Higher mean arterial pressure increases risk of in-hospital mortality in aneurysmal subarachnoid hemorrhage

Main Article Content

Nadya Noor Ramadhania
Ahmad Faisal Darmawan
Achmad Firdaus Sani

Abstract

Background
The majority (80%) of spontaneous subarachnoid hemorrhage (SAH) cases are caused by cerebral aneurysm rupture. The reported case fatality rate of aneurysmal SAH is still as high as 25 to 50%. Even though studies on aneurysmal SAH have been conducted, the mechanism and factors contributing to its mortality have not yet been clearly understood. The present study aimed to determine the predictors of mortality in aneurysmal SAH.

Methods
This was an observational analytic cross-sectional study. Data of 264 patients with aneurysmal SAH was obtained retrospectively from the medical records. Age, degree of consciousness, blood pressure, absence of aneurysmal treatment and mortality were collected. The simple and multiple logistic regression were used to analyze the data.

Results
The in-hospital mortality rate of aneurysmal SAH was still very high, with 140 (53.1%) patients dying during hospitalization. Simple logic regression analysis showed that patients with older age, lower Glasgow Coma Scale (GCS) score, higher mean arterial pressure (MAP) and no aneurysm treatment had higher in-hospital mortality risk. However, multivariate logistic regression showed that the strongest in-hospital mortality predictor was higher MAP (aOR 2.29; p=0.025), while younger age (aOR 0.39; p=0.006) and aneurysm treatment (aOR 0.34; p=0.006) were independent protective factors against in-hospital death.

Conclusion
Patients with higher mean arterial pressure on initial measurement had higher risks of mortality. More endovascular neurointervention facilities are needed to decrease the mortality rate of aneurysmal SAH.

Article Details

How to Cite
Ramadhania, N. N., Darmawan, A. F., & Sani, A. F. (2020). Higher mean arterial pressure increases risk of in-hospital mortality in aneurysmal subarachnoid hemorrhage. Universa Medicina, 39(3), 153–161. https://doi.org/10.18051/UnivMed.2020.v39.153-161
Section
Original Articles
Author Biographies

Nadya Noor Ramadhania, Neurology Department, Faculty of Medicine, Airlangga University – Dr Soetomo General Hospital, Surabaya

Research assistant - Neurology department

Ahmad Faisal Darmawan, Neurology Department, Faculty of Medicine, Airlangga University – Dr Soetomo General Hospital, Surabaya

Research assistant - Neurology department

Achmad Firdaus Sani, Neurology Department, Faculty of Medicine, Airlangga University – Dr Soetomo General Hospital, Surabaya

Head of Interventional Neurology division - Neurology Department

References

Catapano J, Lawton MT. Subarachnoid hemorrhage. In: Joaquim AF, Ghizoni E, Tedeschi H, Ferreira MAT, editors. Fundamentals of neurosurgery: a guide for clinicians and medical students. Cham (Switzerland): Springer;2019.p:111-27. doi: 10.1007/978-3-030-17649-5_8.

Korja M, Lehto H, Juvela S,Kaprio J. Incidence of subarachnoid hemorrhage is decreasing together with decreasing smoking rates. Neurology 2016;87:1118-23. doi: 10.1212/WNL.0000000000003091.

Okon M, Adebobola N, Julius S, et al. Stroke incidence and case fatality rate in an urban population. J Stroke Cerebrovasc Dis 2015;24:771-7. doi: 10.1016/j.jstrokecerebrovasdis.2014.11.004.

Mackey J, Khoury J, Alwell K, et al. Stable incidence but declining case-fatality rates of subarachnoid hemorrhage in a population. Neurology 2016;87:2192-7. doi: 10.1212/WNL.0000000000003353.

Ikawa F, Morita A, Nakayama T, et al. A register-based SAH study in Japan: high incidence rate and recent decline trend based on lifestyle. J Neurosurg 2020;27:1-9. doi: 10.3171/2020.1.jns192848.

