Blood Transfusion is an Important Predictor of Hospital Mortality Among Patients with Aneurysmal Subarachnoid Hemorrhage

Festić, Emir; Rabinstein, Alejandro A.; Freeman, William D.; Mauricio, Elizabeth A.; Robinson, Maisha T.; Mandrekar, Jay; Zubair, Abba C.; Lee, Augustine S.; Gajic, Ognjen

doi:10.1007/s12028-012-9777-y

Cited by 46 publications

(29 citation statements)

References 29 publications

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“…36 Hematologic, renal, and hepatic dysfunction in aSAH could also be influenced by a positive fluid balance. 20,37 Given the consistency of the association on multivariable analyses, even after adjusting with propensity scores, we think that the relationship of positive fluid balance with functional outcome is not related to greater fluid administration in worse cases. Yet, at this point, the reasons to explain the association of positive fluid balance with worse outcomes remain unclear.…”

Section: Discussionmentioning

confidence: 97%

“…The association of transfusion with worse functional outcome remains unexplained but has been previously reported. 37 Hyperglycemia has also been found to be associated with unfavorable prognosis after aSAH 39 although no trial has been conducted to determine if this is a causal association or hyperglycemia is a surrogate marker of more severe disease. 40 Our study has limitations.…”

Section: Discussionmentioning

confidence: 99%

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Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage

Kissoon¹,

Mandrekar²,

Fugate³

et al. 2015

Journal of Stroke and Cerebrovascular Diseases

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Section: Discussionmentioning

confidence: 97%

Section: Discussionmentioning

confidence: 99%

Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage

Kissoon¹,

Mandrekar²,

Fugate³

et al. 2015

Journal of Stroke and Cerebrovascular Diseases

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“…a 10–15% rise in oxygen delivery); it remains to be determined if transfusion of more than one unit of blood would offer additional benefit. Furthermore, any physiologic benefits to oxygen delivery must be balanced against possible risks of transfusion, as suggested in observational studies of SAH patients [40, 41]. …”

Section: Discussionmentioning

confidence: 99%

RBC Transfusion Improves Cerebral Oxygen Delivery in Subarachnoid Hemorrhage

Dhar

Zazulia²,

Derdeyn³

et al. 2017

Critical Care Medicine

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Objective Impaired oxygen delivery due to reduced cerebral blood flow (CBF) is the hallmark of delayed cerebral ischemia (DCI) following subarachnoid hemorrhage (SAH). Since anemia reduces arterial oxygen content, it further threatens oxygen delivery increasing the risk of cerebral infarction. Thus, SAH may constitute an important exception to current restrictive transfusion practices, wherein raising hemoglobin could reduce the risk of ischemia in a critically hypoperfused organ. In this physiologic proof-of-principle study we determined whether transfusion could augment cerebral oxygen delivery, particularly in vulnerable brain regions, across a broad range of hemoglobin values. Design Prospective study measuring CBF and oxygen extraction fraction (OEF) using 15O-PET. Vulnerable brain regions were defined as those with baseline oxygen delivery < 4.5 ml/100g/min. Setting PET facility located within the Neurology/Neurosurgery Intensive Care Unit. Patients 52 patients at risk for DCI after aneurysmal SAH with hemoglobin 7–13 g/dl. Interventions Transfusion of one unit of red blood cells (RBCs) over one hour. Measurements and Main Results Baseline hemoglobin was 9.7 g/dl (range 6.9–12.9) and CBF was 43±11 ml/100g/min. After transfusion, hemoglobin rose from 9.6±1.4 to 10.8±1.4 g/dl (12%, p < 0.001) and oxygen delivery from 5.0 (IQR 4.4–6.6) to 5.5 (4.8–7.0) ml/100g/min (10%, p=0.001); the response was comparable across the range of hemoglobin values. In vulnerable brain regions, transfusion resulted in a greater (16%) rise in oxygen delivery associated with reduction in OEF, independent of Hgb level (p=0.002 vs. normal regions). Conclusions This study demonstrates that RBC transfusion improves cerebral oxygen delivery globally and particularly to vulnerable regions in SAH patients at risk for DCI across a wide range of hemoglobin values and suggests that restrictive transfusion practices may not be appropriate in this population. Large prospective trials are necessary to determine if these physiologic benefits translate into clinical improvement and outweigh the risk of transfusion.

