JOURNAL OF MIUTflRV PHRRMRCO-MCDICINC N°7-20U
STUDY THE RELATIONSHIP BETWEEN CLINICAL CHARACTERISTICS AND COMPLICATIONS IN PATIENTS
WITH ACUTE SUBARACHNOID HERMORRHAGE
Nguyen Hoang Ngoc'; Nguyen Van Tuyen' SUMMARY
Subarachnoid hemon-hage (SAH) accounts for 10% of all stroke. This is a severe disease of the stroke. The main cause of SAH is ruptured cerebral arteries aneurysms accounts for 80%
Patients have more serious complications such as rebleeding, hydrocephalus, electmlyte disorders and particulariy cerebral vasospasm that cause cerebral Infarction and It Is the main cause leading to death or severe disability Patients with subarachnoid hemonhage should be diagnosed early, monitored carefully and managed complications timely to reduce the mortality and mortjidlty.
Objective: Study the clinical characteristics, the relationship between the clinical characteristics and complications in patients with subarachnoid hemorrhage.
Methods. Cmss-sectlonal pmspectlve study on 110 patients who suffered from SAH addmlted to Stroke Center in 108 Hospital, from December 2008 to December 2013.
Results and conclusions: research msults of clinical characteristics and complications during the acute phase of 110 patients with SAH, we found that: the ratio of male/female was 1.6/1;
the mean age was 49.76 (± 18.5); the major clinical symptoms: sudden, sevem headache accounted for 89%; meningeal syndrome (86.4%); hemiplegia (16.4%); the clinical symptoms according to Hunt - Hess scale: fmm grade I to grade 111 accounted for 70%. The results of digital subtraction angiography (DSA): 59% of patients had the aneurysms belong to anterior ammunicatlng artery (27.7%), Intracranial Internal carotid artery (26%), middle cerebral artery (17%), anterior cerebral artery (6.2%), posterior communicating artery (7.7%) and basilar artery (15.4%). The common complications wem cerebral vasospasm accounted for30.9%, ventricular dllatathn 17.3%. These complications reiated to the severity of SAH and the aneurysmal characteristics. Rebleeding accounted for 11.8%, pmsented In the first week. Hyponatremia accounted for 38.2%, occurred on day 5 - 14 (9.8 ± 5.5;, prolonged fever (31.8%). We found also the cardiac arrhythmias and a number of changes in cardiac conduction as prolonged QT, flat T wave accounted for 10.9%, 29.1% and 34.5%, respectively. There was an association between clinical seventy (Hunt - Hess of IV - V), as well as the characteristics of the aneurysms (no Inten/entlon) to Increase the risk of mbleedlng and cerebral vasospasm following SAH.
' Key words: Subarachnoid hemormages; Meningeal syndrome; Hyponatremia; Aneurysms.
INTRODUCTION techniques of cerebral artery intervention, the aneurysms-caused SAH is Intervened Subarachnoid hemorrhage accounts gariy. However, in the acute phase, there for 10 - 20% of all hemorrhagic stroke [6], are many complications that affected to Nowdays, thanks to the new modern outcome of patients with SAH
'108 Hospital
Corresponding author: Nguyen Hoang Ngoc ([email protected]) 101
JOURNAL OF MillTARV PHRRMRCO-MCDICINC N°7-i014 To enhance the effectiveness of treatment and prevent the complications, we studied this subject for the purposes as follows;
- Survey the common complications in the acute phase of SAH.
- Detemiine the relationship between the clinical characteristics and complications occurring during the process of treatment of patients with SAH.
SUBJECTS AND METHODS 1. Subjects.
10 patients treated in the Stroke Center - Central Military Hospital 108 from December 2008 to December 2013, The patients have been deflnitively diagnosed non-traumatic subarachnoid hemorrhage.
2. Methods.
Cross-sectional retrospective, obsewational study.
RESULTS AND DISCUSSION 1. Characteristics of the age and gender.
The mean age was 49.76 (± 18.5), the most common age was from 40 to 59 years old (72%). According to Vo Hong Khoi, the mean age was 46, most commonly from 45 - 54 years old. Not only the young people suffer from SAH as previously thought, in our study there were 28% of patients above 60 years old with SAH.
There were 68 males, 42 females and the ratio of male/female was 1.6;1.
