Page 58 - Cardiac abnormalities after aneurysmal subarachnoid hemorrhage

Chapter 4
Study procedure and data collection:
The World Federation of Neurosurgical Societies (WFNS) grading scale for subarachnoid hemorrhage was used for grading clinical condition, where a WFNS ≥ 3 was considered a poor condition.11
Echocardiography, ECG and testing for myocardial serum markers(N-terminal prohormone of B-Type Natriuretic Peptide (NT-proBNP) and troponin T) was performed as soon as possible after admission and 4 and 8 days after onset of symptoms. The upper limits of normal as defined by the local laboratory were used as reference.
CT-scan:
The amount of blood on the admission CT scans was assessed according to the Hijdra score12 by one investigator (DH), who was unaware of the clinical condition of the patient or the results of the cardiologic examinations. Hydrocephalus was defined as the bicaudate index (=BCI, width of the frontal horns at the level of the foramina of Monro, divided by the corresponding diameter of the brain) on the CT, exceeding the 95th percentile for age. The upper limits are: <36 years of age, 0.16; 36-45 years, 0.17; 46-55 years, 0.18; 56-65 years, 0.19; 66-75 years, 0.20; 76-85 years, 0.21.13
Cardiac examinations:
The investigators who scored the echocardiograms, ECGs or blood results, were unaware of the clinical data of the patient. Criteria for the ECG abnormalities were defined according to the guidelines of the European Society of Cardiology14 and are described earlier.6 ST segment deviation is frequent in aSAH, but often does not represent myocardial ischemia.15 ST deviation was considered suggestive for myocardial ischemia when ST elevation occurred at the J-point in two contiguous leads. Horizontal or down-sloping ST depression in two contiguous leads; and/or T inversion in two contiguous leads with prominent R-wave or R/S ratio >1 were also considered ischemic changes. Transthoracic echocardiography was performed according to the standards of the American Society of Echocardiography (ASE).16 For assessment of systolic function, three cardiologists, independently from each other and unaware of the clinical data of the patients, reviewed all echocardiograms. All segments were scored based on contractility: 0 uninterpretable, 1 normal, 2 hypokinetic, 3 akinetic, 4 dyskinetic, 5 aneurysmal. A wall motion score index (WMSI) was calculated by dividing the sum of wall motion scores by the number of visualized segments. A WMSI > 1 means that WMA were present.
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