الفهرس 
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Abstract
The cardiac manifestations of subarachnoid haemorrhage (SAH) can be varied from asymptomatic to fulminant myocardial damage. Cardiac abnormalities are evidenced by the release of cardiac enzymes, changes in electrocardiography (ECG), clinical or echocardiographic evidence of left ventricular dysfunction. It is important for anaesthesiologists to detect myocardial damage caused by aneurysmal subarachnoid haemorrhage (aSAH). Lack of appreciation of the cardiac dysfunction in SAH patients, especially in mild forms, underreporting, presence of coexisting cardiac diseases with SAH led to unknown true incidence of the various cardiac abnormalities. This may lead to severe complications during anaesthesia and surgery.
The present study was done to evaluate cardiac abnormalities following aneurysmal subarachnoid haemorrhage and to determine impact on outcomes.
Forty adult patients, aged 27-70 years old of either sex, admitted into the neurosurgical intensive care unit in Alexandria university hospital with aneurysmal SAH documented by cerebral computed tomography (CT) scan and/or CT angiogram.
Demographic characteristics, including age, sex and body weight were recorded for the all patients. Comorbidities and risk factors were recorded. Vital signs including mean blood pressure, heart rate, respiratory rate, temperature were been recorded at admission and at every 12 hours in the first 3 days then on day 5, 7, 14 and 21. Severity of SAH was categorized using Hunt-Hess (HH) grade on day 1, 2, 5, 7, 14 and 21. Fisher grade for prediction the risk of cerebral vasospasm was documented at admission. Twelve-lead Electrocardiography (ECG) and measurement of serum sodium were done daily in the first week then on day 14 and 21. TTE, lung ultrasound, blood NT-proBNP and cTnI measurements were done on day 1, 2, 5, 7, 14 and 21. Recording occurrence of complication and assessment of disability at 3 months using modified Rankin scale were done.
In seventeen patients (42.5%), cTnI values were greater than 0.3ng/ml at any time during the study period indicating myocardial injury. The fraction of patients with a cTnI level 1 ng/ml was 10% on study day 1 and 2. The mean (± SD) value on day 1 was 1.54±1.02ng/ml, day 2 was 1.01±0.69ng/ml, day 5 was 0.27±0.16ng/ml, day 7 was 0.15±0.09ng/ml, day 14 was 0.10±0.04ng/ml and day 21 was < 0.09 ng/ml.
In thirty patients, NT-proBNP were greater than 125pg/ml, on the initial 2 days then fell progressively thereafter to achieve levels near the normal range by day 7 to the end of the study. Day 1 was 395.9±255.7pg/ml, day 2 was 592.4±352.5pg/ml day 5 was 439.7±293.4pg/ml day 7 was 307.0±122.0pg/ml day 14 was 302.3±255.2pg/ml, day 21 was 287.2±197.4pg/ml.
In fifteen patients (37.5%) there were left ventricular (LV) abnormalities using the ejection fraction and regional wall motion abnormalities (RWMA) measurements. The RWMA patterns involved were not confined to a single coronary artery territory. 12.5% of patients had regional wall motion score more than 1 on at least 1 study day, suggesting hypokinesia. In addition, 25.0% of patients were characterized by impaired global systolic function (LVEF < 50%). Regardless of the severity of RWMA, a partial or complete reversal within the first week of observation was seen in 40% of patients, at 2 weeks 50% recovery and at 21th day 66% recovery. On day 1 patients had mean (± SD) ejection fraction of 43.24 ± 11.22% versus patients who had not transthoracic echocardiographic abnormalities 64.09 ± 06.49% (p<0.05). On day 2, 41.53 ± 11.31% versus 64.57 ± 06.63% (p<0.05). On day 5, 47.77 ± 12.09% versus 64.61 ± 06.58% (p<0.05). On day 7, 40.23 ± 19.98% versus 64.43 ± 06.38% (p<0.05). On day 14, 49.00 ± 12.14% versus 64.47 ± 06.98% (p<0.05). On day 21, 56.00 ± 15.86% versus 68.50 ± 07.68% (p<0.09).