According to Le Van Thinh; male accounted
for 63.5%, Vo Hong Khoi; male ccounted for 60.4% [1], Other studies in the worid showed that, the women was 1,6 times more than the men [3], Thus, our results are comparable to the others results.
2. Clinical features.
TaWe 1: The clinical symptoms.
CLINICAL SYMPTOMS Sudden, acute onset Sudden,severe headache Nausea and vomiting Selzujes at the onset Hemiplegia Meningeal syndrome Consciousness disorder
Glasgow 3 - 5 points Glasgow 6 - 8 points Glasgow 9-12 points Glasgow^ 13 points Hunt - Hess at admission:
Grade 1 Grade II Grade III Grade IV Grade V
NUMBER OF PATIENTS
(n = 110) 98 104 68 19 18 95
9 16 25 60
15 42 .20 27 6
PERCENTAGE
(%)
89%
945%
61.8%
173%
16.4%
86.4%
8.2%
14.5%
22.7%
54.6%
13.6%
38,2%
18.2%
24.5%
5 5%
Most patients had the sudden severe headache onset (94.5%) and typical signs of meningism with neck stiffness (86.4%), vomiting (61.8%).
102
JOURNfll OF MIUTRRV PHRRMRCO-MCDICINE N°7-2014 A few patients had the warning signs
before rupturing cerebral aneurysma about few days such as headache, neck stiffness, nausea, transient unconsciousness.
Some patients with pain in one side of head or occipital region, depending on the aneurysm location. It may be happened after onset of headache, drooping eyelids due to the 3* cranial nerves palsy (met in the patients with posterior communicating artery aneurysm). In the 110 studied patients, there were 17.3% of paitents with seizure onset. Remarkably, the number of patient initially misdiagnosised about 15%, particularly a lot of patients with mild stroke or eariy fever at the first days, those are misdiagnosised as meningfe.
This Is very dangerous because of approximately 40% of misdiagnosed patients will lead to severe neurological deficits with the complications such as rebleeding, hydrocephalus, cerebraK/asospasm.
These complications may be increased the disability and the mortality for patients SAH [7],
The SAH patients had the most common headaches and persist for weeks. Using the sedative, analgesic to decrease headache is not high effective. SAH patients always have symptoms such as stimulating, struggling, with typical signs of meningitis such as headache - vomitting - neck stiffness. In our study, the symptoms of patients with SAH were also the same with the findings of Le Van Thinh, Vo Hong Khoi; headache (90%), neck stiffness (71,7%), vomiting (66.7%).
The patients with SAH had focal neurological deficits when hematoma occurred In the brain or due to cerebral
vasospasm at the later phase.
According to Vo Hong Khoi, hemiplegia was 19.8%, 3 '" cranial nerves palsy (38.3%), leg paralysis accounted for 10% [1].
The symptoms of plant - neurological disorders such as fever due to absorbed hemoglobin in the cerebro - spinal fluid, hypertention response due to increased cathecolamin, respiratory disorders due to cerebral edema are also common symptoms. The rate of fever in our study was 31%.
3. Characteristic imagings.
Table.2: The Fisher classification of SAH on the brain CT-scan.
FISHER CLASSIFICATION
Number of patients (n = 110) Percentage (%)
GRADE
10 9 1 %
GRADE II
34 30 9%
GRADE III
29 26 4 %
GRADE IV
37 33 6%
According to the Fisher classification of SAH: the grade III - IV are major proportion, accouted for 60%. Our results were the same with results of Vo Hong Khoi: grade I: 16.7%; grade li: 27%; grade III: 36.5%; grade IV: 19.8%, The brain CT- scan has high sensitivity in diagnosing SAH in acute phase. Therefore, the brain CT-scan is the first choice for diagnosis of SAH. When CT-scan is negative, a lumbar puncture is necessary for definitive diagnosis of SAH. The brain CT-scan not only confirms the diagnosis, but also can predict the bleeding location; aneurysmal location; complications such as hydrocephalus, cerebral infarction due to cerebral vasospasm
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JOURNfll OF MIUTRRV PHRRMflCO-MCDICINC N°7-g014
TaWe 3; Location of ruptured aneurysms.
