Plasma D-dimer may predict poor functional outcomes through systemic complications after aneurysmal subarachnoid hemorrhage

Abstract

OBJECTIVE Plasma D-dimer levels elevate during acute stages of aneurysmal subarachnoid hemorrhage (SAH) and are associated with poor functional outcomes. However, the mechanism in which D-dimer elevation on admission affects functional outcomes remains unknown. The aim of this study is to clarify whether D-dimer levels on admission are correlated with systemic complications after aneurysmal SAH, and to investigate their additive predictive value on conventional risk factors for poor functional outcomes. METHODS A total of 187 patients with aneurysmal SAH were retrospectively analyzed from a single-center, observational cohort database. Correlations of plasma D-dimer levels on admission with patient characteristics, initial presentation, neurological complications, and systemic complications were identified. The authors also evaluated the additive value of D-dimer elevation on admission for poor functional outcomes by comparing predictive models with and without D-dimer. RESULTS D-dimer elevation on admission was associated with increasing age, female sex, and severity of SAH. Patients with higher D-dimer levels had increased likelihood of nosocomial infections (OR 1.22 [95% CI 1.07-1.39], p = 0.004), serum sodium disorders (OR 1.11 [95% CI 1.01-1.23], p = 0.033), and cardiopulmonary complications (OR 1.20 [95% CI 1.04-1.37], p = 0.01) on multivariable analysis. D-dimer elevation was an independent risk factor of poor functional outcome (modified Rankin Scale Score 3-6, OR 1.50 [95% CI 1.15-1.95], p = 0.003). A novel prediction model with D-dimer had significantly better discrimination ability for poor outcomes than conventional models without D-dimer. CONCLUSIONS Elevated D-dimer levels on admission were independently correlated with systemic complication, and had an additive value for outcome prediction on conventional risk factors after aneurysmal SAH.

Association of plasma D-dimer level with thromboembolic events after endovascular coil treatment of ruptured cerebral aneurysms

“…6 The plasma level of D-dimer may be elevated not only as an acute systemic response for SAH but also depending on patients' premorbid status, including aging. 10,20 Atherosclerotic change is presumed to be one of the causes of D-dimer elevation in elderly patients. 10,14 Thromboembolic events without visible thrombus formation at the neck of the aneurysm during endovascular coiling may be caused by catheter insertion into a diseased parent vessel, as represented by elevated D-dimer levels.…”

“…10,20 Atherosclerotic change is presumed to be one of the causes of D-dimer elevation in elderly patients. 10,14 Thromboembolic events without visible thrombus formation at the neck of the aneurysm during endovascular coiling may be caused by catheter insertion into a diseased parent vessel, as represented by elevated D-dimer levels. 6 In addition, chronic derangements in systemic coagulation states from comorbid burden, such as deep venous thrombosis and malignancies, may be associated with D-dimer elevations and thromboembolic events unrelated to endovascular procedures, 10,22 although screening for these pathologies was not performed in the present study.…”

“…17 In the treatment of ruptured aneurysms, hypercoagulability as a systemic response to acute subarachnoid hemorrhage (SAH) 9,13 may be associated with an increased incidence of thromboembolic events in addition to the aforementioned anatomical factors. Among possible biomarkers of hypercoagulability, D-dimer concentration is known to be elevated in the acute stages of SAH 9,10,13 and is a useful marker to detect sources of thromboembolism in cerebral ischemic strokes. 16 In this study, we investigate whether levels of D-dimer, a stable ABBREVIATIONS IQR = interquartile range; SAH = subarachnoid hemorrhage; WFNS = World Federation of Neurosurgical Societies.…”

Higher Admission D-Dimer Values Are Associated With an Increased Risk of Nonroutine Discharge in Neurosurgery Patients

“…D-dimers have previously been used to delineate outcome in a number of distinct diseases. In several small series, D-dimer levels in patients with subarachnoid hemorrhage or aneurysms have correlated with various outcome measures, including delayed cerebral ischemia, three-month Glasgow outcome scale, modified Rankin scale (mRS), and infections [ 3 - 6 ]. D-dimers have also been shown to correlate with poor outcomes in patients after ischemic stroke, including the Pediatric Stroke Outcome Measure and mRS [ 10 , 11 ], as well as thrombosis in dural arteriovenous fistulas [ 17 ].…”

“…However, D-dimers are also serum acute-phase proteins (APP) that show upregulated expression after stress, infection, or worsening disease states. The recent literature has suggested that D-dimers can be used to evaluate and predict clinical prognosis in neurosurgical patients, including after subarachnoid hemorrhage [ 3 - 6 ], intracranial hemorrhage [ 7 - 9 ], ischemic stroke [ 10 , 11 ], and trauma [ 12 - 15 ] and in patients with dural arteriovenous fistula (dAVF) [ 16 , 17 ] and intracerebral [ 18 , 19 ] and spinal [ 20 , 21 ] neoplasms. However, within these studies, outcome measures are variable depending on the disease of interest, so a mix of elective and emergent patients are included and patients are derived from different institutions with variation in population demographics.…”