In gratitude of the loyal support of our members, the CNS is offering complimentary 2021 Annual Meeting registration to all members! Learn more.

  • Systemic Inflammatory Response Syndrome and Anemia in Aneurysmal Subarachnoid Hemorrhage: An Exploratory Analysis

    Final Number:
    1406

    Authors:
    Aaron P. Wessell MD; Jeffrey Oliver MD; Matthew J Kole; Gregory Cannarsa MD; J. Marc Simard MD

    Study Design:
    Other

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: We sought to explore the relationship between the systemic inflammatory response, anemia and clinical outcomes after aneurysmal subarachnoid hemorrhage.

    Methods: We performed a retrospective analysis of 194 consecutive patients with aneurysmal subarachnoid hemorrhage. SIRS was characterized by two or more of the following criteria on any given day during the first week of hospitalization: (1) temperature >38°C or <36°C; (2) white blood cell count >12,000 or <4,000; (3) heart rate >90 beats per minute (tachycardia); (4) respiratory rate >20 breaths per minute (tachypnea). Anemia was defined as a hemoglobin level <10 g/dl. The minimum hemoglobin relative percentage (MHRP) was defined as the percentage of the patient’s minimum hemoglobin level during hospitalization relative to their baseline hemoglobin level on admission.

    Results: 57% of patients had SIRS present on day of admission. Mean admission hemoglobin level was 13.17 (±1.95) g/dl (range: 8.4-19.1 g/dl). 67% of patients developed anemia during their hospital stay. Increased cumulative SIRS burden during the first week of hospitalization was associated with increased incidence of anemia and reduced MHRP (P<0.05). Age (OR 0.91, 95% OR 0.87-0.95), WFNS grade >/=4 (OR 0.21, 95% CI 0.08-0.56), modified Fisher score >/=3 (OR 0.28, 95% CI 0.08-0.95), cerebral infarct (OR 0.14, 95% CI 0.05-0.48), SIRS on admission (OR 0.28, 95% CI 0.12-0.66) and MHRP (OR 1.06, 95% CI 1.02-1.12) were independently associated with discharge to home. Increased MHRP was independently associated with a reduced odds of DND (OR 0.93, 95% CI 0.90-0.97), and refractory cerebral vasospasm requiring intra-arterial rescue therapy (OR 0.91, 95% CI 0.88-0.95) on multivariable regression.

    Conclusions: Admission WFNS grade >/=4, admission hemoglobin, and SIRS burden during the first week of hospitalization were independently associated with the development of anemia. Decreases in hemoglobin during hospitalization, defined by the MHRP, were predictive of discharge disposition, the onset of DND, and the need for intra-arterial therapy.

    Patient Care: This research may improve patient care by providing further insight into the potential mechanisms behind the development of anemia following aneurysmal subarachnoid hemorrhage. Additionally, we highlight the potential impact of changes in hemoglobin parameters on patient outcomes and shed light on the potential for improvement in transfusion practices in subarachnoid hemorrhage patients who become critically ill.

    Learning Objectives: The purpose of this exploratory analysis is to further investigate the relationship between SIRS and anemia following aneurysmal subarachnoid hemorrhage. Secondly, we investigate the relationship between SIRS, hemoglobin parameters, and various outcome measures, such as delayed neurologic deficit (DND), cerebral vasospasm, refractory vasospasm requiring intra-arterial rescue therapy, cerebral infarct, and discharge disposition.