LOCATION OF RUPTURED ANEURYSMS Midle cerebral artery
Posterior communicating artery Antenor communicating artery Intracranial internal carotid artery Anterior cerebral artery Basilar cerebral artery, posterior cerebral artery
Angiogram-negative SAH
NUMBER OF PATIENTS
(n = 110) 11 5 18 17 4 10 45
PERCENTAGE (%), (n=110)
10%
4.5%
16.4%
15.5%
3.6%
9%
PERCENTAGE (%).(n'65) ,
17%
7.7%
27.7%
26%
6.2%
15.4%
41 % All 110 patients with SAH were perfomied
CT angiogram (CTA) or digital subtraction angiography (DSA), 45 patients had angiogram negative (41%), 65 patients had angiogram positive with ruptured- aneurysm. The most common location was the anterior communicating artery (27.7%), the intracranial internal carotid artery (25%), other locations such as the
middle cerebral artery (17%), the anterior cerebral artery (6.2%) and posterior communicating artery (7.7%). The circle of Willis is the most common locations for aneurysms, Vo Hong Khoi studied 96 patients with SAH, there were 79,2% of patients with aneurysm, this ratio was relatively high. According to Le Van Thinh, Mayer, this rate was about 80% [8], Table 4: Complications in the treatment process.
COMPLICATIONS Cerebral vasospasm Rebleeding In the acute phase Hydrocephalus
Prolonged fever (non- infections) Hyponatremia
Anhythmia: bradycardia, premature ventricular contractions, premature atrial contractions
Conduction disturbance: prolonged QT Flat T wave
NUMBER OF PATIENTS
{n = 110) 34 13 19 35 42 12 32 38
PERCENTAGE
(%)
30 9%
11.8%
17.3%
31.8%
38.2%
10.9%
29.1%
34 5%
PERIOD OF COMPLICATIONS APPEARED AFTER SAH (days)
5.7 ± 3.4 4.7 ± 2.3 6,8 ± 3.7 4.2 ± 2.7 9.8 ± 5.5
The most common complication was cerebral vasospasm (30.9%), usually occurs In the first week.
JOUANRl OF MIUTRRV PHRRMRCO-MCDICINC N°7-2014 Rebleeding is the most serious
complication, especially when the aneurysm has not been intervented yet. The typical signs of rebleeding is that: patient suddenly have severe headache or seizures and rapidly go into a coma. Among 110 studied patients, there were 13 patients with rebleeding (11.8%), usualy occurs in the first week. 12/13 patients had angiogram positive with ruptured-aneurysm, but not to intervent, 1 patient had done angiogram, but not observed aneurysm in DSA before. According to researchs by other authors, the rate of rebleeding was about 7% and it may be up to 30%, occured in the first two weeks if the aneurysm is not early intervented [8], The risk for rebleeding included large aneurysms with wide neck of aneurysms; and the blood pressure was also high, unstable.
- According to Le Van Thinh (2002), the rate of rebleeding was 27% (at that time, cerebrovascular intervention has not yet developed) [2]; according to Vo Hong Khoi, this rate of rebleeding was 16.7%.
The rate of rebleeding in this study was only 11.8%, because we collaborated with Cerebrovascular Intervention Department to coil aneurysms as soon as possible for patient with SAH, so that the risk decreased.
- Cerebral vasospasm usually occurs from day 3 - 2 1 , most common on day 6 - 8 after stroke. This complication lead to increases mortality and morbidity.
According to the Vo Hong Khoi, cerebral vasospasm was 37.5% [1]. There is an association between the severity of disease and the ruptured-aneurysms SAH with cerebral vasospasm.
- Hyponatremia is a common complication after SAH, accounted approximately 5 - 30% [8], In our study, hyponatremia has been seen In 42 patients (38.2%), this ratio is higher than study by Vo Hong Khoi (13.5%), because we constantly monitor electrolytes in 2 weeks of treatment. IVIany patients with early stage of hyponatremia perfectly normal until 8'" day, there were some special patients with severe hyponatremia until 14* day (123 mmol/1).
- Our results showed that hyponatremia happened the earliest on 4"^ day and latested on 14* day (9 8 ± 5.5 days).
Hyponatremia should be diagnosed eariy and timely to avoid Increase of cerebral edema [5]. There is an association between the severity of SAH (Hunt - Hess grade III, IV, V) and hyponatremia status
- Hydrocephalus Is one of the complications of SAH, may be obstructive hydrocephalus or comunlcatlng hydrocephalus, acute hydrocephalus or chronic hydrocephalus.