The ECG was considered abnormal if there were T-wave changes (inverted or flattened), ST segment changes (elevated or depressed), QT interval was prolonged (>0.4 sec), or arrhythmia. 32 patients (80%) had some ECG abnormalities during the study period. Across the cohort, 17% T wave inversion, 17% ST segment depression and 16% QT interval prolongation.
Cardiac abnormalities in the present study were classified as either cardiac affection or cardiac damage. Cardiac affection was defined as the presence of either cTnI>0.3 ng/ml, NT-pro-BNP>125pg/ml, echocardiographic or ECG abnormalities. Meanwhile, cardiac damage was defined as the presence of both cTnI>0.3 ng/ml and echocardiographic abnormalities.
In the present study, significantly more patients with cardiac affection (NT-pro-BNP >125pg/ml and echocardiographic abnormalities) had higher mean of age. Mean (± SD) of age in years in patients with versus without cardiac affection as regard presence of NT-pro-BNP >125pg/ml, 54.93±13.41 versus 42.60±11.60 (p= 0.003) and as regard echocardiographic abnormalities, 57.93±9.18 versus 48.20±12.07 (p= 0.011).
As regards sex, patients presenting with cTnI>0.3ng/ml were predominantly significantly females 12(70.6%) versus 6 males (29.4%) (p= 0.005). Associated medical conditions included hypertension in 19 (47.5%) patients, diabetes mellitus in 6 (15%) patients, and positive smoking history in 8 (20%) patients. As regards hypertension, there were no significant differences as regard number of patients with cardiac abnormalities who were hypertensive and those with normal blood pressure. As regards diabetes mellitus, nondiabetics were significantly higher in number than diabetics in the presence of cTnI>0.3 ng/ml 17(100%) versus 0(0%) (p=0.030), ECG abnormalities 30(93.7%) versus 2(6.3%) (p=0.001), presence of cardiac damage 18(100%) versus 0(0%) (p=0.016). As regards smoking status, nonsmokers were significantly higher in number than smokers in the presence of cTnI>0.3ng/ml 17(100%) versus 0(0%) (p=0.013), echocardiographic abnormalities 8(100%) versus 0(0%) (p=0.016), ECG abnormalities 28(87.5%) versus 4(12.5%) (p=0.037), presence of cardiac damage 18(100%) versus 0(0%) (p=0.005).
The majority of patients had an admission Hunt Hess grade of 2 (33%) and 1 (32%). Significantly more patients with Hunt Hess grade >2 were presented with cTnI>0.3ng/ml versus patients without cTnI>0.3ng/ml on day 1, 3.59 ± 1.18 versus 1.96 ± 0.98 (p<0.001). On day 2, 3.76 ± 1.03 versus 1.74 ± 0.81 (p<0.001). On day 5, 3.08 ± 1.44 versus 1.83 ± 1.11 (p<0.006). On day 7, 3.15 ± 1.34 versus 1.42 ± 0.61 (p<0.001). On day 14, 3.22 ± 1.30 versus 1.24 ± 0.56 (p<0.001).
Significantly more patients with Hunt Hess grade >2 had NT-proBNP>125 pg/ml versus patients without NT-proBNP>125 pg/ml on day 1, 2.97 ± 1.30 pg/ml versus 1.70 ± 0.95 pg/ml (p<0.001). On day 2, 3.0 ± 1.31 pg/ml versus 1.40 ± 0.52 pg/ml (p<0.001). On day 5, 2.50 ± 1.27 pg/ml versus 1.70 ± 1.49 pg/ml (p=0.02).
Significantly more patients with Hunt Hess grade >2 presented with echocardiographic abnormalities versus patients without echocardiographic abnormalities on day 1, 3.73 ± 1.03 versus 2.0 ± 1.04 (p<0.001). On day 2, 3.67 ± 1.11 versus 1.96 ± 1.06 (p<0.001). On day 5, 2.82 ± 1.25 versus 2.04 ± 1.37 (p=0.041). On day 7, 2.64 ± 1.29 versus 1.86 ± 1.24 (p=0.046). On day 14, 2.78 ± 1.39 versus 1.47 ± 1.01 (p=0.005).
