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Published on: June 18, 2018
Cocaine use as a predictor of outcome in aneurysmal subarachnoid hemorrhage
Jay U Howington1, Scott C Kutz, Gregory E Wilding
1Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana 70112, USA.
Insights
Cocaine use significantly worsens outcomes for patients with aneurysmal subarachnoid hemorrhage (SAH), increasing the risk of cerebral vasospasm and poor neurological recovery. This drug
Area of Science:
- Neurosurgery
- Neurology
- Toxicology
Background:
- Aneurysmal subarachnoid hemorrhage (SAH) is a critical neurological condition with significant morbidity and mortality.
- Cocaine is a potent stimulant with known vasoactive properties that may impact cerebrovascular events.
Purpose of the Study:
- To investigate the association between cocaine use and clinical outcomes in patients presenting with aneurysmal SAH.
- To determine if cocaine use independently influences the risk of cerebral vasospasm and functional recovery after SAH.
Main Methods:
- Retrospective review of 108 patients with aneurysmal SAH treated between 1996 and 2001.
- Analysis of patient demographics, clinical presentation (Hunt and Hess grade, Fisher grade), and substance use history (including cocaine).
- Assessment of outcomes using the Glasgow Outcome Scale (GOS), with a focus on the incidence of vasospasm and dichotomized GOS scores.
Main Results:
- Cocaine users (33.3%) had a significantly higher incidence of severe presentation (Hunt and Hess grade IV-V) compared to non-users (p < 0.0001).
- Cocaine use was associated with a 2.8-fold increased risk of developing cerebral vasospasm (p < 0.0001) and a 3.3-fold increased risk of poor outcome (GOS 1-3) (p < 0.0001).
- The negative impact of cocaine on outcomes was independent of Hunt and Hess grade and the presence of vasospasm.
Conclusions:
- Cocaine use adversely affects both the presentation and outcome of aneurysmal SAH.
- The vasoactive properties of cocaine likely exacerbate SAH-related complications, particularly cerebral vasospasm.
- Cocaine use should be considered a significant factor, equivalent to major systemic illness, in assessing SAH patient prognosis.
Object:
The goal of this study was to analyze the relationship between cocaine use and outcomes of aneurysmal subarachnoid hemorrhage (SAH).
Methods:
A retrospective review was performed of the medical records of patients with intracranial aneurysms treated at a single institution between January 1996 and December 2001. Only patients who presented with SAH were included in the study. The covariates chosen for the statistical analysis included the following: patient age, sex, and race; systolic and mean arterial blood pressure measurements on hospital admission; Hunt and Hess and Fisher grades; pre-existent major systemic disease; and history of alcohol, tobacco, or cocaine use. The Glasgow Outcome Scale (GOS) was used to standardize outcome and was dichotomized such that a score between 1 and 3 was considered a poor outcome and a score of 4 or 5 was considered a favorable outcome. The records of 151 patients were reviewed and 108 of these presented with aneurysmal SAH. Of these 108 patients, 36 (33.3%) had used cocaine within 24 hours before presentation. A Hunt and Hess grade of IV or V was assigned to 20 (55.6%) of 36 patients who used cocaine, compared with eight (11.1%) of 72 patients who did not; this difference was found to be statistically significant (p < 0.0001). Twenty-eight patients (77.8%) in the cocaine user group and 20 patients (27.8%) in the non-cocaine user group experienced clinically significant, angiographically confirmed vasospasm during their hospital course (p < 0.0001). Cocaine use was associated with a 2.8-fold greater risk of developing vasospasm (95% confidence interval [CI] 1.86-4.22). A GOS score of 1, 2, or 3 was assigned to 33 patients (91.7%) in the cocaine user group and to 20 patients (27.8%) in the non-cocaine user group (p < 0.0001). Cocaine use was associated with a 3.3-fold greater risk of poor outcome (95% CI 2.24-4.85). This association was found to be independent of Hunt and Hess grade as well as of vasospasm.
Conclusions:
Cocaine adversely affects both the presentation of and outcome in patients with aneurysmal SAH who are undergoing treatment for this disease. The vasoactive properties of the drug appear to aggravate the already tenuous situation of SAH and increase both the occurrence and influence of cerebral vasospasm. Statistical analysis demonstrates that cocaine directly affects both presentation and outcome in a significant manner. It is the authors' interpretation of the results of this retrospective review that cocaine use negatively affects outcome to such an extent that it should be considered equal to the presence of a major systemic illness when determining Hunt and Hess grade.
