Faculty Bibliography

OBJECTIVE: We sought to determine the frequency, risk factors, and impact on functional outcome and quality of life (QOL) of global cognitive impairment 1 year after subarachnoid hemorrhage. METHODS: We prospectively evaluated global cognitive status 3 and 12 months after hospitalization with the Telephone Interview for Cognitive Status in 232 subarachnoid hemorrhage survivors. Cognitive impairment was defined as a score of 30 or less (scaled 0 = worst, 51 = best). Logistic regression was performed to calculate adjusted odds ratios (AORs) for impairment at 1 year. Basic activities of daily living were evaluated with the Barthel Index, instrumental activities of daily living were assessed with the Lawton scale, and QOL was evaluated with the Sickness Impact Profile. RESULTS: The frequency of cognitive impairment was 27% at 3 months and 21% at 12 months. After the effects of age, education, and race/ethnicity were controlled for, risk factors for cognitive impairment at 12 months included anemia treated with transfusion (AOR, 3.4; P = 0.006), any temperature level higher than 38.6 degrees C (AOR, 2.7; P = 0.016), and delayed cerebral ischemia (AOR, 3.6; P = 0.01). Among cognitively impaired patients at 3 months, improvement at 1 year occurred in 34% and was associated with more than 12 years of education and the absence of fever higher than 38.6 degrees C during hospitalization (P = 0.015). Patients with cognitive impairment at 1 year had worse concurrent QOL and less ability to perform instrumental and basic activities of daily living (all P < 0.001). CONCLUSION: Global cognitive impairment affects more than 20% of subarachnoid hemorrhage survivors at 1 year, is predicted by fever, anemia treated with transfusion, and delayed cerebral ischemia, and adversely affects functional recovery and QOL.

BACKGROUND AND PURPOSE: Vasospasm is an important complication of subarachnoid hemorrhage, but is variably defined in the literature. METHODS: We studied 580 patients with subarachnoid hemorrhage and identified those with: (1) symptomatic vasospasm, defined as clinical deterioration deemed secondary to vasospasm after other causes were eliminated; (2) delayed cerebral ischemia (DCI), defined as symptomatic vasospasm, or infarction on CT attributable to vasospasm; (3) angiographic spasm, as seen on digital subtraction angiography; and (4) transcranial Doppler (TCD) spasm, defined as any mean flow velocity >120 cm/sec. Logistic regression analysis was performed to test the association of each definition of vasospasm with various hospital complications, and 3-month quality of life (sickness impact profile), cognitive status (telephone interview of cognitive status), instrumental activities of daily living (Lawton score), and death or severe disability at 3 months (modified Rankin scale score 4-6), after adjustment for covariates. RESULTS: Symptomatic vasospasm occurred in 16%, DCI in 21%, angiographic vasospasm in 31%, and TCD spasm in 45% of patients. DCI was statistically associated with more hospital complications (N=7; all P<0.05) than symptomatic spasm (N=4), angiographic spasm (N=1), or TCD vasospasm (N=1). Angiographic and TCD vasospasm were not related to any aspect of clinical outcome. Both symptomatic vasospasm and DCI were related to reduced instrumental activities of daily living, cognitive impairment, and poor quality of life (all P<0.05). However, only DCI was associated with death or severe disability at 3 months (adjusted OR, 2.2; 95% CI, 1.2-3.9; P=0.007). CONCLUSIONS: DCI is a more clinically meaningful definition than either symptomatic deterioration alone or the presence of arterial spasm by angiography or TCD.

OBJECTIVE: Critically ill neurological patients are susceptible to infections that may be distinct from other intensive care patients. The aim of this study is to quantify the prevalence, risk factors, and effect on the outcome of nosocomial infectious complications in patients with subarachnoid hemorrhage (SAH). METHODS: We studied 573 consecutive patients with SAH, identified the most prevalent infectious complications, and performed univariate analyses to determine risk factors for each complication. Multiple logistic regression models were constructed to calculate adjusted odds ratios for associated risk factors and to assess the impact of infectious complications on 3-month outcome as evaluated with the modified Rankin Scale. RESULTS: The most prevalent nosocomial infections were pneumonia (n = 114, 20%), urinary tract infection (n = 77, 13%), bloodstream infection (BSI) (n = 48, 8%), and meningitis/ventriculitis (n = 28, 5%). Significant independent associations with pneumonia included older age, poor Hunt and Hess grade, intubation/mechanical ventilation, and loss of consciousness at ictus. Urinary tract infection was associated with female sex and central line use. BSI was also associated with central line use, and meningitis/ventriculitis was associated with the presence of intraventricular hemorrhage and external ventricular drainage (all P < 0.05). After adjustment for Hunt and Hess grade, aneurysm size, and age, pneumonia (adjusted odds ratio, 2.04; 95% confidence interval, 1.12-3.71; P = 0.020) and BSI (adjusted odds ratio, 2.51; 95% confidence interval, 1.14-5.56; P = 0.023) independently predicted death or severe disability at 3 months. Prolonged length of stay was significantly associated with all infection types (P < 0.001). CONCLUSION: Pneumonia and BSI are common infectious complications of SAH and independently predict poor outcome. The implementation of infection-control measures may be needed to improve outcome after SAH.