Predictors of unfavourable outcome in aneurysmal subarachnoid haemorrhage.

BACKGROUND: Mortality rates following aneurysmal subarachnoid haemorrhage (aSAH) have decreased due to improvements in diagnoses and the management of complications, as well as early obliteration of the aneurysms. Neurogenic pulmonary oedema (NPO) is a clinical syndrome associated with an acute increase in intracranial pressure and a release of catecholamines into the circulation. This study investigated independent predictors of unfavourable outcomes (Glasgow Outcome Scores 1, 2 or 3) in patients with aSAH. MATERIALS AND METHODS: A total of 262 patients with aSAH (162 females) were included in this prospective study. Clinical characteristics were assessed, and electrocardiographic, serum cardiac and inflammatory biomarker measurements were recorded on admission. Outcomes were assessed three months after admission. Univariate and multivariate analyses of these data were used to predict unfavourable outcomes. RESULTS: A total of 156 patients (59.54%) had unfavourable outcomes. Compared to those who had favourable outcomes, patients with unfavourable outcomes were significantly older (54.37 ± 10.56 vs. 49.13 ± 10.77 years; p < 0.001) and had more severe aSAHs (Hunt and Hess grades ≥ 3: 82.7% vs. 39.6%; p < 0.001). Patients with unfavourable outcomes were more likely to have NPO (10.3% vs. 2.8%; p = 0.023), hydrocephalus (34.0% vs. 20.8%; p = 0.02), and aneurysm reruptures (28.2% vs. 3.8%; p < 0.001). Independent predictors of an unfavourable outcome included Hunt and Hess grades ≥ 3 (odds ratio [OR], 4.291; 95% confidence interval [CI], 2.168-8.491; p < 0.001), increased systolic blood pressure on admission (OR, 1.020; 95% CI, 1.002-1.038; p = 0.03), increased heart rate (HR) on admission (OR, 1.024; 95% CI, 1.001-1.048; p = 0.04), and aneurysm rerupture (OR, 4.961; 95% CI, 1.461-16.845; p = 0.01). CONCLUSIONS: These findings suggest that aneurysm reruptures, as well as increased blood pressure and HR, are associated with unfavourable outcomes in patients with aSAH.

Could cardiac biomarkers predict neurogenic pulmonary edema in aneurysmal subarachnoid hemorrhage?

BACKGROUND: Neurogenic pulmonary edema (NPE) is a clinical syndrome characterized by the acute onset of pulmonary edema after a significant central nervous system (CNS) insult. NPE occurs as a result of release of catecholamines into the blood immediately after aneurysm rupture. The aim of this study is to investigate the connection between the value of cardiac biomarkers on admission and incidence of NPE in patients with aneurysmal subarachnoid hemorrhage (SAH). METHODS: A total of 262 SAH patients (162 women, 100 men) were prospectively included in the study. Clinical characteristics, electrocardiographic (ECG) changes, serum cardiac and inflammatory biomarkers were measured on admission and on the day of development of NPE. These data were analyzed in order to predict the development NPE. RESULTS: Nineteen patients (7.25%) developed NPE. Comparison revealed that patients who subsequently developed NPE, sustained more severe SAH. Cardiac damage was more severe in these patients, as represented by significantly higher mean values of all examined cardiac biomarkers (P = 0.000), except for troponin I value that was significantly lower (P = 0.000). Multivariate regression analysis revealed that elevated troponin I (OR, 4.980; 95% CI, 1.27-19.49; P = 0.021) and white blood cell count (OR, 22.195; 95% CI, 3.99-123.50; P = 0.000) are predictors of NPE. CONCLUSIONS: Significantly higher values of cardiac biomarkers were observed in SAH patients complicated with NPE. Elevated values of cardiac biomarkers appear to play an active role in prediction of NPE, although white blood cell count may be involved in the prediction of NPE. There is an influence of SAH therapy on predictors of NPE.

[Reverse Trendelenburg's position vs. supine-horizontal position for induction of general anesthesia in obese neurosurgical patients].

INTRODUCTION: The induction of general endotracheal anesthesia (GETA) is associated with variable period of apnea. Obese patients have reduced oxygen supply during period of apnea. Hypoxemia and subsequent hypercarbia, during period of apnea, are strong stimuli of cerebral blood flow and intracranial pressure increase. OBJECTIVE: The objective of our study was to determine the patient position with safe apnea period (SAP), which will minimize the risk of hypoxemia, as an optimal positioning for induction of GETA in obese neurosurgical patients. METHOD: Obese patients (BMI > 30kg m(-2)) were randomly placed to one of two positions for induction of GETA: group I (n=20) consisted of patients assuming 30 degree reverse Trendelenburg's position; group II (n=20) was in supine-horizontal position. After the arterial oxygen saturation of 100% measured by pulse oximetry (SpO2), patients were allowed to remain apneic. The time required for SpO2 to decline from 100% to 94% was recorded as SAP. The lowest SpO2 after restoration of ventilation and recovery time to 98% SpO2 were also recorded. RESULTS Time needed for SpO2 to decline to 94% was: 196.9 +/- 21.53 sec in group I, and 130.65 +/- 25.73 sec in group II. There was significant difference between groups (I vs. II; p < 0.05). SpO2 of patients in the reverse Trendelenburg's position dropped the least and took the shortest time to restore to 98%. The recovery time was much longer in group II, 132.65 +/- 33.75 (I vs. II; p < 0.05). CONCLUSION: 30 degree reverse Trendelenburg's position provides longer SAP when compared with horizontal-supine positions. This extra time may preclude adverse sequelae resulting from hypoxemia during induction of obese neurosurgical patients.