Khalil Yousef

Transcranial regional cerebral oxygen desaturation predicts delayed cerebral ischaemia and poor outcomes after subarachnoid haemorrhage: A correlational study

OBJECTIVES To examine the relationship between regional cerebral oxygen saturation (rSO2), delayed cerebral ischaemia (DCI), and outcomes after aneurysmal subarachnoid haemorrhage (aSAH). RESEARCH METHODOLOGY Subjects (n = 163) with aSAH, age 21-75 years, and Fisher grade >1 were included in the study. Continuous rSO2 monitoring was performed for 5-10 days after injury using near-infrared spectroscopy with sensors over the frontal/temporal cortex. rSO2<50 indicated desaturation. DCI was defined as neurological deterioration due to impaired cerebral blood flow. Three- and 12-month functional outcomes were assessed by the modified Rankin scale (MRS) as good (0-3) and poor (4-6). RESULTS DCI occurred in 57% of patients; of these 66% had rSO2<50. Overall, 56% had rSO2<50 on either side, 21% and 16% had poor MRS at 3 and 12 months. Subjects with rSO2 <50 were 3.25 times more likely to have DCI compared to those with rSO2 >50 (OR 3.25, 95%CI 1.58-6.69), positive predictive value (PPV) = 70%. Subjects with rSO2 <50 were 2.7 times more likely to have poor 3-month MRS compared to those with rSO2 >50 (OR 2.7, 95%CI 1.1-7.2), PPV = 70%. CONCLUSIONS These results suggest that NIRS has the potential for detecting DCI after aSAH. This potential needs to be further explored in a larger prospective study.

Cerebral Perfusion Pressure and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND Whether delayed cerebral ischemia (DCI) mediates the relationship between Hunt and Hess grade and outcomes after aneurysmal subarachnoid hemorrhage remains unknown. OBJECTIVES To investigate the relationship between cerebral perfusion pressure, DCI, Hunt and Hess grade, and outcomes after aneurysmal subarachnoid hemorrhage. METHODS DCI was defined as neurological deterioration due to impaired cerebral blood flow. Relationships between minimum cerebral perfusion pressure and onset and occurrence of DCI were tested by using logistic regression and the accelerated failure time model. The mediation effect of DCI on relationships between Hunt and Hess grade and outcomes was tested by using the bootstrap confidence interval. Outcomes at 3 and 12 months included mortality and neuropsychological, functional, and physical outcomes. RESULTS DCI occurred in 211 patients (42%). About one-third of the patients had poor functional outcome at 3 (32%) and 12 (30%) months. Impaired neuropsychological outcome was observed in 33% of patients at 3 months and 17% at 12 months. For every increase of 10 mm Hg in cerebral perfusion pressure, odds for DCI increased by 2.78 (95% CI, 2.00-3.87). High perfusion pressure was associated with earlier onset of DCI (P < .001). CONCLUSIONS DCI does not mediate the relationship of Hunt and Hess grade to functional outcome or death. The relationship between cerebral perfusion pressure and DCI was most likely due to induced hypertension and hypervolemia. Clinical guidelines may need to include limits for induced hypertension.

Cardiovascular Disease Risk Predicts Health Perception in Prison Inmates

We hypothesized that risk factors for cardiovascular disease (CVD) would be associated with worse health perceptions in prison inmates. This study included 362 inmates recruited from four medium security prisons in Kentucky. Framingham Risk Score was used to estimate the risk of developing CVD within the next 10 years. A single item on self-rated health from the Medical Outcomes Survey–Short Form 36 was used to measure health perception. Multinomial logistic regression showed that for every 1-unit increase in Framingham Risk Score, inmates were 23% more likely to have rated their health as fair/poor and 11% more likely to rate their health as good rather than very good/excellent. These findings demonstrate that worse health perceptions may serve as a starting point for discussing cardiovascular risk factors and prevention with inmates.