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“…The associations of radiological infarctions and transfusion with worse outcomes have been previously reported by our group and other investigators. 3,10,20,24 Nonetheless, these results highlight the need to treat cerebral ischemia aggressively and to favor a conservative transfusion strategy to maximize the chances of attaining an excellent outcome, although the exact cutoff for considering transfusion needs to be better studied.…”

Section: Discussionmentioning

confidence: 99%

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

Pegoli¹,

Mandrekar²,

Rabinstein

et al. 2015

JNS

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116

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A lthough the incidence of aneurysmal subarachnoid hemorrhage (aSAH) has remained stable over time, case fatality rates have decreased by 17% during the last three decades. 11,18 In parallel with refinements in endovascular and surgical treatment and advances in neurocritical care, there has also been an improvement in functional outcome. 2,16,19,23 There are many studies on factors predictive of poor functional and cognitive outcome after aSAH, 5,6,22,25 but much less information on predictors of excellent outcome. In this study, we analyzed predictors of excellent functional outcome in a contemporary series of patients with aSAH. Methods Study PopulationAfter Institutional Review Board approval from the Mayo Clinic, we performed a retrospective chart review of adult patients with aSAH admitted to St. Mary's HospitalMayo Medical Center in Rochester, Minnesota, between February 2001 and June 2013. Subarachnoid hemorrhage (SAH) was confirmed radiologically or by the presence of xanthochromia in the CSF. Only patients with a documented aneurysm on cerebral angiography that was considered to be the cause of the SAH were included.abbreviatioNS aSAH = aneurysmal SAH; DCI = delayed cerebral ischemia; ICH = intracerebral hemorrhage; IVH = intraventricular hemorrhage; mRS = modified Rankin Scale; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies. reSultS Three hundred seventy-three patients were identified with posthospital follow-up. Excellent outcome was noted in 236 patients (63.3%), including an mRS score of 0 in 122 (32.7%) and an mRS score of 1 in 114 (30.6%). On univariate analysis, the following factors were associated with an excellent outcome: indicators of less severe bleeding, such as better World Federation of Neurosurgical Societies grade at any of the times of assessment, better modified Fisher grade, and absence of intracerebral hemorrhage (ICH), intraventricular hemorrhage (IVH), and symptomatic hydrocephalus; aneurysm treatment with coil embolization; absence of symptomatic vasospasm, delayed cerebral ischemia, and radiological infarction; absence of in-hospital seizures; lack of need for CSF diversion; fewer hours with fever; less severe anemia; and absence of transfusion. On multivariable analysis, the 4 variables that were most strongly associated with excellent outcome were presence of good clinical grade after neurological resuscitation, absence of ICH on initial CT scan, blood transfusion during the hospitalization, and radiological infarctions on final brain imaging. coNcluSioNS Excellent outcomes (mRS score 0-1) can be achieved in the majority of patients with aSAH. The likelihood of excellent outcome is predicted by good clinical condition after resuscitation, absence of ICH on presentation, no evidence of infarction on brain imaging, and absence of blood transfusion during hospitalization.

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Blood Transfusion is an Important Predictor of Hospital Mortality Among Patients with Aneurysmal Subarachnoid Hemorrhage

Abstract: Among patients with aSAH, RBC transfusion was independently associated with an increased mortality after adjustment for the most common clinical indications for transfusion.

Cited by 46 publications

References 29 publications

Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage

Positive Fluid Balance Is Associated With Poor Outcomes in Subarachnoid Hemorrhage

RBC Transfusion Improves Cerebral Oxygen Delivery in Subarachnoid Hemorrhage

Predictors of excellent functional outcome in aneurysmal subarachnoid hemorrhage

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