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Trends in Blood Pressure, Osmolality and Electrolytes After Subarachnoid Hemorrhage from Aneurysms

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Trends in Blood Pressure, Osmolality and Electrolytes After Subarachnoid Hemorrhage from Aneurysms LE JOURNAL CANADIEN DES SCIENCES NEUROLOG1QUES Trends in Blood Pressure, Osmolality and Electrolytes after Subarachnoid Hemorrhage from Aneurysms Lew Disney, Bryce Weir, Michael Grace and Paul Roberts ABSTRACT: Daily trends in blood pressure, osmolality and electrolytes were analyzed in a series of 173 operated aneurysm cases who had subarachnoid hemorrhage (SAH) and were admitted within 4 days of the ictus. High blood pressure was associated with a greater risk of mortality and the development of clinically significant vasospasm (VSP). High osmolality shortly after admission was related to mortality but not VSP. Changes in sodium and potassium had no obvious relationship to mortality or VSP. RESUME: Evolution de la pression sanguine, de l'osmolalite et des electrolytes apres une hemorragie sous- arachnoid ienne due a un anevrisme L'evolution quotidienne de la pression sanguine, de l'osmolalite et des elec­ trolytes a ete analysee dans une serie de 173 cas d'anevrismes operes, qui presentaient une hemorragie sous-arachno'i- dienne et qui avaient 6te hospitalises en dedans de 4 jours de l'ictus. L'hypertension arterielle etait associee a un risque accru de mortalite et de developpement d'un vasospasme cliniquement significatif (VSP). Une osmolality elevee peu apres l'admission etait relief a la mortalite, mais non au VSP. Des changements dans les niveaux de sodium et de potassium n'avaient pas de relation evidente avec la mortalite ou le VSP. Can. J. Neurol. Sci. 1989; 16: 299-304 Subarachnoid hemorrhage (SAH) from ruptured aneurysm MATERIALS AND METHODS produces a sudden increase in intracranial pressure, and to maintain cerebral perfusion there is frequently a compensatory Patient Population increase in systemic blood pressure. The volume of blood From 1971 to early 1987, 721 patients with subarachnoid escaping the intravascular space must be a major determinant of hemorrhage from ruptured intracranial aneurysm were seen at the degree of rise in intracranial pressure and thus the amount of the University of Alberta Hospitals or the Royal Alexandra elevation of systemic blood pressure. The quantity of blood Hospital. Of these, 173 (24%) had daily recordings of vital escaping into the subarachnoid space is considered by most signs and common biochemical parameters which had been observers to be pivotal in the evolution of chronic cerebral encoded in a data base set up on the Amdahl mainframe com­ vasospasm (VSP). Similarly, chance of mortality is obviously puter at the University of Alberta. For the purposes of this strongly influenced by the volume of hemorrhage. It is not review, blood pressure, osmolality, and electrolyte concentra­ unreasonable therefore to anticipate that blood pressure might tions and their relation to mortality and the development of clin­ be linked not only to the chance of VSP developing but also of ical vasospasm were studied. Patients required 2 or more days death ensuing. of data to be eligible for inclusion in this study. Data had been Changes in osmolality and certain electrolyte concentrations retrospectively abstracted from the hospital charts, usually as have been observed frequently in patients having SAH. part of previous clinical investigations. Perturbations from normal can be in either direction and reflect Of these patients 102 (59%) were female and 71 (41%) male. both severity of illness as well as iatrogenic influence. There Mean age was 49.2 years with a range of 12 to 81 years. Grade have been few analyses of changes in relation to the exact time on admission, categorized using the scale of Hunt and Hess was of SAH, day of operation, the development of VSP and mor­ as follows: 42 (24%) grade 1,51 (30%) grade 2, 33 (19%) grade tality. 3, 36 (21%) grade 4 and 11 (6%) grade 5. From the Division of Neurosurgery (LD, BW) and Department of Surgery (MG, PR) University of Alberta, Edmonton Received November 9, 1988. Accepted in final form March 21, 1989 Reprint requests to: Bryce Weir, M.D., 2D1.02 Mackenzie Health Sciences Centre, 8440 - 112 Street, Edmonton, Alberta, Canada T6G 2B7 299 Downloaded from https://www.cambridge.org/core. IP address: 170.106.35.234, on 29 Sep 2021 at 04:16:40, subject to the Cambridge Core terms of use, available at https://www.cambridge.org/core/terms. https://doi.org/10.1017/S0317167100029127 https://www.cambridge.org/core/terms Downloaded from © o HIGHEST BLOOD PRESSURE HIGHEST BLOOD PRESSURE PERCENTAGE PERCENTAGE ( SYSTOLIC ) ( SYSTOLIC ) https://www.cambridge.org/core 1 ro ro O * o> 00 O ro vi O o OD o o o o o O O o Ln en o o o o !