Fever after subarachnoid hemorrhage: risk factors and impact on outcome.
OBJECTIVE
To identify risk factors for refractory fever after subarachnoid hemorrhage (SAH), and to determine the impact of temperature elevation on outcome.


METHODS
We studied a consecutive cohort of 353 patients with SAH with a maximum daily temperature (T(max)) recorded on at least 7 days between SAH days 0 and 10. Fever (>38.3 degrees C) was routinely treated with acetaminophen and conventional water-circulating cooling blankets. We calculated daily T(max) above 37.0 degrees C, and defined extreme T(max) as daily excess above 38.3 degrees C. Global outcome at 90 days was evaluated with the modified Rankin Scale (mRS), instrumental activities of daily living (IADLs) with the Lawton scale, and cognitive functioning with the Telephone Interview of Cognitive Status. Mixed-effects models were used to identify predictors of T(max), and logistic regression models to evaluate the impact of T(max) on outcome.


RESULTS
Average daily T(max) was 1.15 degrees C (range 0.04 to 2.74 degrees C). The strongest predictors of fever were poor Hunt-Hess grade and intraventricular hemorrhage (IVH) (both p < 0.001). After controlling for baseline outcome predictors, daily T(max) was associated with an increased risk of death or severe disability (mRS > or = 4, adjusted OR 3.0 per degrees C, 95% CI 1.6 to 5.8), loss of independence in IADLs (OR 2.6, 95% CI 1.2 to 5.6), and cognitive impairment (OR 2.5, 95% CI 1.2 to 5.1, all p < or = 0.02). These associations were even stronger when extreme T(max) was analyzed.


CONCLUSIONS
Treatment-refractory fever during the first 10 days after subarachnoid hemorrhage (SAH) is predicted by poor clinical grade and intraventricular hemorrhage, and is associated with increased mortality and more functional disability and cognitive impairment among survivors. Clinical trials are needed to evaluate the impact of prophylactic fever control on outcome after SAH.
Fernandez
A
A
Neurological Intensive Care Unit, Division of Stroke and Critical Care, Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
Schmidt
J M
JM
Claassen
J
J
Pavlicova
M
M
Huddleston
D
D
Kreiter
K T
KT
Ostapkovich
N D
ND
Kowalski
R G
RG
Parra
A
A
Connolly
E Sander
ES
Mayer
S A
SA
D000082:Acetaminophen / Q000627:therapeutic use; D018712:Analgesics, Non-Narcotic / Q000627:therapeutic use; D001831:Body Temperature / Q000502:physiology*; D001921:Brain / Q000503:physiopathology*; D002543:Cerebral Hemorrhage / Q000150:complications / Q000503:physiopathology; D003072:Cognition Disorders / Q000209:etiology / Q000503:physiopathology / Q000517:prevention & control; D015331:Cohort Studies; D005260:Female; D005334:Fever / Q000209:etiology* / Q000503:physiopathology* / Q000628:therapy; D006801:Humans; D007036:Hypothermia, Induced / Q000706:statistics & numerical data; D020547:Lateral Ventricles / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011379:Prognosis; D012307:Risk Factors; D013345:Subarachnoid Hemorrhage / Q000150:complications* / Q000175:diagnosis / Q000503:physiopathology
D018712:Analgesics, Non-Narcotic; D000082:Acetaminophen