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

  • Nosocomial Infections are Associated with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

    Final Number:

    Paul M Foreman MD; Michelle Hui Juan Chua BS; Mark R. Harrigan MD; Winfield S. Fisher MD; Nilesh A. Vyas MD; Robert Lipsky; Beverly C. Walters MD, MSc, FRCS(C), FACS; R. Shane Tubbs PhD, PA-C; Mohammadali Mohajel Shoja; Christoph Johannes Griessenauer MD

    Study Design:

    Subject Category:
    Aneurysm/Subarachnoid Hemorrhage

    Meeting: AANS/CNS Cerebrovascular Section 2016 Annual Meeting

    Introduction: Delayed cerebral ischemia (DCI) is a recognized complication of aneurysmal subarachnoid hemorrhage (aSAH) that contributes to poor outcome. This study seeks to determine the effect of nosocomial infection on the incidence of DCI and patient outcome.

    Methods: An exploratory analysis was performed on 156 aSAH patients enrolled in the Cerebral Aneurysm Renin Angiotensin System (CARAS) study. Clinical and radiographic data were analyzed with univariate analysis to detect risk factors for the development of DCI and poor outcome. Multivariate logistic regression was performed to identify independent predictors of DCI.

    Results: One hundred and fifty three patients with aSAH were included. Delayed cerebral ischemia was identified in 32 (20.9%) patients. Nosocomial infection, ventriculitis, aneurysm rerupture, and clinical vasospasm were independently associated with the development of DCI [3.5 (1.93 – 6.35), p < 0.00; 25.3 (4.39 – 110.9), p = 0.03; 7.55 (2.72 – 20.9), p = 0.05; 43.4 (23.6 - 79.8), p < 0.00; respectively]. Diagnosis of nosocomial infection preceded the diagnosis of DCI in 15 of 21 (71.4%) patients. Patients diagnosed with nosocomial infection experienced significantly worse outcomes as measured by mRS at discharge and 1 year (p < 0.00 and p = 0.03, respectively).

    Conclusions: Nosocomial infection is independently associated with DCI. This association is hypothesized to be partly causative through the exacerbation of systemic inflammation leading to thrombosis and subsequent ischemia.

    Patient Care: This research explores clinical risk factors associated with delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. Nosocomial infection was identified as an independent risk factor for DCI. This finding indicates that systemic inflammation plays a role in the pathophysiology of DCI in aSAH patients. Additionally, it identifies a potentially modifiable risk factor for DCI in these patients.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) identify clinical risk factors for DCI, 2) understand that nosocomial infection is associated with DCI, 3) contemplate possible pathophysiologic mechanisms to explain the association between infection and DCI.