The Relationships Between BNP and Neurocardiac Injury Severity, Noninvasive Cardiac Output, and Outcomes After Aneurysmal Subarachnoid Hemorrhage

Introduction: Neurocardiac injury, a type of myocardial dysfunction associated with neurological insult to the brain, occurs in 31–48% of aneurysmal subarachnoid hemorrhage (aSAH) patients. Cardiac troponin I (cTnI) is commonly used to diagnose neurocardiac injury. Brain natriuretic peptide (BNP), another cardiac marker, is more often used to evaluate degree of heart failure. The purpose of this study was to examine the relationships between BNP and (a) neurocardiac injury severity according to cTnI, (b) noninvasive continuous cardiac output (NCCO), and (c) outcomes in aSAH patients. Method: This descriptive longitudinal study enrolled 30 adult aSAH patients. Data collected included BNP and cTnI levels and NCCO parameters for 14 days and outcomes (modified Rankin Scale [mRS] and mortality) at discharge and 3 months. Generalized estimating equations were used to evaluate associations between BNP and cTnI, NCCO, and outcomes. Results: BNP was significantly associated with cTnI. For every 1 unit increase in log BNP, cTnI increased by 0.05 ng/ml (p = .001). Among NCCO parameters, BNP was significantly associated with thoracic fluid content (p = .0003). On multivariable analyses, significant associations were found between BNP and poor mRS. For every 1 unit increase in log BNP, patients were 3.16 times more likely to have a poor mRS at discharge (p = .021) and 5.40 times more likely at 3 months (p < .0001). Conclusion: There were significant relationships between BNP and cTnI and poor outcomes after aSAH. BNP may have utility as a marker of neurocardiac injury and outcomes after aSAH.

Temporal Profiles of Cerebral Perfusion Pressure After Subarachnoid Hemorrhage.

ABSTRACT: Introduction: Insufficient cerebral perfusion pressure (CPP) after aneurysmal subarachnoid hemorrhage can impair cerebral blood flow. We examined the temporal profiles of CPP change and tested whether these profiles were associated with delayed cerebral ischemia (DCI). Method: CPP values were retrospectively reviewed for 238 subjects. Intracranial pressure and mean arterial pressure values were obtained every 2 hours for 14 days. Induced hypertension was utilized to prevent vasospasm. The linear and quadratic CPP changes over time were tested using growth curve analysis. Multivariable logistic regression was utilized to examine the association between DCI and percentages of CPP values of >110, >100, <70, and <60 mm Hg. DCI was defined as neurological deterioration because of impaired cerebral blood flow. Results: Between-subject differences accounted for 39% of variation in CPP values. There was a significant linear increase in CPP values over time (&bgr; = 0.06, SE = 0.006, p < .001). The covariance (−0.52, SE = 0.09, p < .001) between initial CPP and linear parameter was negative, indicating that subjects with high CPP on admission had a slower rate of increase whereas those with low CPP had a faster rate of increase. For every 10% increase in the proportion of CPP of >100 or >110 mm Hg, the odds of DCI increased by 1.21 and 1.43, respectively (p < .05). Conclusions: The longer the time patients spent with high CPP, the greater the odds for DCI. When used prophylactically, induced hypertension contributes to higher CPP values. On the basis of the CPP trends and correlations observed, induced hypertension may not confer expected benefits in patients with aneurysmal subarachnoid hemorrhage.

Stress, cognitive appraisal, coping, and event free survival in patients with heart failure

Objectives: To describe self‐reported stress level, cognitive appraisal and coping among patients with heart failure (HF), and to examine the association of cognitive appraisal and coping strategies with event‐free survival. Methods: This was a prospective, longitudinal, descriptive study of patients with chronic HF. Assessment of stress, cognitive appraisal, and coping was performed using Perceived Stress Scale, Cognitive Appraisal Health Scale, and Brief COPE scale, respectively. The event‐free survival was defined as cardiac rehospitalization and all‐cause death. Results: A total of 88 HF patients (mean age 58 ± 13 years and 53.4% male) participated. Linear and cox regression showed that harm/loss cognitive appraisal was associated with avoidant emotional coping (&bgr; = ‐0.28; 95% CI: ‐0.21 – 0.02; p = 0.02) and event free survival (HR = 0.53; 95% CI: 0.28 – 1.02; p = 0.05). Conclusions: The cognitive appraisal of the stressors related to HF may lead to negative coping strategies that are associated with worse event‐free survival.

