Neurocritical Care

, Volume 13, Issue 3, pp 359–365

Left Ventricular Dysfunction and Cerebral Infarction from Vasospasm After Subarachnoid Hemorrhage

  • Richard E. Temes
  • Elena Tessitore
  • J. Michael Schmidt
  • Andrew M. Naidech
  • Andres Fernandez
  • Noeleen D. Ostapkovich
  • Jennifer A. Frontera
  • Katja E. Wartenberg
  • Marco R. Di Tullio
  • Neeraj Badjatia
  • E. Sander Connolly
  • Stephan A. Mayer
  • Augusto Parra
Original Article

Abstract

Background

Although neurogenic stunned myocardium (NSM) after aneurysmal subarachnoid hemorrhage (SAH) is well described, its clinical significance remains poorly defined. We investigated the influence of left ventricular (LV) dysfunction and cerebral vasospasm on cerebral infarction, serious cardiovascular events, and functional outcome after SAH.

Methods

Of the 481 patients enrolled in the University Columbia SAH Outcomes Project between 10/96 and 05/02, we analyzed a subset of 119 patients with at least one echocardiogram, serial transcranial Doppler (TCD) data, and with no prior history of cardiac disease. LV dysfunction was defined as an ejection fraction <40% on echocardiography. Infarction from vasospasm was adjudicated by the study team after comprehensive review of all clinical and imaging data. Functional outcome was assessed at 15 and 90 days with the modified Rankin Scale (mRS).

Results

Eleven percent of patients had LV dysfunction (N = 13). Younger age, hydrocephalus, and complete filling of the quadrigeminal and fourth ventricles were associated with LV dysfunction (all P < 0.05). Despite a similar frequency of pre-existing hypertension, 0% of patients with LV dysfunction reported taking antihypertensive medication, compared to 35% of those without (P = 0.009). There was a significant association between LV dysfunction and infarction from vasospasm after adjusting for clinical grade, age, and peak TCD flow velocity (P = 0.03). Patients with LV dysfunction also had higher rates of hypotension requiring vasopressors (P = 0.001) and pulmonary edema (P = 0.002). However, there was no association between LV dysfunction and outcome at 14 days after adjustment for established prognostic variables.

Conclusions

LV dysfunction after SAH increases the risk of cerebral infarction from vasospasm, hypotension, and pulmonary edema, but with aggressive ICU support does not affect short-term survival or functional outcome. Antihypertensive medication may confer cardioprotection and reduce the risk of catecholamine-mediated injury after SAH.

Keywords

Subarachnoid hemorrhage Cerebral infarction Vasospasm Neurogenic stunned myocardioum Left ventricular dysfunction Echocardiography 

