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Subarachnoid hemorrhage: who dies, and why?

Lantigua H, Ortega-Gutierrez S, Schmidt JM, Lee K, Badjatia N, Agarwal S, Claassen J, Connolly ES, Mayer SA - Crit Care (2015)

Bottom Line: The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55%), aneurysm rebleeding (17%), and medical complications (15%).Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave, New York, NY, 10032, USA. hectorlantigua@gmail.com.

ABSTRACT

Introduction: Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Causes and mechanisms of in-hospital death after SAH in the modern era of neurocritical care remain incompletely understood.

Methods: We studied 1200 consecutive SAH patients prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. Analysis was performed to identify predictors of in-hospital mortality.

Results: In-hospital mortality was 18% (216/1200): 3% for Hunt-Hess grade 1 or 2, 9% for grade 3, 24% for grade 4, and 71% for grade 5. The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55%), aneurysm rebleeding (17%), and medical complications (15%). Among those who died, brain death was declared in 42%, 50% were do-not-resuscitate at the time of cardiac death (86% of whom had life support actively withdrawn), and 8% died despite full support. Admission predictors of mortality were age, loss of consciousness at ictus, admission Glasgow Coma Scale score, large aneurysm size, Acute Physiology and Chronic Health Evaluation II (APACHE II) physiologic subscore, and Modified Fisher Scale score. Hospital complications that further increased the risk of dying in multivariable analysis included rebleeding, global cerebral edema, hypernatremia, clinical signs of brain stem herniation, hypotension of less than 90 mm Hg treated with pressors, pulmonary edema, myocardial ischemia, and hepatic failure. Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.

Conclusion: Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

No MeSH data available.


Related in: MedlinePlus

Survival analysis stratified by mode of death and level of support during the first 2 weeks after SAH. An additional 17 patients (8 % of those who died overall) died after SAH day 30 but prior to discharge. DNR do-not-resuscitate, SAH subarachnoid hemorrhage
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Fig2: Survival analysis stratified by mode of death and level of support during the first 2 weeks after SAH. An additional 17 patients (8 % of those who died overall) died after SAH day 30 but prior to discharge. DNR do-not-resuscitate, SAH subarachnoid hemorrhage

Mentions: Survival analysis stratified by mode of death and level of support is shown in Fig. 2. Thirty percent of deaths occurred within 48 h of admission, 56 % had occurred by SAH day 7, and 76 % had occurred by SAH day 14. The majority of brain dead patients (74 %, 67/90) died within 7 days of SAH, whereas death due to active withdrawal of support was more likely to occur after day 7 (55 %, 51/93). Overall, the most common adjudicated primary causes of death (Fig. 3) were direct effect of the primary hemorrhage (55 %), aneurysm rebleeding (17 %), medical complications (15 %), cerebral edema (5 %), and DCI from vasospasm (5 %).Fig. 2


Subarachnoid hemorrhage: who dies, and why?

Lantigua H, Ortega-Gutierrez S, Schmidt JM, Lee K, Badjatia N, Agarwal S, Claassen J, Connolly ES, Mayer SA - Crit Care (2015)

Survival analysis stratified by mode of death and level of support during the first 2 weeks after SAH. An additional 17 patients (8 % of those who died overall) died after SAH day 30 but prior to discharge. DNR do-not-resuscitate, SAH subarachnoid hemorrhage
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4556224&req=5

Fig2: Survival analysis stratified by mode of death and level of support during the first 2 weeks after SAH. An additional 17 patients (8 % of those who died overall) died after SAH day 30 but prior to discharge. DNR do-not-resuscitate, SAH subarachnoid hemorrhage
Mentions: Survival analysis stratified by mode of death and level of support is shown in Fig. 2. Thirty percent of deaths occurred within 48 h of admission, 56 % had occurred by SAH day 7, and 76 % had occurred by SAH day 14. The majority of brain dead patients (74 %, 67/90) died within 7 days of SAH, whereas death due to active withdrawal of support was more likely to occur after day 7 (55 %, 51/93). Overall, the most common adjudicated primary causes of death (Fig. 3) were direct effect of the primary hemorrhage (55 %), aneurysm rebleeding (17 %), medical complications (15 %), cerebral edema (5 %), and DCI from vasospasm (5 %).Fig. 2

Bottom Line: The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55%), aneurysm rebleeding (17%), and medical complications (15%).Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

View Article: PubMed Central - PubMed

Affiliation: Department of Neurology, Columbia University College of Physicians and Surgeons, 177 Fort Washington Ave, New York, NY, 10032, USA. hectorlantigua@gmail.com.

ABSTRACT

Introduction: Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Causes and mechanisms of in-hospital death after SAH in the modern era of neurocritical care remain incompletely understood.

Methods: We studied 1200 consecutive SAH patients prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. Analysis was performed to identify predictors of in-hospital mortality.

Results: In-hospital mortality was 18% (216/1200): 3% for Hunt-Hess grade 1 or 2, 9% for grade 3, 24% for grade 4, and 71% for grade 5. The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55%), aneurysm rebleeding (17%), and medical complications (15%). Among those who died, brain death was declared in 42%, 50% were do-not-resuscitate at the time of cardiac death (86% of whom had life support actively withdrawn), and 8% died despite full support. Admission predictors of mortality were age, loss of consciousness at ictus, admission Glasgow Coma Scale score, large aneurysm size, Acute Physiology and Chronic Health Evaluation II (APACHE II) physiologic subscore, and Modified Fisher Scale score. Hospital complications that further increased the risk of dying in multivariable analysis included rebleeding, global cerebral edema, hypernatremia, clinical signs of brain stem herniation, hypotension of less than 90 mm Hg treated with pressors, pulmonary edema, myocardial ischemia, and hepatic failure. Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality.

Conclusion: Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.

No MeSH data available.


Related in: MedlinePlus