nursing, Pittsburgh, PA 15261, USA.
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