References

  1. 1.
    Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, Wu KC, Rade JJ, Bivalacqua TJ, Champion HC. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539–48.CrossRefPubMedGoogle Scholar
  2. 2.
    Parekh N, Venkatesh B, Cross D, Leditschke A, Atherton J, Miles W, Winning A, Clague A, Rickard C. Cardiac troponin I predicts myocardial dysfunction in aneurysmal subarachnoid hemorrhage. J Am Coll Cardiol. 2000;36:1328–35.CrossRefPubMedGoogle Scholar
  3. 3.
    Minegishi A, Ishizaki T, Yoshida Y, Ahagon A, Shibata N, Kobayashi H. Plasma monoaminergic metabolites and catecholamines in subarachnoid hemorrhage. Clinical implications. Arch Neurol. 1987;44:423–8.PubMedGoogle Scholar
  4. 4.
    Kawahara E, Ikeda S, Miyahara Y, Kohno S. Role of autonomic nervous dysfunction in electrocardio-graphic abnormalities and cardiac injury in patients with acute subarachnoid hemorrhage. Circ J. 2003;67:753–6.CrossRefPubMedGoogle Scholar
  5. 5.
    Pilati CF, Bosso FJ, Maron MB. Factors involved in left ventricular dysfunction after massive sympathetic activation. Am J Physiol. 1992;263(3 Pt 2):H784–91.PubMedGoogle Scholar
  6. 6.
    Crago EA, Kerr ME, Kong Y, Baldisseri M, Horowitz M, Yonas H, Kassam A. The impact of cardiac complications on outcomes in the SAH population. Acta Neurol Scand. 2000;110:248–53.CrossRefGoogle Scholar
  7. 7.
    Kono T, Morita H, Kuroiwa T, Onaka H, Takatsuka H, Fujiwara A. Left ventricular wall motion abnormalities in patients with subarachnoid hemorrhage: neurogenic stunned myocardium. J Am Coll Cardiol. 1994;24:636–40.CrossRefPubMedGoogle Scholar
  8. 8.
    De Marchena E, Pittaluaga JM, Ferreira AC, Lowery M, Romanelli R, Morales A. Subarachnoid hemorrhage simulating myocardial infarction. Cathet Cardiovasc Diagn. 1996;37:170–3.CrossRefPubMedGoogle Scholar
  9. 9.
    Keller C, Williams A. Cardiac dysrhythmias associated with central nervous system dysfunction. J Neurosci Nurs. 1993;25(6):349–55.CrossRefPubMedGoogle Scholar
  10. 10.
    Carruth JE, Silverman ME. Torsade de pointe atypical ventricular tachycardia complicating subarachnoid hemorrhage. Chest. 1980;78:886–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Andreoli A, di Pasquale G, Pinelli G, Grazi P, Tognetti F, Testa C. Subarachnoid hemorrhage: frequency and severity of cardiac arrhythmias. A survey of 70 cases studied in the acute phase. Stroke. 1987;18:558–64.PubMedGoogle Scholar
  12. 12.
    Parizel G. Life threatening arrhythmias in subarachnoid hemorrhage. Angiology. 1973;24:17–21.CrossRefPubMedGoogle Scholar
  13. 13.
    Naidech AM, Kreiter KT, Janjua N, Ostapkovich ND, Parra A, Commichau C, Fitzsimmons B-F, Connolly ES, Mayer SA. Cardiac troponin elevation, cardiovascular morbidity, and outcome after subarachnoid hemorrhage. Circulation. 2005;112:2851–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Bulsara KR, McGirt MJ, Liao L, Vilavicencio AT, Borel C, Alexander MJ, Friedman AH. Use of the peak troponin value to differentiate myocardial infarction from reversible neurogenic left ventricular dysfunction associated with aneurysmal subarachnoid hemorrhage. J Neurosurg. 2003;98:524–8.CrossRefPubMedGoogle Scholar
  15. 15.
    Deibert E, Barzilai B, Braverman AC, Edwards DF, Aiyagari V, Dacey R, Diringer M. Clinical significance of elevated troponin I levels in patients with nontraumatic subarachnoid. J Neurosurg. 2003;98:741–6.CrossRefPubMedGoogle Scholar
  16. 16.
    Mayer SA, Fink ME, Homma S, Sherman D, LiMandri G, Lennihan L, Solomon RA, Klebanoff LM, Beckford A, Raps EC. Cardiac injury associated with neurogenic pulmonary edema following subarachnoid hemorrhage. Neurology. 1994;44:815–20.PubMedGoogle Scholar
  17. 17.
    Tung P, Kopelnik A, Banki N, Ong K, Ko N, Lawton MT, Gress D, Drew B, Foster E, Parmley W, Zaroff J. Predictors of neurocardiogenic injury after subarachnoid hemorrhage. Stroke. 2004;35:548–51.CrossRefPubMedGoogle Scholar