    References: 1. Giller CA, Wills MJ, Giller AM, Samson D. Distribution of hematocrit values after aneurysmal subarachnoid hemorrhage. Journal of neuroimaging : official journal of the American Society of Neuroimaging. 1998 Jul;8(3):169-70. PubMed PMID: 9664854. 2. Kramer AH, Gurka MJ, Nathan B, Dumont AS, Kassell NF, Bleck TP. Complications associated with anemia and blood transfusion in patients with aneurysmal subarachnoid hemorrhage. Critical care medicine. 2008 Jul;36(7):2070-5. PubMed PMID: 18552682. 3. Naidech AM, Drescher J, Ault ML, Shaibani A, Batjer HH, Alberts MJ. Higher hemoglobin is associated with less cerebral infarction, poor outcome, and death after subarachnoid hemorrhage. Neurosurgery. 2006 Oct;59(4):775-9; discussion 9-80. PubMed PMID: 17038943. 4. Naidech AM, Jovanovic B, Wartenberg KE, Parra A, Ostapkovich N, Connolly ES, et al. Higher hemoglobin is associated with improved outcome after subarachnoid hemorrhage. Critical care medicine. 2007 Oct;35(10):2383-9. PubMed PMID: 17717494. 5. Kramer AH, Zygun DA, Bleck TP, Dumont AS, Kassell NF, Nathan B. Relationship between hemoglobin concentrations and outcomes across subgroups of patients with aneurysmal subarachnoid hemorrhage. Neurocritical care. 2009;10(2):157-65. PubMed PMID: 19116699. 6. Stein M, Brokmeier L, Herrmann J, Scharbrodt W, Schreiber V, Bender M, et al. Mean hemoglobin concentration after acute subarachnoid hemorrhage and the relation to outcome, mortality, vasospasm, and brain infarction. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2015 Mar;22(3):530-4. PubMed PMID: 25533213. 7. Kurtz P, Schmidt JM, Claassen J, Carrera E, Fernandez L, Helbok R, et al. Anemia is associated with metabolic distress and brain tissue hypoxia after subarachnoid hemorrhage. Neurocritical care. 2010 Aug;13(1):10-6. PubMed PMID: 20383611. 8. Tam AK, Ilodigwe D, Mocco J, Mayer S, Kassell N, Ruefenacht D, et al. Impact of systemic inflammatory response syndrome on vasospasm, cerebral infarction, and outcome after subarachnoid hemorrhage: exploratory analysis of CONSCIOUS-1 database. Neurocritical care. 2010 Oct;13(2):182-9. PubMed PMID: 20593247. 9. Yoshimoto Y, Tanaka Y, Hoya K. Acute systemic inflammatory response syndrome in subarachnoid hemorrhage. Stroke. 2001 Sep;32(9):1989-93. PubMed PMID: 11546886. 10. Gruber A, Reinprecht A, Illievich UM, Fitzgerald R, Dietrich W, Czech T, et al. Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage. Critical care medicine. 1999 Mar;27(3):505-14. PubMed PMID: 10199529. 11. Dhar R, Diringer MN. The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage. Neurocritical care. 2008;8(3):404-12. PubMed PMID: 18196475. Pubmed Central PMCID: 2538678. 12. Sampson TR, Dhar R, Diringer MN. Factors associated with the development of anemia after subarachnoid hemorrhage. Neurocritical care. 2010 Feb;12(1):4-9. PubMed PMID: 19777386. Pubmed Central PMCID: 2824166. 13. Connolly ES, Jr., Rabinstein AA, Carhuapoma JR, Derdeyn CP, Dion J, Higashida RT, 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 Jun;43(6):1711-37. PubMed PMID: 22556195. 14. Dhar R, Zazulia AR, Derdeyn CP, Diringer MN. RBC Transfusion Improves Cerebral Oxygen Delivery in Subarachnoid Hemorrhage. Critical care medicine. 2017 Apr;45(4):653-9. PubMed PMID: 28169942. Pubmed Central PMCID: 5350019. 15. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. The New England journal of medicine. 1999 Feb 11;340(6):409-17. PubMed PMID: 9971864. 16. Teasdale GM, Drake CG, Hunt W, Kassell N, Sano K, Pertuiset B, et al. A universal subarachnoid hemorrhage scale: report of a committee of the World Federation of Neurosurgical Societies. Journal of neurology, neurosurgery, and psychiatry. 1988 Nov;51(11):1457. PubMed PMID: 3236024. Pubmed Central PMCID: 1032822. 17. Frontera JA, Claassen J, Schmidt JM, Wartenberg KE, Temes R, Connolly ES, Jr., et al. Prediction of symptomatic vasospasm after subarachnoid hemorrhage: the modified fisher scale. Neurosurgery. 2006 Jul;59(1):21-7; discussion -7. PubMed PMID: 16823296. 18. Weidauer S, Lanfermann H, Raabe A, Zanella F, Seifert V, Beck J. Impairment of cerebral perfusion and infarct patterns attributable to vasospasm after aneurysmal subarachnoid hemorrhage: a prospective MRI and DSA study. Stroke. 