SpringerLink
Log in

Left Ventricular Dysfunction and Cerebral Infarction from Vasospasm After Subarachnoid Hemorrhage

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript

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.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price includes VAT (Spain)

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  9. Keller C, Williams A. Cardiac dysrhythmias associated with central nervous system dysfunction. J Neurosci Nurs. 1993;25(6):349–55.

    Article  CAS  PubMed  Google Scholar 

  10. Carruth JE, Silverman ME. Torsade de pointe atypical ventricular tachycardia complicating subarachnoid hemorrhage. Chest. 1980;78:886–8.

    Article  CAS  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  12. Parizel G. Life threatening arrhythmias in subarachnoid hemorrhage. Angiology. 1973;24:17–21.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  19. Teasdale G, Jennett B. Assessment of coma and impaired consciousness: a practical scale. Lancet. 1974;2:81–3.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  21. Fisher CM, Kistler JP, Davis JM. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1981;6:1–9.

    Article  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    Article  CAS  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

  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.

    Article  Google Scholar 

  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.

    Article  PubMed  Google Scholar 

  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.

    CAS  PubMed  Google Scholar 

Download references

Acknowledgment

This research was supported in part by a Grant-in-Aid (No. 9750432N) from the American Heart Association to Dr Mayer.

Conflict of interest

None.

Author information

Author notes

  1. Richard E. Temes

    Present address: Rush University Medical Center, Chicago, IL, USA

  2. Jennifer A. Frontera

    Present address: Mt Sinai Medical Center, New York, NY, USA

  3. Katja E. Wartenberg

    Present address: Martin-Luther-Universität Halle-Wittenberg, Halle, Germany

  4. Augusto Parra

    Present address: University of Texas, San Antonio, TX, USA

Authors and Affiliations

  1. Neurological Intensive Care Unit, Columbia University College of Physicians and Surgeons, New York, NY, USA

    Richard E. Temes, J. Michael Schmidt, Andres Fernandez, Noeleen D. Ostapkovich, Jennifer A. Frontera, Katja E. Wartenberg, Neeraj Badjatia, E. Sander Connolly, Stephan A. Mayer & Augusto Parra

  2. Division of Medicine, Department of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY, USA

    Marco R. Di Tullio

  3. Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY, USA

    Elena Tessitore

  4. Department of Neurology, Northwestern University School of Medicine, Chicago, IL, USA

    Andrew M. Naidech

  5. Division of Neurocritical Care, Milstein Hospital Building, 177 Fort Washington Avenue, MHB-8-300 Center, New York, 10032, NY, USA

    Stephan A. Mayer

  6. Department of Neurosurgery, 7703 Floyd Curl Dr., Suite MC 7843, Medical School Building, 102F, San Antonio, TX, 78229-3900, USA

    Augusto Parra

Authors
  1. Richard E. Temes
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Elena Tessitore
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. J. Michael Schmidt
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Andrew M. Naidech
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Andres Fernandez
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Noeleen D. Ostapkovich
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Jennifer A. Frontera
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Katja E. Wartenberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Marco R. Di Tullio
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Neeraj Badjatia
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. E. Sander Connolly
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Stephan A. Mayer
    View author publications

    You can also search for this author in PubMed Google Scholar

  13. Augusto Parra
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding authors

Correspondence to Stephan A. Mayer or Augusto Parra.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Temes, R.E., Tessitore, E., Schmidt, J.M. et al. Left Ventricular Dysfunction and Cerebral Infarction from Vasospasm After Subarachnoid Hemorrhage. Neurocrit Care 13, 359–365 (2010). https://doi.org/10.1007/s12028-010-9447-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s12028-010-9447-x

Keywords

Search

Navigation