Significantly more patients with Hunt Hess grade >2 were presented with cardiac damage versus patients without cardiac damage on day 1, 3.61 ± 1.14 versus 1.86 ± 0.89 (p<0.001). On day 2, 3.78 ± 1.0 versus 1.64 ± 0.66 (p<0.001). On day 5, 3.07 ± 1.38 versus 1.77 ± 1.11 (p=0.02). On day 7, 3.14 ± 1.29 versus 1.33 ± 0.49 (p<0.001). On day 14, 3.20 ± 1.23 versus 1.13 ± 0.34 (p<0.001). In univariate analysis, on day 1 (Odd ratio=4.628, p=0.001), on day 2 (Odd ratio=18.753, p=0.002), on day 5 (Odd ratio=2.250, p=0.012).
Baseline imaging showed that 34 patients (85%) had aneurysm(s) in the anterior circulation (middle cerebral, posterior communicating artery, or anterior communicating artery), and 3 patients (15%) had posterior circulation artery aneurysms. 17 patients (43%) had small aneurysms, 18 patients (45%) had 12-24mm aneurysms and 5 patients (13%) had aneurysms larger than 24mm.
On admission, 24 patients (60%) presented with a good radiological (Fisher 1&2) and 16 patients (40%) presented with a poor radiological grade (Fisher 3&4). Patients with initial cTnI>0.3 ng/ml had significantly (p<0.001) higher mean (±SD) Fisher grade 3.0(±0.83) than patients with initial cTnI≤0.3 ng/ml 1.91(±0.90). Patients with initial NT-proBNP>125 pg/ml had significantly (p<0.001) higher mean (±SD) Fisher grade 2.53(±1.11) than patients with initial NT-proBNP≤125pg/ml 2.0(±0.67). Patients with echocardiographic abnormalities had significantly (p=0.001) higher mean (±SD) Fisher grade 3.07(±0.80) than patients without echocardiographic abnormalities 2.0(±0.96). Patients who were defined as having cardiac damage had significantly (p=0.001) higher mean (±SD) Fisher grade 3.00(±0.84) than patients without echocardiographic abnormalities 1.91(±0.92).
Eight (20%) patients showed B-line in lung ultrasound. cTnI>0.3 ng/ml was present in (6, 6, 4, and 3) patients on day (1, 2, 5, and 14) (p value was 0.003, 0.003, 0.012 and 0.032) respectively. Echocardiographic abnormalities were present in (6, 6, 4, 3, and 3) patients on day (1, 2, 5, 7 and 14) (p value was 0.001, 0.001, 0.006, 0.033 and 0.032) respectively. Cardiac damage was present in (6, 6 and 3) patients on day (1, 2 and 14) (p value was 0.005, 0.005 and 0.046) respectively.
26 patients suffered from hyponatremia (<136 mmol/L) in at least one day of this study. Serum sodium (mean±SD) in patients with cTnI>0.3 ng/ml versus patients without cTnI>0.3 ng/ml finding was (131.35±6.70 mmol/L versus 137.43±6.88 mmol/L, p= 0.008) on day 2, (130.77±6.15 mmol/L versus 137.26±6.84 mmol/L, p= 0.008) on day 3, (130.23±3.98 mmol/L versus 136.83±6.0 mmol/L, p= 0.001) on day 4, (131.0±6.08 mmol/L versus 137.0±5.77 mmol/L,p= 0.006) on day 5, (131.69±7.41 mmol/L versus 137.26±4.48 mmol/L, p= 0.026) on day 6 and (132.0±7.84 mmol/L versus 137.79±4.59 mmol/L, p= 0.013) on day 7.
In patients with echocardiographic abnormalities versus patients without echocardiographic abnormalities, serum sodium (mean±SD) was (131.27±8.18 mmol/L versus 137.0±6.04 mmol/L, p= 0.015) on day 2, (129.82±6.78 mmol/L versus 137.16±6.34 mmol/L, p= 0.004) on day 3, (129.82±3.31 mmol/L versus 136.48±6.10 mmol/L, p= 0.002) on day 4, (130.64±5.82 mmol/L versus 136.68±5.98 mmol/L, p= 0.008) on day 5, (131.18±7.35 mmol/L versus 137.00±4.88 mmol/L, p= 0.012) on day 6.