  18. 18.
    Zaroff JG, Rordorf GA, Ogilvy CS, Picard MH. Regional patterns of left ventricular systolic dysfunction after subarachnoid hemorrhage: evidence for neurally mediated cardiac injury. J Am Soc Echocardiogr. 2000;13:774–9.CrossRefPubMedGoogle Scholar
  19. 19.
    Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–3.CrossRefPubMedGoogle Scholar
  20. 20.
    Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28:14–20.CrossRefPubMedGoogle Scholar
  21. 21.
    Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1981;6:1–9.CrossRefGoogle Scholar
  22. 22.
    Hijdra A, van Gijn J, Nagelkerke NJ, Vermeulen M, van Crevel H. Prediction of delayed cerebral ischemia, rebleeding, and outcome after aneurysmal subarachnoid hemorrhage. Stroke. 1988;19:1250–6.PubMedGoogle Scholar
  23. 23.
    van Gijn J, Hijdra A, Wijdicks EF, Vermeulen M, van Crevel H. Acute hydrocephalus after aneurysmal subarachnoid hemorrhage. J Neurosurg. 1985;63:355–62.CrossRefPubMedGoogle Scholar
  24. 24.
    Van Swieten JC, Koudstaal PJ, Visser MC, Schouten HJ, van Gijn J. Interobserver agreement for the assessment of handicap in stroke patients. Stroke. 1988;19:604–7.PubMedGoogle Scholar
  25. 25.
    Cruickshank JM, Hayes Y, Neil-Dwyer G, Degaute JP, Hayes Y, Kuurne T, Kytta J, Vincent JL, Carruthers ME, Patel S. Stress/catecholamine-induced cardiac necrosis. Reduction by beta 1-selective blockade. Lancet. 1987;2(8559):585–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Zaroff JG, Pawlikowska L, Miss JC, Yarlagadda S, Ha C, Achrol A, Kwok PY, McCulloch CE, Lawton MT, Ko N, Smith W, Young WL. Adrenoceptor polymorphisms and the risk of cardiac injury and dysfunction after subarachnoid hemorrhage. Stroke. 2006;37:1680–5.CrossRefPubMedGoogle Scholar
  27. 27.
    Mayer SA, Lin J, Homma N, Solomon RA, Lennihan L, Sherman D, Fink ME, Beckford A, Klebanoff LM. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke. 1999;30:780–6.PubMedGoogle Scholar
  28. 28.
    Carrerra E, Schmidt JM, Oddo M, Fernandez L, Claassen J, Seder D, Lee K, Badjatia N, Connolly ES, Mayer SA. Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Neurosurgery. 2009;65:316–24.CrossRefGoogle Scholar
  29. 29.
    Schmidt JM, Rincon F, Fernandez A, Resor C, Kowalski RG, Claassen J, Connolly ES, Fitzsimmons B-F, Mayer SA. Cerebral infarction associated with acute subarachnoid hemorrhage. Neurocrit Care. 2007;7:10–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Pollick C, Cujec B, Parker S, Tator C. Left ventricular wall motion abnormalities in subarachnoid hemorrhage: an echocardiographic study. J Am Coll Cardiol. 1988;12:600–5.PubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Richard E. Temes
    • 1
    • 5
  • Elena Tessitore
    • 3
  • J. Michael Schmidt
    • 1
  • Andrew M. Naidech
    • 4
  • Andres Fernandez
    • 1
  • Noeleen D. Ostapkovich
    • 1
  • Jennifer A. Frontera
    • 1
    • 6
  • Katja E. Wartenberg
    • 1
    • 7
  • Marco R. Di Tullio
    • 2
  • Neeraj Badjatia
    • 1
  • E. Sander Connolly
    • 1
  • Stephan A. Mayer
    • 1
    • 9
  • Augusto Parra
    • 1
    • 8
    • 10
  1. 1.Neurological Intensive Care UnitColumbia University College of Physicians and SurgeonsNew YorkUSA
  2. 2.Division of Medicine, Department of CardiologyColumbia University College of Physicians and SurgeonsNew YorkUSA
  3. 3.Department of Internal MedicineAlbert Einstein College of MedicineBronxUSA
  4. 4.Department of NeurologyNorthwestern University School of MedicineChicagoUSA
  5. 5.Rush University Medical CenterChicagoUSA
  6. 6.Mt Sinai Medical CenterNew YorkUSA
  7. 7.Martin-Luther-Universität Halle-WittenbergHalleGermany
  8. 8.University of TexasSan AntonioUSA
  9. 9.Division of Neurocritical CareNew YorkUSA
  10. 10.Department of NeurosurgerySan AntonioUSA

Personalised recommendations