39: PERSISTENT GLOBAL LONGITUDINAL STRAIN ABNORMALITY BY ECHOCARDIOGRAM PREDICTED BY CARDIAC TROPONIN I

Learning Objectives: We have demonstrated that machine learning (ML) algorithms can evaluate emerging patterns in monitored vital signs (VS) and distinguish between artifact and real cardiorespiratory instability (CRI) alerts with clinically meaningful accuracy. However, we sampled our VS every 20 seconds (s), which may exceed data acquisition and storage capabilities for most hospital information systems. We now assess the impact of decreasing VS sampling frequency on our model’s performance to improve feasibility of model use for monitor alert screening. Methods: A set of 200 step-down unit patient stays provided continuous VS monitoring data recorded each 20 s which was evaluated for monitor alerts (any VS excursion beyond stability thresholds), then annotated as due to artifact or real CRI. For each alert, statistical features (mean, variance, slope, min and max) were extracted from VS data from a 15-min window preceding threshold exceedance. We built random forest models to differentiate between alerts or artifact using every 20 s data and computed the leave-one-patient-out cross-validation scores. We repeated the experiment using decreasing VS sampling frequencies of 1, 2, 4 and 60 minutes (m). We quantified performance as the model’s ability to distinguish artifact from real CRI alerts. Results: The area under the curve (AUC) of the Receiver Operating Characteristic for differentiating between artifact and real CRI alerts at 20 s sampling was 0.962. AUC scores for the 1, 2, 4 and 60 m sampling were 0.955, 0.940, 0.891 and 0.597 respectively. Only the 4 and 60 m AUC scores were statistically different from the 20 s model. Differences in true positive (P) and true negative (N) rates for the 20 s and 1 m models at 1% false determination rates (of P or N respectively) were not significant. Conclusions: Decreasing VS sampling frequency to once a minute results in acceptable ML model performance for separating artifact from real CRI alerts, but it deteriorates at less frequent sampling intervals. Since most bedside monitoring systems are capable of reporting their VS data every minute, our results suggest that collecting per minute bedside VS data will yield modeling results sufficiently close to a harder to obtain threefold higher sampling frequency. Embedding such feasible models in bedside monitoring systems may decrease alert fatigue. However future studies should also compare performance of 1 m sampling frequency VS data streams to beat-to-beat or waveform analysis. Funding: NIH R01NR013912

Clinical Presentation to the Emergency Department Predicts Subarachnoid Hemorrhage-Associated Myocardial Injury