In patients with cardiac damage versus patients without cardiac damage, serum sodium (mean±SD) was (131.9±6.88 mmol/L versus 137.3±7.00 mmol/L, p= 0.02) on day 2, (131.4±6.31 mmol/L versus 137.2±6.99 mmol/L, p= 0.016) on day 3, (130.4±3.90 mmol/L versus 137.0±6.08 mmol/L, p= 0.001) on day 4, (131.1±5.87 mmol/L versus 137.2±5.84 mmol/L, p= 0.005) on day 5, (131.7±7.12 mmol/L versus 137.6±4.42 mmol/L, p= 0.014) on day 6, (131.9±7.55 mmol/L versus 138.2±4.31 mmol/L, p= 0.005) on day 7.
Patients presenting with cTnI>0.3 ng/ml, NT-proBNP>125 pg/ml and cardiac damage did not show any significant difference in cumulative fluid balance with patients who had not these findings. While on day 5, patients presenting with echocardiographic abnormalities and ECG abnormalities showed significantly positive fluid balance versus patients who had not these findings (165.82±628.81 versus -42.69±744.90 (p=0.014) and 272.6±588.7 versus -700±868.5 p=0.004) respectively.
In the present study, 21 patients had surgical intervention by clipping, 17 had medical management and 2 had endovascular coiling. No significant differences in type of management were found in patients with or without cardiac abnormalities.
A total of 14 patients died during the course of the study, 8 (20%) developed delayed cerebral ischemia (DCI), 6 (15%) had intracranial rebleeding and 4 (10%) developed pneumonia. Patients with echocardiographic abnormalities had significant difference in occurrence of and DCI (6 versus 2 patients, p=0.036). Death was significantly higher in patients with cTnI>0.3 ng/ml (11 versus 3 patients, p=0.001) and cardiac damage (12 versus 2 patients, p<0.001).
Mean modified Rankin scale (mRS) was higher significantly in patients presenting with cTnI>0.3 ng/ml, NT-proBNP>125 pg/ml, echocardiographic abnormalities and cardiac damage versus patients without these findings (4.65 ± 2.0 versus 1.96±2.06, p<0.001), (3.53±2.34 versus 1.80±2.25, p<0.001), (4.07±2.31 versus 2.52±2.33, p=0.049) and (4.72±1.96 versus 1.77±1.90, p<0.001).
As to the need of vasopressors for hemodynamic stabilization, in 13 out of 40 patients (33%) continuous infusion was needed during the acute stage after admission 8 (20%) patients received dopamine, 2 (5%) received adrenaline and 3 (8%) received noradrenaline infusion. Maximum dosages applied were: 7 mcg/kg/min for dopamine, 0.1 mcg/kg/min for adrenaline and noradrenaline. There were no any significant differences in vasopressor among cardiac abnormalities (affection/damage) and those with no abnormalities.
In the present study, 20 patients were mechanically ventilated. The duration ranged 47-336 hours with mean (±SD) of 144.2±96.97 hours. No significance difference was found as regard duration of intensive care stay and hospital stay and duration of mechanical ventilation among patients with cardiac abnormalities (affection/damage) and those with no abnormalities.
from these results, we concluded that biochemical markers and ultrasonography are rapid and simple tools to assess the cardiac abnormalities after aSAH. ECG abnormalities are common finding after aSAH patients and have limited value in prognosticating poor outcomes. There were significant relationships between RWMA and elevated cTnI levels and severity of haemorrhage and poor outcomes after aSAH. Patients who had elevated cTnI and RWMA had higher incidence of B-line in lung ultrasound. The presence of a cardiac abnormalities raises two anesthetic management issues: first, the optimum timing of anesthesia and surgery and, second, the risk of perioperative cardiovascular deterioration.