Cocaine use as an independent predictor of seizures after aneurysmal subarachnoid hemorrhage (original) (raw)
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Impact of Acute Cocaine Use on Aneurysmal Subarachnoid Hemorrhage
Stroke, 2013
Background and Purpose— Acute cocaine use has been temporally associated with aneurysmal subarachnoid hemorrhage (aSAH). This study analyzes the impact of cocaine use on patient presentation, complications, and outcomes. Methods— Data of patients admitted with aSAH between 1991 and 2009 were reviewed to determine impact of acute cocaine use (C). These patients were compared with aSAH patients without recent cocaine exposure (NC) in relation to their presentation, complications such as aneurysmal rerupture and delayed cerebral ischemia, and outcomes including hospital mortality and functional outcome. Results— Data of 1134 aSAH patients were reviewed; 142 patients (12.5%) had associated cocaine use. Cocaine users were more likely to be younger (mean age: C, 49±11; NC, 53±14; P <0.001). There were no differences in rates of poor-grade Hunt and Hess (4–5); (C, 21%; NC, 26%; P >0.05), associated intraventricular hemorrhage (C, 56%; NC, 51%; P >0.05), or hydrocephalus on admissi...
Intracranial hemorrhage associated with cocaine abuse
Neurology, 1998
It would be a more helpful study design to compare all of the EEGs the patient had received during the course of seizure care (before and after the decision to withdraw AEDs) to minimize this bias. This seems to make more sense clinically as a patient whose EEGs have been consistently normal during seizure care clearly should have a different risk of relapse compared with a patient with recurrent abnormalities. If the data from Tinuper et al.'s chart is considered, evidence to support this assumption can be ascertained. Excluding patients with simple partial seizures, 52 patients had a normal EEG reported during all nine EEGs performed during this study. Of these patients, 21 (40%) had a seizure relapse. This is compared with the remaining 48 patients who had a n abnormal EEG at some point (or consistently) during the study. Of these, 34 (70%) had a seizure relapse. It appears that because the study design included only serial EEGs during AED withdrawal, the conclusion was that useful prognostic information was gained by the EEGs performed in this manner; however, the data can be construed to indicate that perhaps serial EEGs might provide prognostically significant information even before the decision to withdraw AEDs. The recommendations of this study should be regarded with skepticism.
Journal of Neurosurgery, 2013
Object At present, the administration of prophylactic antiepileptic medication following aneurysmal subarachnoid hemorrhage (SAH) is controversial, and the practice is heterogeneous. Here, the authors sought to inform clinical decision making by identifying factors associated with the occurrence of seizures following aneurysm rupture. Methods Exploratory analysis was performed on 413 patients enrolled in CONSCIOUS-1 (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring after Subarachnoid Hemorrhage), a prospective randomized trial of clazosentan for the prevention of angiographic vasospasm. The association among clinical, laboratory, and radiographic covariates and the occurrence of seizures following SAH were determined. Covariates with a significance level of p < 0.20 on univariate analysis were entered into a multivariate logistic regression model. Receiver operating characteristic (ROC) curve analysis was used to define optimal predictive thresholds. Results...
Perioperative care of the cocaine-dependent neurosurgical patient
Purpose: Cocaine, a commonly abused drug, can cause life-threatening complications, significantly impacting patient management. Cocaine is associated with an increased risk of stroke including subarachnoid hemorrhage (SAH) that may require expectant surgical management. Patients presenting for anesthesia with acute cocaine toxicity pose additional concerns. Clinical Features: A 48 year old woman presented with a seizure, acute cocaine intoxication, and was diagnosed with a SAH. Further diagnostic evaluation revealed a bleeding cerebral aneurysm requiring urgent surgical aneurysm clipping. Her perioperative course was complicated by hypertension requiring treatment to minimize further aneurysm bleeding before clipping. Cocaine-associated cardiac complications impacting management included a non-ST elevation myocardial infarction and severe anteroseptal hypokinesis on echocardiogram. Conclusion: Hemodynamic management with a recent SAH and acute cocaine intoxication required special considerations. Perioperative SAH management initially focused to prevent additional bleeding before clipping and then after clipping to minimize cerebral ischemia. Benzodiazepines were used early in this case to treat seizures and cocaine-associated hemodynamic effects. Specific treatments for life-threatening ventricular arrhythmias are discussed including sodium bicarbonate as a first line treatment and potential benefits of magnesium administration. With prolongation of a QT interval secondary to cocaine and/ or SAH, medications that often are utilized during the perioperative period may further prolong the QT interval and should be avoided.