—*•'» — *—1—, ip 1 .1 o O T\ d / 4 • \ . https://doi.org/10.1017/S0317167100029127 \l • 4 V ! I o . IPaddress: • < \ ro I/) ro D C> \ 1 1 , 1 • i I 5 \ D 0 I CJ - PAT1EN PATIEN 1 «l 170.106.35.234 i O z 1 1 a 1 1 • a* > so * DOE SURVIVE / S / NO T S T 8 8 SU , on / / R 29 Sep2021 at04:16:40 ro m w (/> ^ in t/> \l HIGHEST BLOOD PRESSURE HIGHEST BLOOD PRESSURE HIGHEST BLOOD PRESSURE HIGHEST BLOOD PRESSURE ( SYSTOLIC ) ( SYSTOLIC ) ( SYSTOLIC ) ( SYSTOLIC ) , subjectto theCambridgeCore termsofuse,available at _.-.-»-. ro ro ro ro ro o 00 o-»N>OJ-&-ma>viooi0O o oo o ro O O *• en ooooooooooo o o o O o o o o o o o O O ———« !_, ^ CD \ \ 7P ro - *—» GJ i -•—• 1 1 \ *• \ 1 i ' • < o > P H • m o 3 i 5 I m V) i O ? O) 1—1 1 -^—. o S . ,-* » 1 m m • » —< » * I 2 *> vl it) ! 1 1 * 5 > I i 2 i VASOSPA i • VASOSPA » -•—4- 00 J i i 4 <o S 1 S i I r E £ o oO Oo II SNO * i. nUR ro * r 88 i S i T ro CCU ~7i R LE JOURNAL CANADIEN DES SCIENCES NEUROLOGIQUES The day of subarachnoid hemorrhage was defined as day 0. is little difference between groups but beginning day 3 and con­ The first 2 weeks following SAH were studied as this period tinuing to day 14 there are significantly higher pressures in the encompasses the peak time for vasospasm.1 Mortality was based vasospasm group. This difference in pressure progressively on deaths in hospital, occurring in 56 (32%) of patients leaving increases over time. It is interesting to note that the increase in 117 (68%) survivors. Vasospasm was defined as a delayed neu­ blood pressure occurs before the onset of clinical vasospasm. A rologic deterioration occurring more than 4 days after subarach­ striking difference in the incidence of vasospasm is seen when noid hemorrhage associated with angiographic vasospasm. cases on each day are categorized by whether they were above or below the mean highest systolic blood pressure for the group Statistical Methods for that day (Figure IE). Again after day 3 the low blood pres­ Information from the data base was edited for analysis by the sure cases were half as likely to develop VSP as the high blood SPSS statistical package on the University of Alberta computer. pressure cases. Not every patient had complete data for each of the first 14 days Operation to clip the aneurysm was carried out in a variable post SAH. This meant that the N value for each of the day by temporal relationship to the day of hemorrhage. In later years it day analyses often differed from the study population total of has been the policy at University of Alberta to operate early 173. Comparisons between groups were performed both with after SAH, particularly in good grade patients. Operation itself t-tests and the Kruskal-Wallis one-way analysis of variance. did not appear to cause any discernible shift in the mean highest Both tests were performed for each comparison to provide a systolic blo6d pressure (Figure IF). The adverse effect of form of internal verification of results. There was complete higher blood pressure on both mortality and incidence of VSP agreement in every instance. The level of significance was were still seen when times are calculated in relation to day of taken as p < 0.05. operation (Figure 1G, 1H). Similar analyses were carried out using mean highest dias­ RESULTS tolic blood pressures. Trends were similar although slightly less Blood Pressure marked than with systolic blood pressure. The highest systolic blood pressure of each patient was Osmolality recorded daily. The highest mean systolic blood pressure was on The initial mean osmolality on day 0 was 295 mOsm/L (Fig. the day of SAH. In this group of patients it was about 163 torn 2A). It fell gradually to a nadir around 280 mOsm/L on day 8 It fell on day 1 post-SAH then rose gradually until beginning to post-SAH, remaining relatively stable thereafter. Figure 2B fall again after day 8 (Figure 1 A). The blood pressure was high­ categorizes patients into survivors and non-survivors. Those er on every day except day 3 post-SAH for patients who ulti­ who died had higher osmolalities throughout the first 14 days mately died than for survivors (Figure IB). Differences between post-SAH. This difference was statistically significant on days survivors and non-survivors were statistically significant days 0, 0-4, 6, 7, 10, and 11. Figure 2C depicts mortality for those 1 and 7-11. The blood pressure in fatal cases showed consider­ whose osmolality fell above or below the mean for that particu­ able variation over time. It was high initially (180 torr), falling lar day. The difference in mortality is most marked in the first 3 by day 2 and then showed a secondary rise starting day 3. This days post-SAH with patients in the "hyperosmolar" group hav­ elevation peaked about day 7 and fell after day 11.
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