Left Ventricular Dysfunction and Cerebral Infarction from Vasospasm After Subarachnoid Hemorrhage

BackgroundAlthough 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.MethodsOf 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).ResultsEleven 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.ConclusionsLV 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.

[1]  J. van Gijn,et al.  Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. , 1988, Stroke.

[2]  S. Mayer,et al.  Cardiac Troponin Elevation, Cardiovascular Morbidity, and Outcome After Subarachnoid Hemorrhage , 2005, Circulation.

[3]  E. Wijdicks,et al.  Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. , 1985, Journal of neurosurgery.

[4]  W. Hunt,et al.  Surgical risk as related to time of intervention in the repair of intracranial aneurysms. , 1968, Journal of neurosurgery.

[5]  Fisher Cm,et al.  Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. , 1980, Neurosurgery.

[6]  T. Ishizaki,et al.  Plasma monoaminergic metabolites and catecholamines in subarachnoid hemorrhage. Clinical implications. , 1987, Archives of neurology.

[7]  A. Friedman,et al.  Use of the peak troponin value to differentiate myocardial infarction from reversible neurogenic left ventricular dysfunction associated with aneurysmal subarachnoid hemorrhage. , 2003, Journal of neurosurgery.

[8]  E. de Marchena,et al.  Subarachnoid hemorrhage simulating myocardial infarction. , 1996, Catheterization and cardiovascular diagnosis.

[9]  H. Yonas,et al.  The impact of cardiac complications on outcome in the SAH population , 2004, Acta neurologica Scandinavica.

[10]  B. Drew,et al.  Predictors of Neurocardiogenic Injury After Subarachnoid Hemorrhage , 2004, Stroke.

[11]  C. McCulloch,et al.  Adrenoceptor Polymorphisms and the Risk of Cardiac Injury and Dysfunction After Subarachnoid Hemorrhage , 2006, Stroke.

[12]  E. Deibert,et al.  Clinical significance of elevated troponin I levels in patients with nontraumatic subarachnoid hemorrhage. , 2003, Journal of neurosurgery.

[13]  S. Mayer,et al.  Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage , 1994, Neurology.

[14]  G. Parizel.  Life-Threatening Arrhythmias in Subarachnoid Hemorrhage , 1973, Angiology.

[15]  B. Jennett,et al.  Assessment of coma and impaired consciousness. A practical scale. , 1974, Lancet.

[16]  S. Mayer,et al.  Myocardial injury and left ventricular performance after subarachnoid hemorrhage. , 1999, Stroke.

[17]  H. Morita,et al.  Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. , 1994, Journal of the American College of Cardiology.

[18]  Charles Tator,et al.  Left ventricular wall motion abnormalities in subarachnoid hemorrhage: an echocardiographic study. , 1988, Journal of the American College of Cardiology.

[19]  J. Vincent,et al.  REDUCTION OF STRESS/ CATECHOLAMINE-INDUCED CARDIAC NECROSIS BY BETA1-SELECTIVE BLOCKADE , 1987, The Lancet.

[20]  S. Kohno,et al.  Role of autonomic nervous dysfunction in electrocardio-graphic abnormalities and cardiac injury in patients with acute subarachnoid hemorrhage. , 2003, Circulation journal : official journal of the Japanese Circulation Society.

[21]  A. Williams,et al.  Cardiac Dysrhythmias Associated with Central Nervous System Dysfunction , 1993, The Journal of neuroscience nursing : journal of the American Association of Neuroscience Nurses.

[22]  Katherine C. Wu,et al.  Neurohumoral features of myocardial stunning due to sudden emotional stress. , 2005, The New England journal of medicine.

[23]  A. Andreoli,et al.  Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase. , 1987, Stroke.

[24]  Jan Claassen,et al.  TRANSCRANIAL DOPPLER FOR PREDICTING DELAYED CEREBRAL ISCHEMIA AFTER SUBARACHNOID HEMORRHAGE , 2009, Neurosurgery.

[25]  C. Ogilvy,et al.  Regional patterns of left ventricular systolic dysfunction after subarachnoid hemorrhage: evidence for neurally mediated cardiac injury. , 2000, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[26]  C. F. Pilati,et al.  Factors involved in left ventricular dysfunction after massive sympathetic activation. , 1992, The American journal of physiology.

[27]  R. Bloch,et al.  Interobserver agreement for the assessment of handicap in stroke patients. , 1988, Stroke.

[28]  J. Atherton,et al.  Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. , 2000, Journal of the American College of Cardiology.

[29]  Charles D. Resor,et al.  Cerebral infarction associated with acute subarachnoid hemorrhage , 2007, Neurocritical care.

[30]  M. Silverman,et al.  Torsade de pointe atypical ventricular tachycardia complicating subarachnoid hemorrhage. , 1980, Chest.