Nabaweesi-Batuka J, Kitunguu PK, Kiboi JG. Pattern of cerebral aneurysms in a Kenyan population as seen at an urban hospital. World Neurosurg 2016;87:255-65. doi: 10.1016/j.wneu.2015.09.061.

Wáng YXI, He J, Zhang L, et al. A higher aneurysmal subarachnoid hemorrhage incidence in women prior to menopause: a retrospective analysis of 4,895 cases from eight hospitals in China. Quant Imaging Med Surg 2016;6:151-6. doi: 10.21037/qims.2016.01.06.

Brown R, Broderick J. Unruptured intracranial aneurysms: epidemiology, natural history, management options, and familial screening. Lancet Neurol 2014;13:393-404. doi: 10.1016/S1474-4422(14)70015-8.

Etminan N, Chang H, Hackenberg K, et al. Worldwide incidence of aneurysmal subarachnoid hemorrhage according to region, time period, blood pressure, and smoking prevalence in the population. JAMA Neurol 2019;76:588. doi: 10.1038/nrneurol.2016.150.

Kurtelius A, Kurki M, von und zu Fraunberg M, et al. Saccular intracranial aneurysms in children when both parents are sporadic or familial carriers of saccular intracranial aneurysms. Neuroepidemiology 2018;52:47-54. doi: 10.1159/000493856.

Chan D, Abrigo J, Cheung T, et al. Screening for intracranial aneurysms? Prevalence of unruptured intracranial aneurysms in Hong Kong Chinese. J Neurosurg 2016;124:1245-9. doi: 10.3171/2015.4.JNS142938.

Galea J, Dulhanty L, Patel H. Predictors of outcome in aneurysmal subarachnoid hemorrhage patients. Stroke 2017;48:2958-63. doi: 10.1161/STROKEAHA.117.017777.

Stienen M, Germans M, Burkhardt J, et al. Predictors of in-hospital death after aneurysmal subarachnoid hemorrhage. Stroke 2018;49:333-40. doi: 10.1161/STROKEAHA.117.019328.

Schuss P, Hadjiathanasiou A, Borger V, Wispel C, Vatter H, Güresir E. Poor-grade aneurysmal subarachnoid hemorrhage: factors influencing functional outcome—a single-center series. World Neurosurg 2016;85:125-9. doi: 10.1016/j.wneu.2015.08.046.

Goldberg J, Schoeni D, Mordasini P, et al. Survival and outcome after poor-grade aneurysmal subarachnoid hemorrhage in elderly patients. Stroke 2018;49:2883-9. doi: 10.1161/STROKEAHA.118.022869.

Witsch J, Frey H, Patel S, et al. Prognostication of long-term outcomes after subarachnoid hemorrhage: the FRESH score. Ann Neurol 2016;80:46-58. doi: 10.1002/ana.24675.

Shimamura N, Naraoka M, Katagai T, et al. Analysis of factors that influence long-term independent living for elderly subarachnoid hemorrhage patients. World Neurosurg 2016;90:504-20. doi: 10.1016/j.wneu.2016.03.057.

Dasenbrock H, Rudy R, Smith, T, et al. Hospital-acquired infections after aneurysmal subarachnoid hemorrhage: a nationwide analysis. World Neurosurg 2016;88:459-74. doi: 10.1016/j.wneu.2015.10.054.

Foreman P, Chua M, Harrigan M, et al. Association of nosocomial infections with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neurosurg 2016;125:1383-9. doi: 10.3171/2015.10.JNS151959.

Wan A, Jaja B, Schweizer T, Macdonald R. Clinical characteristics and outcome of aneurysmal subarachnoid hemorrhage with intracerebral hematoma. J Neurosurg 2016;125:1344-51. doi: 10.3171/2015.10.JNS151036.

Chugh C, Nyirjesy S, Nawalinski K, et al. Red blood cell distribution width is associated with poor clinical outcome after subarachnoid hemorrhage: a pilot study. Neurocrit Care 2015;23:217-24. doi: 10.1007/s12028-015-0117-x.

