Higher Hemoglobin is Associated with Less Cerebral Infarction, Poor Outcome, and Death after Subarachnoid Hemorrhage

169

Background and Purpose— Established predictors of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage are large amounts of extravasated blood and poor clinical condition on admission. The predictive value of other factors is uncertain. Methods— We searched MEDLINE (1960–2012) for clinical, laboratory, and radiological predictors routinely available within 72 hours after subarachnoid hemorrhage. The studies were categorized according to methodological quality. Crude data and effect estimates (odds ratio [OR], hazard ratios, and risk ratio) with 95% CI were extracted, (re-)calculated and pooled if possible. For every potential predictor we assessed all effect estimates on consistency (point estimates in equal direction) and clinical relevance (size and 95% CI). Results— Fifty-two studies on 33 potential predictors were included. There was strong evidence (≥3 high-quality studies) for a higher risk of delayed cerebral ischemia in smokers (pooled OR, 1.2; 95% CI, 1.1–1.4), and moderate evidence (2 high-quality studies) for an increased risk in patients with hyperglycemia (OR, 3.2; 1.8–5.8 and hazard ratios, 1.7; 1.1–2.5), hydrocephalus (OR, 1.3; 1.1–1.5 and OR, 2.6; 1.2–5.5), history of diabetes mellitus (pooled OR, 6.7; 1.7–26), and early systemic inflammatory response syndrome (pooled OR, 2.1; 1.4–3.3). Evidence was limited for increased risk in women (pooled OR, 1.3; 1.1–1.6) and in patients with history of hypertension (pooled OR, 1.5; 1.3–1.7). The evidence on initial loss of consciousness, history of migraine, previous use of selective serotonin reuptake inhibitors, hypomagnesemia, low hemoglobin, or high blood flow on early transcranial Doppler was also limited. Conclusions— There is strong evidence that smoking is a predictor of delayed cerebral ischemia. For several other potential predictions the evidence is moderate, limited, or inconsistent.

Section: Resultsmentioning

confidence: 99%

Delayed Cerebral Ischemia After Subarachnoid Hemorrhage

Rooij

Rinkel

Dankbaar

et al. 2013

169

“…327 Data obtained from prospective registries of patients with aSAH suggest that higher hemoglobin values are associated with improved outcomes after aSAH. 328,329 Nevertheless, thresholds for blood transfusion have been dictated in a nonsystematic manner and have therefore varied widely. Furthermore, red blood cell transfusions, as used in daily practice, have been associated with worse outcomes in aSAH in some series.…”

Section: Management Of Medical Complications Associated With Asahmentioning

confidence: 99%

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage

Connolly¹,

Rabinstein²,

Carhuapoma³

et al. 2012

Self Cite

2,961

1,375

Purpose— The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods— A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council's Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. Results— Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. Conclusions— aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

“…Recent single-center studies suggest that the maintenance of Hgb concentrations Ͼ11 g/dL may improve outcome after SAH. 13,31 This would implicate that a liberal strategy for red blood cell transfusion may be indicated in SAH, although whether this applies to all patients, ie, those with and without adequate cerebrovascular reserve, is unclear. Furthermore, these results are in contrast to several studies conducted in critically ill nonneurological patients [32][33][34][35][36][37] and in patients with severe brain injury 14 -16 that showed that a liberal strategy of red blood cell transfusion to maintain Hgb concentrations Ͼ10 g/dL do not confer any significant advantage to patient outcome when compared with a more restrictive transfusion strategy (Hgb target 7 to 9 g/dL).…”

Section: Symptomatic Vasospasm (N=8)mentioning

confidence: 99%

Hemoglobin Concentration and Cerebral Metabolism in Patients With Aneurysmal Subarachnoid Hemorrhage

Oddo

Milby

Chen

et al. 2009

136

Background and Purpose-The optimal hemoglobin (Hgb) target after aneurysmal subarachnoid hemorrhage is not precisely known. We sought to examine the threshold of Hgb concentration associated with an increased risk of cerebral metabolic dysfunction in patients with poor-grade subarachnoid hemorrhage. Methods-Twenty consecutive patients with poor-grade subarachnoid hemorrhage who underwent multimodality neuromonitoring (intracranial pressure, brain tissue oxygen tension, cerebral microdialysis) were studied prospectively. Brain tissue oxygen tension and extracellular lactate/pyruvate ratio were used as markers of cerebral metabolic dysfunction and the relationship between Hgb concentrations and the incidence of brain hypoxia (defined by a brain tissue oxygen tension Ͻ20 mm Hg) and cell energy dysfunction (defined by a lactate/pyruvate ratio Ͼ40) was analyzed.