Patients with typical sigh of hydrocephalus such as diminution of the tevel consciousness, convulsions, nausea, and vomiting. The rate of hydrocephalus in our study was 17.3%. According to Le Van Thinh 6% [2];
Vo Hong Khoi 12.5% [1]. In this study, the hydrocephalus occured about 3 - 7 days after onset. The patients suffered from hydro cephalus should be closely montored to diagnose and drain ventricular liquid in time.
- Some other complications of SAH are arrhythmias due to increase of catecholamine such as bradycardia, premature atrial contractions, premature ventricular contractions
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JOURNRL OF MIUTRRV PHRRMBCO-MCDICINC N°7-2014 (10.9%), flat T wave (34.5%), prolonged QT (29,1%). According to the authors in our country and abroad, the cardiac arrhythmias are also common in patients with SAH. Even about 10% of patients with abnormal changes on the electrocardiogram. This is a risk for complications of myocardial infarction [8].
- Prolonged fever due to absorption of blood in cerebrospinal fluid was 31.8%, fever started from day 2 onwards, the mean days 4 - 5 . Period of fever lasts about 1 - 2 weeks. Prolonged fever also affect the mortality and morbidity. Some factors related to the fever (non-infections) are level of blood bleeding, particularly in intraventricular.
TaWe 5: The relations between the grade of Hunt - Hess and complications.
COMPLICATIONS Cerebral vasopasm (n = 34) Rebleeding in acute phase (n == 13) Hydrocephalus (n = 19) Prolonged fever (non- infections) (n = 35)
Hyponatremia (n = 42)
HUNT-HESS 111-IV-V (n.53) 28 52.8%
7 13.2%
16 30,2%
25 47.1%
26 49,1%
HUNT - HESS l-ll (n = 57) 6 10.5%
6 10.5%
3 5.3%
10 17.5%
16 28.1%
P
< 0 001
>0.D6
< 0,001
< 0.005
< 0.005 The patients with the Hunt - Hess grade lit or higher had more complications than patients with the Hunt - Hess grade I and II, the differences were statistically significant with p < 0.05. Only rebleeding in the acute phase did not differ between the two groups.
Table 6: The relations between the aneurysms and complications.
COtylPLICATIONS
Cerebtal vasospasm (n = 34) Rebleeding in acute phase (n = 13) Hydrocephalus (n = 19) Prolonged fever (non- infections)
(n = 35) Hyponatremia (n = 42)
PATIENTS WITH ANEURYSM
(n = 65) 25 38 5%
12 18.5%
12 18.5%
22 33.8%
26 40%
PATIENTS WITHOUT ANEURYSM
Cn = 45) 9 20%
1 2,2%
7 15.6%
13 28.9%
16 35.6%
'
<0.D1
< 0.001
>0.06
>0.05
>0.05 Patients with SAH due to ruptured cerebral aneurysm had rate of cerebral vasospasm higher than patients with undiscovered cerebral aneurysm (p < 0.01). The rate of rebleeding in patients with SAH due to ruptured cerebral aneurysm was 18.5%, this difference was statistically significant with p < 0.001.
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JOURNfll OF MIUTflflV PHRRMRCO-MCDICINC N°7-2ai4 CONCLUSION
Study the clinical characteristics and complications in 110 patients with SAH in the acute phase, we found that:
- Mean age 49.76 (± 18.5), ages from 40 to 59 accounted for the highest percentage (72%), male/female was 1,6/1. The major clinical symptoms:
sudden, severe headache accounted for 89%; meningeal syndrome (86.4%);
hemiplegia (16.4%) ; Hunt - Hess scale:
grade I, II, 111, accounted for 70%.
- Image of DSA showed that 45 patients had angiogram negative with aneurysm (41%), 65 patients had angiogram positive with ruptured-aneurysm (59%). The most common location was the anterior communicating artery (27.7%), the intracranial intemal carotid artery (26%), other locations such as the middle cerebral artery (17%), the anterior cerebral artery (6.2%) and posterior communicating artery (7.7%), the basilar artery and the posterior cerebral artery (15.4%).
The common complications were cerebral vasospasm accounted for 30.9%, related to the severe disease and the njptured aneurysm. Hydrocephalus was 17,3%; rebleeding was 11.8%, often occurs in the first week; hyponatremia was 38.2%, occurs on day 5 - 1 4 (9.8 ± 5 5); Prolonged fever was 31.8%, related to Hunt-Hess scale of grade IV-V. The arthythmias.
prolonged QT, fiat T wave accounted for 10,.%, 29.1% and 34.5%, respectively.
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