2007 Jun;38(6):1831-6. PubMed PMID: 17446425. 19. Wray NR, Yang J, Goddard ME, Visscher PM. The genetic interpretation of area under the ROC curve in genomic profiling. PLoS genetics. 2010 Feb 26;6(2):e1000864. PubMed PMID: 20195508. Pubmed Central PMCID: 2829056. 20. Metz CE. Basic principles of ROC analysis. Seminars in nuclear medicine. 1978 Oct;8(4):283-98. PubMed PMID: 112681. 21. Gruber A, Rossler K, Graninger W, Donner A, Illievich MU, Czech T. Ventricular cerebrospinal fluid and serum concentrations of sTNFR-I, IL-1ra, and IL-6 after aneurysmal subarachnoid hemorrhage. Journal of neurosurgical anesthesiology. 2000 Oct;12(4):297-306. PubMed PMID: 11147377. 22. Naredi S, Lambert G, Friberg P, Zall S, Eden E, Rydenhag B, et al. Sympathetic activation and inflammatory response in patients with subarachnoid haemorrhage. Intensive care medicine. 2006 Dec;32(12):1955-61. PubMed PMID: 17058068. 23. Means RT, Jr., Krantz SB. Progress in understanding the pathogenesis of the anemia of chronic disease. Blood. 1992 Oct 01;80(7):1639-47. PubMed PMID: 1391934. 24. Krantz SB. Pathogenesis and treatment of the anemia of chronic disease. The American journal of the medical sciences. 1994 May;307(5):353-9. PubMed PMID: 8172230. 25. Gabriel A, Kozek S, Chiari A, Fitzgerald R, Grabner C, Geissler K, et al. High-dose recombinant human erythropoietin stimulates reticulocyte production in patients with multiple organ dysfunction syndrome. The Journal of trauma. 1998 Feb;44(2):361-7. PubMed PMID: 9498512. 26. Corwin HL, Krantz SB. Anemia of the critically ill: "acute" anemia of chronic disease. Critical care medicine. 2000 Aug;28(8):3098-9. PubMed PMID: 10966311. 27. Bell DL, Kimberly WT, Yoo AJ, Leslie-Mazwi TM, Rabinov JD, Bell JE, et al. Low neurologic intensive care unit hemoglobin as a predictor for intra-arterial vasospasm therapy and poor discharge modified Rankin Scale in aneurysmal subarachnoid haemorrhage-induced cerebral vasospasm. Journal of neurointerventional surgery. 2015 Jun;7(6):438-42. PubMed PMID: 24814068. 28. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Critical care medicine. 1985 Oct;13(10):818-29. PubMed PMID: 3928249. 29. Harrison DA, Parry GJ, Carpenter JR, Short A, Rowan K. A new risk prediction model for critical care: the Intensive Care National Audit & Research Centre (ICNARC) model. Critical care medicine. 2007 Apr;35(4):1091-8. PubMed PMID: 17334248. 30. Dhar R, Zazulia AR, Videen TO, Zipfel GJ, Derdeyn CP, Diringer MN. Red blood cell transfusion increases cerebral oxygen delivery in anemic patients with subarachnoid hemorrhage. Stroke. 2009 Sep;40(9):3039-44. PubMed PMID: 19628806. Pubmed Central PMCID: 2742367. 31. Dhar R, Scalfani MT, Zazulia AR, Videen TO, Derdeyn CP, Diringer MN. Comparison of induced hypertension, fluid bolus, and blood transfusion to augment cerebral oxygen delivery after subarachnoid hemorrhage. Journal of neurosurgery. 2012 Mar;116(3):648-56. PubMed PMID: 22098203. Pubmed Central PMCID: 3763719. 32. Broessner G, Lackner P, Hoefer C, Beer R, Helbok R, Grabmer C, et al. Influence of red blood cell transfusion on mortality and long-term functional outcome in 292 patients with spontaneous subarachnoid hemorrhage. Critical care medicine. 2009 Jun;37(6):1886-92. PubMed PMID: 19384223. 33. Festic E, Rabinstein AA, Freeman WD, Mauricio EA, Robinson MT, Mandrekar J, et al. Blood transfusion is an important predictor of hospital mortality among patients with aneurysmal subarachnoid hemorrhage. Neurocritical care. 2013 Apr;18(2):209-15. PubMed PMID: 22965325. 34. Kramer AH, Diringer MN, Suarez JI, Naidech AM, Macdonald LR, Le Roux PD. Red blood cell transfusion in patients with subarachnoid hemorrhage: a multidisciplinary North American survey. Critical care. 2011;15(1):R30. PubMed PMID: 21244675. Pubmed Central PMCID: 3222066.

We use cookies to improve the performance of our site, to analyze the traffic to our site, and to personalize your experience of the site. You can control cookies through your browser settings. Please find more information on the cookies used on our site. Privacy Policy