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Journal of Neurology, Neurosurgery, and Psychiatry logoLink to Journal of Neurology, Neurosurgery, and Psychiatry
. 1997 May;62(5):512–516. doi: 10.1136/jnnp.62.5.512

Impact on clinical outcome of secondary brain insults during the neurointensive care of patients with subarachnoid haemorrhage: a pilot study.

P Enblad 1, L Persson 1
PMCID: PMC486871  PMID: 9153612

Abstract

OBJECTIVE: To analyse the occurrence and influence on outcome of secondary brain insults during neurointensive care of patients with subarachnoid haemorrhage. METHODS: Sixty one seriously ill patients with subarachnoid haemorrhage with a poor neurological grade, acute hydrocephalus, or intraventricular and/or intracerebral haemorrhages, who were referred as emergency cases to the neurosurgical intensive care unit during 1990 and 1991, comprised the study patients. RESULTS: The follow up performed according to the Glasgow outcome scale 14 months (median) later showed 23 patients with good recovery (38%), 11 with moderate disability (18%), seven with severe disability (11%), and two in a vegetative state (3%); 18 patients had died (30%). Clinical outcome was significantly related to the CT modified Hunt and Hess grade (P = 0.006). In total, 164 secondary brain insults (potentially avoidable factors) of various types were seen at the unit during the first seven days after the haemorrhage. Patients with a favourable outcome had significantly fewer secondary insults than patients with an unfavourable outcome (P = 0.0008). The occurrence of insults in each patient was related to the neurological grade (CT modified Hunt and Hess grade, P = 0.05). Multivariate analysis with the CT modified Hunt and Hess grade and the number of secondary brain insults during the first week as explanatory variables and favourable outcome as the dependent variable, showed that the number of complications was a significant independent predictor of favourable outcome (beta = -0.38, SE(beta) = 0.17, P = 0.03), whereas the CT modified Hunt and Hess grade did not reach significance (beta = -1.2, SE(beta) = 0.81, P = 0.14). CONCLUSIONS: The clinical outcome after subarachnoid haemorrhage is at least partly determined by the number of secondary insults. Therefore, vigorous attempts should be made to avoid all events that may potentially increase the risk of secondary cerebral ischaemia. Prospective studies must be initiated to define the role of "priming" of the brain and the impact of specific individual secondary insults in patients with subarachnoid haemorrhage.

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Selected References

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  1. Fisher C. M., Kistler J. P., Davis J. M. Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery. 1980 Jan;6(1):1–9. doi: 10.1227/00006123-198001000-00001. [DOI] [PubMed] [Google Scholar]
  2. Gentleman D., Jennett B. Audit of transfer of unconscious head-injured patients to a neurosurgical unit. Lancet. 1990 Feb 10;335(8685):330–334. doi: 10.1016/0140-6736(90)90615-c. [DOI] [PubMed] [Google Scholar]
  3. Gentleman D., Jennett B. Hazards of inter-hospital transfer of comatose head-injured patients. Lancet. 1981 Oct 17;2(8251):853–854. doi: 10.1016/s0140-6736(81)91115-6. [DOI] [PubMed] [Google Scholar]
  4. Hunt W. E., Hess R. M. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968 Jan;28(1):14–20. doi: 10.3171/jns.1968.28.1.0014. [DOI] [PubMed] [Google Scholar]
  5. Jennett B., Bond M. Assessment of outcome after severe brain damage. Lancet. 1975 Mar 1;1(7905):480–484. doi: 10.1016/s0140-6736(75)92830-5. [DOI] [PubMed] [Google Scholar]
  6. Jones P. A., Andrews P. J., Midgley S., Anderson S. I., Piper I. R., Tocher J. L., Housley A. M., Corrie J. A., Slattery J., Dearden N. M. Measuring the burden of secondary insults in head-injured patients during intensive care. J Neurosurg Anesthesiol. 1994 Jan;6(1):4–14. [PubMed] [Google Scholar]
  7. Marshall L. F., Toole B. M., Bowers S. A. The National Traumatic Coma Data Bank. Part 2: Patients who talk and deteriorate: implications for treatment. J Neurosurg. 1983 Aug;59(2):285–288. doi: 10.3171/jns.1983.59.2.0285. [DOI] [PubMed] [Google Scholar]
  8. Miller J. D., Becker D. P. Secondary insults to the injured brain. J R Coll Surg Edinb. 1982 Sep;27(5):292–298. [PubMed] [Google Scholar]
  9. Miller J. D., Sweet R. C., Narayan R., Becker D. P. Early insults to the injured brain. JAMA. 1978 Aug 4;240(5):439–442. [PubMed] [Google Scholar]
  10. Nornes H. The role of intracranial pressure in the arrest of hemorrhage in patients with ruptured intracranial aneurysm. J Neurosurg. 1973 Aug;39(2):226–234. doi: 10.3171/jns.1973.39.2.0226. [DOI] [PubMed] [Google Scholar]
  11. Piek J., Chesnut R. M., Marshall L. F., van Berkum-Clark M., Klauber M. R., Blunt B. A., Eisenberg H. M., Jane J. A., Marmarou A., Foulkes M. A. Extracranial complications of severe head injury. J Neurosurg. 1992 Dec;77(6):901–907. doi: 10.3171/jns.1992.77.6.0901. [DOI] [PubMed] [Google Scholar]
  12. Reilly P. L., Graham D. I., Adams J. H., Jennett B. Patients with head injury who talk and die. Lancet. 1975 Aug 30;2(7931):375–377. doi: 10.1016/s0140-6736(75)92893-7. [DOI] [PubMed] [Google Scholar]
  13. Rose J., Valtonen S., Jennett B. Avoidable factors contributing to death after head injury. Br Med J. 1977 Sep 3;2(6087):615–618. doi: 10.1136/bmj.2.6087.615. [DOI] [PMC free article] [PubMed] [Google Scholar]
  14. Sharples P. M., Storey A., Aynsley-Green A., Eyre J. A. Avoidable factors contributing to death of children with head injury. BMJ. 1990 Jan 13;300(6717):87–91. doi: 10.1136/bmj.300.6717.87. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Säveland H., Sonesson B., Ljunggren B., Brandt L., Uski T., Zygmunt S., Hindfelt B. Outcome evaluation following subarachnoid hemorrhage. J Neurosurg. 1986 Feb;64(2):191–196. doi: 10.3171/jns.1986.64.2.0191. [DOI] [PubMed] [Google Scholar]
  16. Valtysson J., Jiang M., Persson L. Transient elevation of the intracranial pressure increases the infarct size and perifocal edema after subsequent middle cerebral artery occlusion in the rat. Neurosurgery. 1992 Jun;30(6):887–890. doi: 10.1227/00006123-199206000-00012. [DOI] [PubMed] [Google Scholar]
  17. Voldby B., Enevoldsen E. M. Intracranial pressure changes following aneurysm rupture. Part 1: clinical and angiographic correlations. J Neurosurg. 1982 Feb;56(2):186–196. doi: 10.3171/jns.1982.56.2.0186. [DOI] [PubMed] [Google Scholar]

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