Al-Mufti F, Misiolek K. Roh D, et al. White blood cell count improves prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. Neurosurgery 2019;84:397-403. doi: 10.1093/neuros/nyy045.

Ahn S, Savarraj J, Pervez M, et al. The subarachnoid hemorrhage early brain edema score predicts delayed cerebral ischemia and clinical outcomes. Neurosurgery 2017;83:137-45. doi: 10.1093/neuros/nyx364.

Mukhtar T, Molyneux A, Hall N, et al. The falling rates of hospital admission, case fatality, and population-based mortality for subarachnoid hemorrhage in England, 1999–2010. J Neurosurg 2016;125:698-704. doi: 10.3171/2015.5.JNS142115.

Vergouwen MDI, Fa AVJT, Algra A, Rinkel G. Time trends in causes of death after aneurysmal subarachnoid hemorrhage. Neurology 2015;86:59-63. doi: 10.1212/WNL.0000000000002239.

Udy AA, Vladic C, Saxby ER, et al. Subarachnoid hemorrhage patients admitted to intensive care in Australia and New Zealand. Crit Care Med 2017;45:e138-e45. doi: 10.1097/CCM.0000000000002059.

Chan V, Lindsay P, McQuiggan J, Zagorski B, Hill M, O’Kelly C. Declining admission and mortality rates for subarachnoid hemorrhage in Canada between 2004 and 2015. Stroke 2019;50:181-4. doi: 10.1161/STROKEAHA.118.022332.

Sodhi H, Savardekar A, Mohindra S, Chhabra R, Gupta V, Gupta S. The clinical profile, management, and overall outcome of aneurysmal subarachnoid hemorrhage at the neurosurgical unit of a tertiary care center in India. J Neurosci Rural Pract 2014;5:118-26. doi: 10.4103/0976-3147.131650.

Rezvani M, Ghandehari K, Ahmadi F, Afzalnia A. Results of surgical and non-surgical treatment of aneurysms in Iran. ARYA Atheroscler 2011;6:136-9.

van Donkelaar C, Bakker N, Veeger N, et al. Predictive factors for rebleeding after aneurysmal subarachnoid hemorrhage. Stroke 2015;46:2100-6. doi: 10.3171/2016.1.JNS152136.

Konczalla J, Gessler F, Bruder M, Berkefeld J, Marquardt G, Seifert V. Outcome after subarachnoid hemorrhage from blood blister–like aneurysm rupture depends on age and aneurysm morphology. World Neurosurg 2017;105:944-51.e1. doi: 10.1016/j.wneu.2017.06.129

Kanamaru H, Kawakita F, Asada R, et al. Prognostic factors varying with age in patients with aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2020;76:118-25. doi: 10.1016/j.jocn.2020.04.022.

Nieuwkamp D, Vaartjes I, Algra A, Bots M, Rinkel G. Age- and gender-specific time trend in risk of death of patients admitted with aneurysmal subarachnoid hemorrhage in the Netherlands. Int J Stroke 2013;8 Suppl A100:90-4. doi: 10.1111/ijs.12006.

Orakdogen M, Emon ST, Somay H, Engin T, Ates O, Berkman MZ. Prognostic factor in patients who underwent aneurysmal clipping due to spontaneous subarachnoid hemorrhage. Turk Neurosurg 2016;26:840-8. doi: 10.5137/1019-5149.JTN.13654-14.1.

Yue Q, Liu Y, Leng B, et al. A prognostic model for early post-treatment outcome of elderly patients with aneurysmal subarachnoid hemorrhage. World Neurosurg 2016;95:253-61. doi: 10.1016/j.wneu.2016.08.020.

Tommasino N, Saravia M, Rodriguez A, Mizraji R. Epidemiologic and evolutionary profile of patients with subarachnoid hemorrhage with Glasgow Coma Scale score of 8 or less who entered the follow-up program of the National Institute of Donation and Transplantation. Transplant Proc 2018;50:405-7. doi: 10.1016/j.transproceed.2017.12.047.

