Tonic-clonic activity at subarachnoid hemorrhage onset: impact on complications and outcome.
OBJECTIVE
Tonic-clonic activity (TCA) at onset complicates 3% to 21% of cases of subarachnoid hemorrhage (SAH). The impact of onset TCA on in-hospital complications, including seizures, remains unclear. One study associated onset TCA with poor clinical outcome at 6 weeks after SAH, but to our knowledge no other studies have confirmed this relationship. This study aims to assess the impact of onset TCA on in-hospital complications, poor functional outcome, mortality, and epilepsy at 3 months.


METHODS
Analysis of a prospective study cohort of 1479 SAH patients admitted to Columbia University Medical Center between 1996 and 2012. TCA within 6 hours of hemorrhage onset was identified based on accounts of emergency care providers or family witnesses.


RESULTS
TCA at onset was described in 170 patients (11%). Patients with onset TCA were younger (P = 0.002), presented more often with poor clinical grade (55% vs. 26%, P<0.001) and had larger amounts of cisternal, intraventricular, and intracerebral blood than those without onset TCA (all, P<0.001). After adjusting for known confounders, onset TCA was significantly associated with in-hospital seizures (OR 3.80, 95%-CI: 2.43-5.96, P<0.001), in-hospital pneumonia (OR 1.56, 95%-CI: 1.06-2.31, p = 0.02), and delayed cerebral ischemia (OR 1.77, 95%-CI: 1.21-2.58, P = 0.003). At 3 months, however, onset TCA was not associated with poor functional outcome, mortality, and epilepsy after adjusting for age, admission clinical grade, and cisternal blood volume.


CONCLUSIONS
Onset TCA is not a rare event as it complicates 11% of cases of SAH. New and clinically relevant findings are the association of onset TCA with in-hospital seizures, pneumonia and delayed cerebral ischemia. Despite the increased risk of in-hospital complications, onset TCA is not associated with disability, mortality, and epilepsy at 3 months.
Departments of Neurology and Neurosurgery, Columbia University College of Physicians and Surgeons, New York, New York, United States of America.
Gian Marco
GM
De Marchis
Deborah
D
Pugin
Hector
H
Lantigua
Christopher
C
Zammit
Prasanna
P
Tadi
J Michael
JM
Schmidt
M Cristina
MC
Falo
Sachin
S
Agarwal
Stephan A
SA
Mayer
Jan
J
Claassen
D000328:Adult; D002545:Brain Ischemia / Q000209:etiology; D004830:Epilepsy, Tonic-Clonic / Q000209:etiology*; D005260:Female; D006760:Hospitalization; D006801:Humans; D008297:Male; D008875:Middle Aged; D063868:Patient Outcome Assessment; D011014:Pneumonia / Q000209:etiology; D013345:Subarachnoid Hemorrhage / Q000150:complications*; D018746:Systemic Inflammatory Response Syndrome / Q000209:etiology