Article
Impact of beginning, duration, and severity of anemia on the outcome of aneurysmal subarachnoid haemorrhage
Auswirkungen des Beginns, der Dauer und des Schweregrads einer Anämie auf das Ergebnis einer aneurysmatischen Subarachnoidalblutung
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Published: | May 25, 2022 |
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Objective: The clinical course after acute aneurysmal subarachnoid hemorrhage (SAH) is often associated with anemia. Although previous reports based on small case series indicated a negative impact of anemia on SAH outcome, there are still no specific recommendations on anemia management in SAH. We aimed to analyze the impact of post-SAH anemia on the patients’ outcome.
Methods: All eligible SAH cases treated at our institution between 01/2005 and 06/2016 were included in this study (n=598). Severity of anemia was assessed according to the documented nadir hemoglobin [nHB] level at one-mg/dL-steps intervals (<11/<10/<9/<8/<7 mg/dL). In addition, begin (time after ictus) and duration of each level of anemia severity were also documented. Study endpoints were the occurrence of: 1) delayed cerebral ischemia (DCI) and 2) multi-territorial infarcts on the follow-up computed tomography scans, 3) in-hospital mortality, and 4) poor outcome at 6 months post-SAH defined as a modified Rankin scale >3. The associations between the severity of anemia and the study endpoints were adjusted for patients’ age, sex, initial severity of SAH (WFNS / Fisher grades and acute hydrocephalus), treatment modality, duration of hospital stay, development of ICP increase >20 mmHg, and angiographic vasospasm.
Results: The rates of anemia were 85.8%, 70.7%, 42.3%, 16.5% and 4.7% for the nHB of 11/<10/<9/<8/<7 mg/dL respectively. In the multivariable analysis, the risk of DCI increased with each level of nHB decline (<10 – <7 mg/dL). For the risk of multi-territorial infarcts, in-hospital mortality and poor outcome at 6 months, independent associations were observed with increasing anemia severity (nHB <9 – <7 mg/dL). The beginning of anemia (nHB <11 – <9 mg/dL) was inversely associated with the risk of in-hospital mortality. In the ROC analysis, the duration of anemia at nHB values between <10 and <9 mg/dL showed the highest diagnostic accuracy for prediction of all study endpoints, with the clinically relevant cutoffs between days 1 and 2.
Conclusion: Occurrence, and particularly, the severity of anemia is a major contributor to the outcome of SAH patients. nHB decline to <9 mg/dL was strongly associated with all study endpoints. Also, the DCI risk already increased at a nHB of <10 mg/dL. SAH patients with an early occurrence of anemia are prone to shorter survival.