Lee V, Ouyang B, John S, et al. Risk stratification for the in-hospital mortality in subarachnoid hemorrhage: the HAIR score. Neurocrit Care 2014;21:14-9. doi: 10.1007/s12028-013-9952-9.

Suwatcharangkoon S, Meyers E, Falo C, et al. Loss of consciousness at onset of subarachnoid hemorrhage as an important marker of early brain injury. JAMA Neurol 2016;73:28. doi: 10.1001/jamaneurol.2015.3188.

Khanal K, Bhandari S, Shrestha N, Acharya S, Marhatta M. Comparison of outcome predictions by the Glasgow coma scale and the full outline of unresponsiveness score in the neurological and neurosurgical patients in the Intensive Care Unit. Indian J Crit Care Med 2016;20:473-6. doi: 10.4103/0972-5229.188199.

Zafar SF, Postma EN, Biswal S, et al. Electronic health data predict outcomes after aneurysmal subarachnoid hemorrhage. Neurocrit Care 2018;28:184–93. doi: 10.1007/s12028-017-0466-8.

Lindbohm J, Kaprio J, Jousilahti P, Salomaa V, Korja M. Risk factors of sudden death from subarachnoid hemorrhage. Stroke 2017;48:2399-404. doi: 10.1161/STROKEAHA.117.018118.

Rodriguez DR, Matamoro CS, Cue F, Hernandez JLM, Sanchez YP, Nellar JP. Factors associated with poor outcome for aneurysmal subarachnoid haemorrhage in a series of 334 patients. Neurologia 2017;32:15-21. doi: 10.1016/j.nrl.2014.12.006.

Brown RJ, Kumar A, McCullough LD, Butler K. A survey of blood pressure parameters after aneurysmal subarachnoid hemorrhage. Int J Neurosc 2017;127:1-8. doi: 10.3109/00207454.2016.1138952.

Brooks FA, Ughwanogho U, Henderson GV, Black-Schaffer R, Sorond FA, Tan CO. The link between cerebrovascular hemodynamics and rehabilitation outcomes after aneurysmal subarachnoid hemorrhage. Am J Phys Med Rehabil 2018;97:309-15. doi: 10.1097/PHM.0000000000000886.

Gaasch M, Schiefecker AJ, Kofler M, et al. Cerebral autoregulation in the prediction of delayed cerebral ischemia and clinical outcome in poor-grade aneurysmal subarachnoid hemorrhage patients. Crit Care Med 2018;46:774-80. doi: 10.1097/CCM.0000000000003016.

Wajngarten M, Silva GS. Hypertension and stroke: update on treatment. Eur Cardiol Rev 2019;14:111-5. doi: 10.15420/ecr.2019.11.1.

Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012;43:1711–37. doi: 10.1161/STR.0b013e3182587839.

Korja M, Kivisaari R, Jahromi BR, Lehto H. Natural history of ruptured but untreated intracranial aneurysms. Stroke 2017;48:1081–4. doi: 10.1161/STROKEAHA.116.015933.

Sonig A, Shallwani H, Natarajan S, et al. Better outcomes and reduced hospitalization cost are associated with ultra-early treatment of ruptured intracranial aneurysms: a US Nationwide Data Sample Study. Neurosurgery 2018;82:497-505. doi: 10.1093/neuros/nyx241.

Rush B, Romano K, Ashkanani M, McDermid R, Celi L. Impact of hospital case-volume on subarachnoid hemorrhage outcomes: a nationwide analysis adjusting for hemorrhage severity. J Crit Care 2017;37:240-3. doi: 10.1016/j.jcrc.2016.09.009.

van Lieshout JH, Bruland I, Fischer I, et al. Increased mortality of patients with aneurysmatic subarachnoid hemorrhage caused by prolonged transport time to a high-volume neurosurgical unit. Am J Emerg Med 2017;35:45–50. doi: 10.1016/j.ajem.2016.09.067.