Introduction: Aneurysmal subarachnoid hemorrhage (aSAH) is frequently seen in emergency departments. Secondary injury, such as subarachnoid hemorrhage‐associated myocardial injury (SAHMI), affects one third of survivors and contributes to poor outcomes. SAHMI is not attributed to ischemia from myocardial disease but can result in hypotension and arrhythmias. It is important that emergency nurses recognize which clinical presentation characteristics are predictive of SAHMI to initiate proper interventions. The aim of this study was to determine whether patients who present to the emergency department with clinical aSAH are likely to develop SAHMI, as defined by troponin I ≥ 0.3 ng/mL. Methods: This was a prospective descriptive study. SAHMI was defined as troponin I ≥ 0.3 ng/mL. Predictors included demographics and clinical characteristics, severity of injury, admission 12‐lead electrogardiogram (ECG), initial emergency department vital signs, and pre‐hospital symptoms at time of aneurysm rupture. Results: Of 449 patients, 126 (28%) had SAHMI. Patients with SAHMI were more likely to report seizures and unresponsiveness with significantly lower Glasgow coma score and higher proportion of Hunt and Hess grades 3 to 5 and Fisher grades III and IV (all P < .05). Patients with SAHMI had higher atrial and ventricular rates and longer QTc intervals on initial ECG (P < .05). On multivariable logistic regression, poor Hunt and Hess grade, report of prehospital unresponsiveness, lower admission Glasgow coma score, and longer QTc interval were significantly and independently predictive of SAHMI (P < .05). Discussion: Components of the clinical presentation of subarachnoid hemorrhage to the emergency department predict SAHMI. Identifying patients with SAHMI in the emergency department can be helpful in determining surveillance and care needs and informing transfer unit care. Contribution to Emergency Nursing PracticeNeurocardiac nursing assessment in the emergency department can be utilized to triage patients with subarachnoid hemorrhage.Emergency nurses need to be vigilant for cardiac complications in patient with unresponsiveness at the time of subarachnoid hemorrhage.Nurses are the first step in patient care. To provide patients with the best care possible, nurses need to be highly competent in recognizing alarming symptoms.

NEUROCARDIAC INJURY IN PATIENTS WITH SUBARACHNOID HEMORRHAGE IS ASSOCIATED WITH REGIONAL LEFT VENTRICULAR DISCOORDINATION

Aneurysmal subarachnoid hemorrhage (SAH) may be associated with acute cardiac dysfunction which is variable. The aim was to test the hypothesis that neurocardiac injury in SAH is associated with left ventricular (LV) regional discoordination. We prospectively studied 151 patients with SAH (

739: NEUROCARDIAC INJURY PREDICTS FUNCTIONAL DISABILITY AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Learning Objectives: Patients with aneurysmal subarachnoid hemorrhage (aSAH) may experience the complication of neurocardiac myocardial injury (SAHMI). Although the myocardial dysfunction usually corrects before hospital discharge, it is not well understood if its early presence results in poorer outcomes. We sought to determine if patients with SAHMI had more functional disability measured by the Modified Rankin Scale (MRS) at 3 months. Methods: We recruited 65 aSAH patients (inclusion: age 21–75 years, Fisher grade >1; exclusions: chronic neurological deficit, history myocardial infarction) who also had 3-month outcome data. Serum cardiac troponin I (cTnI) was measured daily, and daily peak used to dichotomize patients as No SAHMI (cTnI <0.3 ng/ml) or SAHMI (cTnI ≥0.3 ng/ml.). Demographics (age, gender, race) and aSAH severity (Hunt and Hess grade [HH; good 1–2; poor 3–5]) were obtained at admission. MRS was obtained at 3 months, and dichotomized as good MRS (0–2) or poor MRS (3–6) functional outcome. Between group differences were assessed by t-tests or Fisher’s exact test. Binomial logistic regression assessed the ability of SAHMI to predict poor MRS. Results: Of the 65 patients, 18 (28%) had SAHMI. There was no between group difference in age (SAHMI 52 ± 12 vs. No SAHMI 55 ± 11 yrs, p=0.43), gender (SAHMI female 89% vs. No SAHMI 81%, p=0.44), or race (SAHMI White 94% vs No SAHMI 85%, p=0.43). Significantly more SAHMI patients had poor grade HH (SAHMI 89% vs No SAHMI 30%, p<0.001). In binomial logistic regression, poor HH grade was associated with poor MRS at 3 months (OR 4.58, 95% CI 1.25–16.85, p=0.022). But even after controlling for HH, SAHMI independently predicted poor MRS at 3 months (OR 8.12, 95% CI 1.77–37.38, p=0.007) with a positive predictive value of 83% and negative predictive value of 77%.Conclusions: Even after controlling for aSAH severity by HH, patients with SAHMI were 8-fold more likely to have functional disability at 3-mo. Mechanistic links between SAHMI and postdischarge disability must be determined to prevent the debilitating consequences of this aSAH complication. FUNDING NIH R01NR014221