Storm Liebling

Reduced Platelet Activity Is Associated With Early Clot Growth and Worse 3-Month Outcome After Intracerebral Hemorrhage

Background and Purpose— Antiplatelet medication use and reduced platelet activity may be associated with mortality after intracerebral hemorrhage (ICH). We tested the hypothesis that reduced platelet activity is associated with early ICH clot growth and worse outcomes. Methods— We prospectively identified patients with spontaneous ICH, measured platelet activity (VerifyNow-ASA, Accumetrics) on admission, and recorded antiplatelet medication use. ICH volume was calculated using computerized volumetric analysis. Data were analyzed with nonparametric statistics and repeated measures ANOVA as appropriate. Patients were prospectively followed for functional outcomes. Data are presented as mean±SD or median [Q1 to Q3]. Results— Reduced platelet activity (≤550 aspirin reaction units [ARU]) was associated with increased ICH volume growth (P<0.05) for patients with the diagnostic CT within 12 hours. In the subset of patients not known to take aspirin, 24% had reduced platelet activity. Sixteen (24%) patients received a platelet transfusion 21.2±11.4 hours after symptom onset with an increase in platelet activity (448 [414-479] to 586 [530-639] ARU, P=0.001), but without impact on outcomes. Reduced platelet activity was associated with worse modified Rankin Scores at 3 months (P=0.02). Conclusions— Reduced platelet activity was associated with early ICH volume growth and worse functional outcome. Because platelet activity can be increased with platelet transfusion, increasing platelet activity is a potential method to reduce ICH volume growth and improve functional outcomes.

Anticonvulsant Use and Outcomes After Intracerebral Hemorrhage

Background and Purpose— There are few data on the effectiveness and side effects of antiepileptic drug therapy after intracerebral hemorrhage. We tested the hypothesis that antiepileptic drug use is associated with more complications and worse outcome after intracerebral hemorrhage. Methods— We prospectively enrolled 98 patients with intracerebral hemorrhage and recorded antiepileptic drug use as either prophylactic or therapeutic along with clinical characteristics. Antiepileptic drug administration and free phenytoin serum levels were retrieved from the electronic medical records. Patients with depressed mental status underwent continuous electroencephalographic monitoring. Outcomes were measured with the National Institutes of Health Stroke Scale and modified Rankin Scale at 14 days or discharge and the modified Rankin Scale at 28 days and 3 months. We constructed logistic regression models for poor outcome at 3 months with a forward conditional model. Results— Seven (7%) patients had a clinical seizure, 5 on the day of intracerebral hemorrhage. Phenytoin was associated with more fever (P=0.03), worse National Institutes of Health Stroke Scale at 14 days (23 [9 to 42] versus 11 [4 to 23], P=0.003), and worse modified Rankin Scale at 14 days, 28 days, and 3 months. In a forward conditional logistic regression model, phenytoin prophylaxis was associated with an increased risk of poor outcome (OR, 9.8; 1.4 to 68.6; P=0.02), entering after admission National Institutes of Health Stroke Scale and age. Excluding patients with a seizure did not change the results. Levetiracetam was not associated with demographics, seizures, complications, or outcomes. Conclusions— Phenytoin was associated with more fever and worse outcomes after intracerebral hemorrhage.

Blood Pressure Reduction, Decreased Diffusion on MRI, and Outcomes After Intracerebral Hemorrhage

Background and Purpose— Decreased diffusion (DD) consistent with acute ischemia may be detected on MRI after acute intracerebral hemorrhage (ICH), but its risk factors and impact on functional outcomes are not well-defined. We tested the hypotheses that DD after ICH is related to acute blood pressure (BP) reduction and lower hemoglobin and presages worse functional outcomes. Methods— Patients who underwent MRI were prospectively evaluated for DD by certified neuroradiologists blinded to outcomes. Hemoglobin and BP data were obtained via electronic queries. Outcomes were obtained at 14 days and 3 months with the modified Rankin Scale, a functional scale scored from 0 (no symptoms) to 6 (dead). We used logistic regression for dependence or death (modified Rankin Scale score 4–6). Results— DD distinct from the hematoma was found on MRI in 39 of 95 patients (41%). DD was associated with greater BP reductions from baseline and a higher risk of dependence or death at 3 months (odds ratio, 4.8; 95% confidence interval, 1.7–13.9; P=0.004) after correction for ICH score (1.8 per point; 95% confidence interval, 1.2–3.1; P=0.01). Lower hemoglobin was associated with worse ICH score, larger hematoma volume, and worse outcomes, but not DD. Conclusions— DD is common after ICH, associated with greater acute BP reductions, and associated with disability and death at 3 months in multivariate analysis. The potential benefits of acute BP reduction to reduce hematoma growth may be limited by DD. The prevention and treatment of cerebral ischemia manifested as DD are potential methods to improve outcomes.

Reliability of the validated clinical diagnosis of pneumonia on validated outcomes after intracranial hemorrhage

PURPOSE Reducing the incidence of hospital-acquired pneumonia (PNU) is important but depends on accurate assessment. We sought to determine the interrater reliability of diagnosis of PNU and its impact on resource utilization and functional outcomes in a high-risk population. MATERIALS AND METHODS Patients admitted in 2007 with intracranial hemorrhage were prospectively identified. Pneumonia was prospectively diagnosed by Centers for Disease Control criteria by a neurointensivist and infection control. An independent retrospective determination was made by a fellow, an infectious disease attending physician, and a pulmonologist after review of the electronic medical records and radiographs. Interrater reliability was analyzed with κ statistics. One and 3-month outcomes were measured with the modified Rankin scale. RESULTS Of 103 patients, the incidence of PNU ranged from 5% to 25%. Interrater reliability was poor (median κ = 0.30 [0.19-0.42]; P < .001). Any ascertainment of PNU was associated with longer intensive care unit length of stay, more fever and ventilator dependence, and worse functional outcomes. CONCLUSIONS Pneumonia had poor interrater reliability despite highly trained reviewers and validated criteria. Although the clinical assessment of PNU is difficult, it was associated with greater resource use and worse outcomes. Diagnosis of clinical PNU may be suboptimal for measuring quality of intensive care.

Packed red blood cell age does not impact adverse events or outcomes after subarachnoid haemorrhage

Objectives: To determine if the age of packed red blood cells (PRBCs) is associated with adverse events or outcomes in patients with subarachnoid haemorrhage (SAH).