title: Predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a cardiac focus.
abstract: BACKGROUND
  Myocardial injury after aneurysmal subarachnoid hemorrhage (aSAH) is associated with poor outcomes. Delayed cerebral ischemia (DCI) is also a complication of aSAH. We sought to determine whether (1) DCI could be predicted by demographics, aSAH severity/aneurysm location, or aSAH-associated myocardial injury (SAHMI), and (2) DCI is associated with increased mortality after aSAH.
  
  
  METHODS
  Prospective longitudinal study of 149 aSAH subjects with definitive DCI evaluation, age 18-75 years, Hunt and Hess (HH) ≥ 3, and/or Fisher ≥ 2, and admitted to the Neurovascular ICU. DCI was defined by the presence of neurological deterioration accompanied by evidence of abnormal cerebral blood flow.
  
  
  RESULTS
  Subjects were 48% DCI(+) and 52% DCI(-). DCI(+) subjects had more severe aSAH [HH (P = 0.002), Fisher (P = 0.004), admission Glasgow Coma Scale (P = 0.018)]. More DCI(+) subjects had pulmonary congestion than DCI(-) subjects (63 vs. 39%, P = 0.003). On echocardiogram, cardiac output (CO, liters per minute [LPM]) was significantly higher in DCI(+) than in DCI(-) subjects (6 ± 2 vs. 5 ± 1 LPM; P = 0.015). Multivariate analysis identified CO and Fisher grade as independent predictors of DCI (P = 0.02, 0.019). For each 1 LPM increase in CO, the odds of DCI increased by 1.5 (95% CI: 1.1-2.1). Fisher grade 4 increased the odds of DCI by 6.5 compared to Fisher grade 2 (95% CI: 1.6-25.8). After controlling for Fisher grade, CO remained an independent predictor of DCI (P = 0.02). Three-month mortality rate was not significantly different between DCI groups, P = 0.786.
  
  
  CONCLUSIONS
  Elevated CO and Fisher grade are predictors of DCI after aSAH. However, prevention of DCI may not decrease mortality.
authors.affiliation: School of Nursing, University of Pittsburgh, 365 Victoria Building, 3500 Victoria Street, Pittsburgh, PA 15261, USA. Kmy12@pitt.edu
authors.forename: Khalil
authors.initials: K
authors.lastname: Yousef
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Crago
authors.forename: Chien-Wen
authors.initials: CW
authors.lastname: Kuo
authors.forename: Michael
authors.initials: M
authors.lastname: Horowitz
authors.forename: Marilyn
authors.initials: M
authors.lastname: Hravnak
mesh_terms: D000328:Adult; D000368:Aged; D002545:Brain Ischemia / Q000175:diagnosis* / Q000401:mortality* / Q000503:physiopathology; D002302:Cardiac Output; D002560:Cerebrovascular Circulation; D003422:Critical Care; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D015994:Incidence; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012720:Severity of Illness Index; D013345:Subarachnoid Hemorrhage / Q000175:diagnosis* / Q000401:mortality* / Q000503:physiopathology; D013997:Time Factors