Faculty Bibliography

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.

OBJECTIVE: Serious cardiac arrhythmias have been described in approximately 5% of patients after subarachnoid hemorrhage (SAH). The aim of this study was to identify the frequency, risk factors and clinical impact of cardiac arrhythmia after SAH. METHODS: We prospectively studied 580 spontaneous SAH patients and identified risk factors and complications associated with the development of clinically significant arrhythmia. Multiple logistic regression analysis was used to calculate adjusted odds ratios for the effect of arrhythmia on hospital complications and 3-month outcome, as measured by the modified Rankin Scale, after controlling for age, neurological grade, APACHE-2 physiologic subscore, brain herniation and aneurysm size. RESULTS: Arrhythmia occurred in 4.3% (n = 25) of patients. Atrial fibrillation and flutter were the most common arrhythmias, occurring in 76% (n = 19) of these patients. Admission predictors of cardiac arrhythmia included older age, history of arrhythmia and abnormal admission electrocardiogram (all p < 0.05). After adjusting for length of stay, hospital complications associated with arrhythmia included myocardial ischemia, hyperglycemia, and herniation (all p < 0.05). Arrhythmia was associated with an excess ICU stay of 5 days (p = 0.002). After adjusting for other predictors of outcome, arrhythmia was associated with an increased risk of death (adjusted OR 8.0, 95% confidence interval 1.9-34.0, p = 0.005), and death or severe disability (adjusted OR 6.9, 95% confidence interval 1.5-32.0, p = 0.014). CONCLUSIONS: Clinically important arrhythmias, most often atrial fibrillation or flutter, occurred in 4% of SAH patients. Arrhythmias are associated with an increased risk of cardiovascular comorbidity, prolonged hospital stay and poor outcome or death after SAH, after adjusting for other predictors of poor outcome.

OBJECTIVE: To determine the frequency and significance of electrographic seizures and other EEG findings in patients with intracerebral hemorrhage (ICH). METHODS: We reviewed 102 consecutive patients with ICH who underwent continuous electroencephalographic monitoring (cEEG). Demographic, clinical, radiographic, and cEEG findings were recorded. Using multivariate logistic regression analysis, we determined factors associated with 1) electrographic seizures, 2) periodic epileptiform discharges (PEDs), and 3) poor outcome (death, vegetative or minimally conscious state) at hospital discharge. RESULTS: Seizures occurred in 31% (n = 32) of patients with ICH, prior to cEEG in 19 patients. Eighteen percent (n = 18) of patients had electrographic seizures; only one of these patients also had clinical seizures while on cEEG. After controlling for demographic and clinical predictors, only an increase in ICH volume of 30% or more between admission and 24-hour follow-up CT scan was associated with electrographic seizures (33% vs 15%; OR 9.5, 95% CI 1.7 to 53.8). PEDs were less frequently seen in those with hemorrhages located at least 1 mm from the cortex (8% vs 29%; OR 0.2, 95% CI 0.1 to 0.7). PEDs were independently associated with poor outcome (65% vs 17%; OR 7.6, 95% CI 2.1 to 27.3). In patients with electrographic seizures, the first seizure was detected within the first hour of cEEG monitoring in 56% and within 48 hours in 94%. CONCLUSIONS: Seizures occurred in one third of patients with intracerebral hemorrhage (ICH) and over half were purely electrographic. Electrographic seizures were associated with expanding hemorrhages, and periodic discharges with cortical ICH and poor outcome. Further research is needed to determine if treating or preventing seizures or PEDs might lead to improved outcome after ICH.