Extracerebral Organ Dysfunction and Sleep Disorders in Subarachnoid Hemorrhage

Abstract

Cardiac and pulmonary complications are common in subarachnoid hemorrhage (SAH), but also other extracerebral complications are frequently observed. This thesis focuses on the occurrence of extracerebral organ dysfunction and the additional value of markers of these medical complications in prognosticating the occurrence of delayed cerebral ischemia or poor outcome.

The electrocardiogram and serum cardiac troponin I level are simple tools to screen patients for cardiac dysfunction. ECG abnormalities did not predict the occurrence of delayed cerebral ischemia and have limited value in prognosticating poor outcome. Cardiac Troponin I is a powerful predictor for the occurrence of pulmonary and cardiac complications in patients with aneurysmal SAH.

Pulmonary edema and depressed cardiac contractile function were frequently observed in the first 5 days after SAH. A depressed cardiac output was also frequently seen but usually mild and self limiting within one day. A depressed cardiac contractile function in at least one day in the first 5 days after SAH onset was more prevalent in patients with an elevated cardiac troponin I. Single transpulmonary thermodilution technique (providing estimates of pulmonary edema and cardiac function) is a promising tool for monitoring SAH patients especially with elevated cardiac troponin I on admission.

An important and frequently used severity of illness score in the intensive care unit (the SAPS II score) is a useful and reliable prognosticator in SAH patients. This score may in some circumstances provide more information than specific SAH rating scales in predicting poor outcome or the occurrence of delayed cerebral ischemia. Of the individual parameters of the SAPS II score, PaO2/ FiO2 ratio, serum urea, age and the GCS were independent prognosticators of poor outcome.

Of the 83 patients who completed quality of life (QoL) questionnaires 9 patients (11%) had a poor outcome on the modified Rankin scale. Forty three (53%) of patients complained of tiredness and 42 (51%) had negative job consequences. In these patients disorders of sleep and wake occurred in one-third. Patients with severe sleep disturbances often have a considerably reduced QoL.

To epitomize: extracerebral organ dysfunction is frequently seen after SAH. Grading scales incorporating signs of extracerebral organ dysfunction should be used more frequently by neurologists and neurosurgeons treating SAH patients. Cardiac troponin I can be used as marker to identify patients who are at risk of developing cardiopulmonary complications and could benefit from early invasive hemodynamic monitoring. Additional studies using single transpulmonary thermodilution are required to study the effects of cardiac and pulmonary estimates on delayed cerebral ischemia and outcome in SAH patients. Also studies with extended follow-up are required to evaluate whether a therapeutic strategy taking into account cardiac index, cardiac contractile function and extravascular lung water can improve supportive therapy and outcome. The improvement of long-term outcome should focus on attention for sleep disorders in patients complaining of daytime fatigue, restless or, nonrestorative sleep, snoring and restless legs syndrome.