Extracerebral organ dysfunction and neurologic outcome after aneurysmal subarachnoid hemorrhage

Objective: To analyze the influence of extracerebral organ system dysfuncti on after aneurysmal subarachnoid hemorrhage (SAH) on mortality and neurolog ic outcome. Design: Observational study with retrospective data extraction. Setting: Neurosurgical intensive care unit (NICU) at a primary level univer sity hospital, supervised and staffed by both members of the Clinic of Neur osurgery and the Clinic of Anesthesiology and General Intensive Care, Patients: Two hundred forty-two patients treated for intracranial aneurysm rupture within 7 days of the most recent SAH, Interventions: Routine neuros urgical interventions for obliteration of the ruptured aneurysm (microsurge ry, Guglielmi Detachable Coils embolization) and for treatment of posthemor rhagic hydrocephalus (ventriculostomy, cerebrospinal fluid shunt implantati on). Measurements and Main Results: Respiratory, renal, hepatic, cardiovascular, and hematologic organ system functions were evaluated both individually an d in aggregate by using a modified version of the Multiple Organ Dysfunctio n (mMOD) score, of 1,452 organ system functions assessed in 242 patients du ring their NICU stay, 714 organ system functions were intact (cerebral: 0, extracerebral: 714), 556 organ systems had mild-to-moderate dysfunctions (m MOD score(max) 1-2 for the affected organ system; cerebral: 153, extracereb ral: 403), and 182 organ systems failed (mMOD score(max) 3 for the affected organ system; cerebral: 89, extracerebral: 93). Severity of extracerebral organ system dysfunctions correlated with the degree of neurologic impairme nt (Hunt and Hess [H&H] score) in a graded fashion. Similarly, the chance t o develop systemic inflammatory response syndrome (SIRS) during the NICU st ay increased with increasing admission H&H grade. The incidence of SIRS and septic shock was 29% and 10.3%, respectively. The mortality rate was 40.2% in patients with SIRS and 80% for patients suffering septic shock. Seventy -seven percent of extracerebral organ system failures (OSFs) occurred in co njunction with SIRS: 51% of respiratory OSFs, 97% of renal OSFs, 100% of he patic OSFs, 96% of cardiovascular OSFs, and 73% of hemato poietic OSFs. Bot h CNS dysfunction and extracerebral organ system dysfunctions were signific antly related to neurologic outcome. The probability of unfavorable neurolo gic outcome significantly increased with both decreasing cerebral perfusion pressure (CPP) and increasing severity of extracerebral organ dysfunction. Conclusion: Aneurysmal SAH and its neurologic sequelae accounted for the pr incipal morbidity and mortality in the current series. Development of extra cerebral organ system dysfunction was associated with a higher probability of unfavorable neurologic outcome. Systemic inflammation (SIRS) and seconda ry organ dysfunction were the principal non neurologic causes of death.