Intracranial hemorrhage and cocaine use
Stroke, 1987
Cocaine use has increased rapidly over the past few years. This has led to an increase in the number and variety of cocaine-related conditions for which medical attention is sought. Among these have been several cases of intracranial hemorrhage. Four cases reported in the literature and 6 from our own institution are presented here. They represent different diagnoses including hemorrhage from aneurysms and arteriovenous malformations, hemorrhage into a tumor, and spontaneous hemorrhage with no underlying lesion with and without preexisting hypertension. Analysis of these cases suggests that the hypertension induced by cocaine secondary to sympathetic stimulation may be the common factor. Cocaine may also cause arterial spasm. Although the pathophysiology has not been entirely resolved, the clinical significance of this association is clear. Intracranial hemorrhage should be considered in the differential diagnosis whenever a patient presents with an acute alteration in neurologic ex...
Journal of vascular and interventional neurology, 2017
Seizures are a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) and occur most commonly in the immediate posthemorrhagic period. Most commonly used antiepileptic drugs (AEDs) for seizure prophylaxis in aSAH include phenytoin and levetiracetam. There is no reliable data available on the safety and efficacy of restricting AED prophylaxis only till the aneurysm is secured. We retrospectively chart reviewed patients admitted to our neurosciences intensive care unit (NICU) with aSAH during the past two years. Seizure incidence was studied in patients treated with phenytoin versus levetiracetam and in patients treated for 3-7 days vs. those where AED was discontinued immediately after aneurysm was secured. In 28 patients, AED prophylaxis was discontinued immediately after the aneurysm was secured, and in 21 patients, it was continued for 3-7 days. Of the 28 patients who received AED prophylaxis for less than or equal to two days, phenytoin was used in 20 patients and l...
Anticonvulsant Drug Therapy After Aneurysmal Subarachnoid Hemorrhage
The Neurologist, 2010
Background: Seizures are a complication of aneurysmal subarachnoid hemorrhage (aSAH). Objective: To evaluate whether antiepileptic drug (AED) prophylaxis after aSAH reduces seizure risk and whether it is associated with improved neurological outcomes. Methods: The objective was addressed through the development of a critically appraised topic that included a clinical scenario, structured question, search strategy, critical appraisal, assessment of results, evidence summary, commentary, and bottom line conclusions. Neurology consultants and residents, a medical librarian, clinical epidemiologists, and content experts in the fields of epilepsy, neurosurgery, and critical care contributed to the review and placed the evidence in clinical context. Results: There were no relevant randomized, controlled trials that addressed the question. A post hoc analysis of data from 4 trials of tirilazad for aSAH showed that prophylactic AED therapy was associated with worse Glasgow Outcome Scale scores at 3 months (odds ratio 1.56, 95% confidence interval 1.16-2.10; P = 0.003) but numerous confounders limit data interpretation. Conclusions: There are insufficient data to support or refute the prophylactic use of AED therapy after aSAH. Randomized, controlled trials are needed to address the efficacy and risks of AEDs in this setting and should take into account factors such as aneurysmal factors (location, hemorrhage grade, degree of parenchymal injury), type of aneurysm surgery (clip vs. coil), and evaluate the timing and duration of AED use.
Epilepsy-associated long-term mortality after aneurysmal subarachnoid hemorrhage
Neurology, 2017
Objective:To elucidate the epilepsy-associated causes of death and subsequent excess long-term mortality among 12-month survivors of subarachnoid hemorrhage from saccular intracranial aneurysm (SIA-SAH).Methods:The Kuopio SIA Database (kuopioneurosurgery.fi) includes all SIA-SAH patients admitted to the Kuopio University Hospital from its defined catchment population in Eastern Finland. The study cohort consists of 779 patients, admitted from 1995 to 2007, who were alive at 12 months after SIA-SAH. Their use of reimbursable antiepileptic drugs and the causes of death (ICD-10) were fused from the Finnish national registries from 1994 to 2014.Results:The 779 12-month survivors were followed up until death (n = 197) or December 31, 2014, a median of 12.0 years after SIA-SAH. Epilepsy had been diagnosed in 121 (15%) patients after SIA-SAH, and 34/121 (28%) had died at the end of follow-up, with epilepsy as the immediate cause of death in 7/34 (21%). In the 779 patients alive at 12 month...
Neurocritical Care
Background We aimed to evaluate the association between seizures as divided by timing and type (seizures or status epilepticus) and outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods All consecutive patients with aSAH admitted to the neurocritical care unit of the University Hospital Zurich between 2016 and 2020 were included. Seizure type and frequency were extracted from electronic patient files. Results Out of 245 patients, 76 experienced acute symptomatic seizures, with 39 experiencing seizures at onset, 18 experiencing acute seizures, and 19 experiencing acute nonconvulsive status epilepticus (NCSE). Multivariate analysis revealed that acute symptomatic NCSE was an independent predictor of unfavorable outcome (odds ratio 14.20, 95% confidence interval 1.74–116.17, p = 0.013) after correction for age, Hunt-Hess grade, Fisher grade, and delayed cerebral ischemia. Subgroup analysis showed a significant association of all seizures/NCSE with higher Fisher gr...