    References: 1. Adams HP, Jr., Kassell NF, Torner JC, Haley EC, Jr.: Predicting cerebral ischemia after aneurysmal subarachnoid hemorrhage: influences of clinical condition, CT results, and antifibrinolytic therapy. A report of the Cooperative Aneurysm Study. Neurology 37:1586-1591, 1987 2. Badjatia N, Monahan A, Carpenter A, Zimmerman J, Schmidt JM, Claassen J, et al: Inflammation, negative nitrogen balance, and outcome after aneurysmal subarachnoid hemorrhage. Neurology 84:680-687, 2015 3. 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 43:1711-1737, 2012 4. de Rooij NK, Rinkel GJ, Dankbaar JW, Frijns CJ: Delayed cerebral ischemia after subarachnoid hemorrhage: a systematic review of clinical, laboratory, and radiological predictors. Stroke 44:43-54, 2013 5. Dhar R, Diringer MN: The burden of the systemic inflammatory response predicts vasospasm and outcome after subarachnoid hemorrhage. Neurocrit Care 8:404-412, 2008 6. Dreier JP, Major S, Manning A, Woitzik J, Drenckhahn C, Steinbrink J, et al: Cortical spreading ischaemia is a novel process involved in ischaemic damage in patients with aneurysmal subarachnoid haemorrhage. Brain 132:1866-1881, 2009 7. Fergusen S, Macdonald RL: Predictors of cerebral infarction in patients with aneurysmal subarachnoid hemorrhage. Neurosurgery 60:658-667; discussion 667, 2007 8. Fisher CM, Kistler JP, Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1-9, 1980 9. Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, et al: Impact of nosocomial infectious complications after subarachnoid hemorrhage. Neurosurgery 62:80-87; discussion 87, 2008 10. Fujii Y, Takeuchi S, Sasaki O, Minakawa T, Koike T, Tanaka R: Ultra-early rebleeding in spontaneous subarachnoid hemorrhage. J Neurosurg 84:35-42, 1996 11. Griesshammer M, Bangerter M, Sauer T, Wennauer R, Bergmann L, Heimpel H: Aetiology and clinical significance of thrombocytosis: analysis of 732 patients with an elevated platelet count. J Intern Med 245:295-300, 1999 12. Gruber A, Dietrich W, Czech T, Richling B: Recurrent aneurysmal subarachnoid haemorrhage: bleeding pattern and incidence of posthaemorrhagic ischaemic infarction. Br J Neurosurg 11:121-126, 1997 13. Hashim IA, Walsh A, Hart CA, Shenkin A: Cerebrospinal fluid interleukin-6 and its diagnostic value in the investigation of meningitis. Ann Clin Biochem 32 ( Pt 3):289-296, 1995 14. Inagawa T, Kamiya K, Ogasawara H, Yano T: Rebleeding of ruptured intracranial aneurysms in the acute stage. Surg Neurol 28:93-99, 1987 15. Kasius KM, Frijns CJ, Algra A, Rinkel GJ: Association of platelet and leukocyte counts with delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. Cerebrovasc Dis 29:576-583, 2010 16. Kim JH, Desai NS, Ricci J, Stieg PE, Rosengart AJ, Hartl R, et al: Factors contributing to ventriculostomy infection. World Neurosurg 77:135-140, 2012 17. Kistler JP, Crowell RM, Davis KR, Heros R, Ojemann RG, Zervas T, et al: The relation of cerebral vasospasm to the extent and location of subarachnoid blood visualized by CT scan: a prospective study. Neurology 33:424-436, 1983 18. Laban KG, Rinkel GJ, Vergouwen MD: Nosocomial infections after aneurysmal subarachnoid hemorrhage: time course and causative pathogens. Int J Stroke 10:763-766, 2015 19. Leng LZ, Fink ME, Iadecola C: Spreading depolarization: a possible new culprit in the delayed cerebral ischemia of subarachnoid hemorrhage. Arch Neurol 68:31-36, 2011 20. Levi M, van der Poll T, Buller HR: Bidirectional relation between inflammation and coagulation. Circulation 109:2698-2704, 2004 21. Lord AS, Fernandez L, Schmidt JM, Mayer SA, Claassen J, Lee K, et al: Effect of rebleeding on the course and incidence of vasospasm after subarachnoid hemorrhage. Neurology 78:31-37, 2012 22. McMahon CJ, Hopkins S, Vail A, King AT, Smith D, Illingworth KJ, et al: Inflammation as a predictor for delayed cerebral ischemia after aneurysmal subarachnoid haemorrhage. J Neurointerv Surg 5:512-517, 2013 23. Muroi C, Hugelshofer M, Seule M, Tastan I, Fujioka M, Mishima K, et al: Correlation among systemic inflammatory parameter, occurrence of delayed neurological deficits, and outcome after aneurysmal subarachnoid hemorrhage. Neurosurgery 72:367-375; discussion 375, 2013 24. Oda S, Hirasawa H, Shiga H, Nakanishi K, Matsuda K, Nakamua M: Sequential measurement of IL-6 blood levels in patients with systemic inflammatory response syndrome (SIRS)/sepsis. Cytokine 29:169-175, 2005 25. Ohkuma H, Manabe H, Tanaka M, Suzuki S: Impact of cerebral microcirculatory changes on cerebral blood flow during cerebral vasospasm after aneurysmal subarachnoid hemorrhage. Stroke 31:1621-1627, 2000 26. Osuka K, Suzuki Y, Tanazawa T, Hattori K, Yamamoto N, Takayasu M, et al: Interleukin-6 and development of vasospasm after subarachnoid haemorrhage. Acta Neurochir (Wien) 140:943-951, 1998 27. Otite F, Mink S, Tan CO, Puri A, Zamani AA, Mehregan A, et al: Impaired cerebral autoregulation is associated with vasospasm and delayed cerebral ischemia in subarachnoid hemorrhage. Stroke 45:677-682, 2014 28. Pegoli M, Mandrekar J, Rabinstein AA, Lanzino G: Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage. J Neurosurg 122:414-418, 2015 29. Rabinstein AA, Friedman JA, Weigand SD, McClelland RL, Fulgham JR, Manno EM, et al: Predictors of cerebral infarction in aneurysmal subarachnoid hemorrhage. Stroke 35:1862-1866, 2004 30. Roos YB, de Haan RJ, Beenen LF, Groen RJ, Albrecht KW, Vermeulen M: Complications and outcome in patients with aneurysmal subarachnoid haemorrhage: a prospective hospital based cohort study in the Netherlands. J Neurol Neurosurg Psychiatry 68:337-341, 2000 31. Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL: Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 38:2315-2321, 2007 32. Sarrafzadeh A, Schlenk F, Meisel A, Dreier J, Vajkoczy P, Meisel C: Immunodepression after aneurysmal subarachnoid hemorrhage. Stroke 42:53-58, 2011 33. Schoch B, Regel JP, Nierhaus A, Wichert M, Mueller OM, Sandalcioglu IE, et al: Predictive value of intrathecal interleukin-6 for ventriculostomy-related Infection. Zentralbl Neurochir 69:80-86, 2008 34. Sehba FA, Mostafa G, Friedrich V, Jr., Bederson JB: Acute microvascular platelet aggregation after subarachnoid hemorrhage. J Neurosurg 102:1094-1100, 2005 35. Singh TD, Maloney P, Rabinstein AA, Hocker S: Significance of routine cerebrospinal fluid analysis in subarachnoid hemorrhage. J Neurosurg Sci, 2015 36. Solenski NJ, Haley EC, Jr., Kassell NF, Kongable G, Germanson T, Truskowski L, et al: Medical complications of aneurysmal subarachnoid hemorrhage: a report of the multicenter, cooperative aneurysm study. Participants of the Multicenter Cooperative Aneurysm Study. Crit Care Med 23:1007-1017, 1995 37. Vergouwen MD, Ilodigwe D, Macdonald RL: Cerebral infarction after subarachnoid hemorrhage contributes to poor outcome by vasospasm-dependent and -independent effects. Stroke 42:924-929, 2011 38. Vergouwen MD, Vermeulen M, Coert BA, Stroes ES, Roos YB: Microthrombosis after aneurysmal subarachnoid hemorrhage: an additional explanation for delayed cerebral ischemia. J Cereb Blood Flow Metab 28:1761-1770, 2008 39. Wartenberg KE, Schmidt JM, Claassen J, Temes RE, Frontera JA, Ostapkovich N, et al: Impact of medical complications on outcome after subarachnoid hemorrhage. Crit Care Med 34:617-623; quiz 624, 2006

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