MEDICAL COMPLICATIONS OF ANEURYSMAL SUBARACHNOID HEMORRHAGE - A REPORT OF THE MULTICENTER, COOPERATIVE ANEURYSM STUDY

Objectives: This report examines the frequency, type, and prognostic f actors of medical (nonneurologic) complications after subarachnoid hem orrhage in a large, prospective study. The influences of contemporary neurosurgical, neurological, and critical care practice on mortality a nd morbidity rates after aneurysmal subarachnoid hemorrhage are evalua ted. Design: A study of medical complications observed in the placebo limb of a large, randomized, controlled trial of the calcium antagonis t, nicardipine, after subarachnoid hemorrhage. Setting: Patients were recruited from 50 hospitals in 41 neurosurgical centers in the United States and Canada. Patients: A total of 451 patients with subarachnoid hemorrhage, greater than or equal to 18 yrs of age, were randomly ass igned to the placebo group. All patients arrived at the participating center within 7 days (mean 1.0 +/- 1.8 [SD] days) of rupture of an ang iographically documented saccular aneurysm. Measurements and Main Resu lts: The frequency rates of symptomatic vasospasm, rebleeding, and tot al mortality rate after subarachnoid hemorrhage at 3-month follow-up w ere 46%, 7%, and 19%, respectively. The frequency of having at least o ne severe (life-threatening) medical complication was 40%. The proport ion of deaths from medical complications was 23%. This value was compa rable with the proportion of deaths attributed to the direct effects o f the initial hemorrhage (19%), rebleeding (22%), and vasospasm (23%) after aneurysmal rupture. The frequency of life-threatening cardiac ar rhythmias was 5%; less ominous rhythm disturbances occurred in 30% of the patients. There was an increased frequency of cardiac arrhythmias on the day of, or day after, aneurysm surgery. Pulmonary edema occurre d in 23% of the patients, with a 6% occurrence rate incidence of sever e pulmonary edema. There was a wide variation from center to center, w ith the greatest frequency on days 3 through 7. There was a nonsignifi cant association of pulmonary edema with the use of hypertensive hyper volemic therapy (p = .10), and a significant association with the timi ng of surgery (p < .05). Some degree of hepatic dysfunction was noted in 24% of patients, the majority with only mild abnormalities of hepat ic enzymes with no clinical accompaniment (4% frequency of severe hepa tic dysfunction). Thrombocytopenia occurred in 4% of patients, usually in the setting of sepsis. Renal dysfunction was reported in 7% of the patients, with 15% of that figure deemed to be of life-threatening se verity. There was an association (p = .001) with antibiotic therapy. C onclusions: Potentially preventable medical complications after ruptur ed cerebral aneurysm add to the total mortality rate of patients, and may increase length of hospital stay in the critical care setting. The proportion of deaths after subarachnoid hemorrhage from medical compl ications equals those deaths from either direct effects, rebleeding, o r vasospasm individually. Pulmonary complications are the most common nonneurologic cause of death. Cardiac arrhythmia, although frequent, w as not associated with significant mortality. The frequency of cardiac arrhythmia and pulmonary edema increased on the day of, or day after, aneurysm surgery. Renal and hepatic dysfunction, and blood dyscrasias , were also observed, underscoring the need for meticulous monitoring for metabolic and hematologic derangements.