Nicotine replacement therapy during the acute phase of aneurysmal subarachnoid hemorrhage

Many patients who suffer an aneurysmal subarachnoid hemorrhage (aSAH) are active smokers that may experience nicotine withdrawal following hospital admission. Nicotine replacement therapy (NRT) could alleviate abstinence and delirium but may have unwanted side-effects. Cerebral vasospasm (VS) is a feared complication of aSAH that can worsen outcome. The impact of NRT on VS, complications and outcome is still not fully delineated.

Retrospective study using anonymized data from a prospective quality registry. Patients smoking status, age, sex, comorbidities, along with aSAH severity were registered. Smokers were dichotomized into non-NRT and NRT groups depending on whether they had received a nicotine patch or not and subdivided into light smokers (≤ 10 cigarettes/day) and moderate to heavy smokers (> 10 cigarettes/day). We also registered radiological/sonological and clinical VS, delayed cerebral ischemia (DCI) related infarction and other common aSAH complications. Outcome was scored in terms of mortality and modified Rankin Score (mRS) at 90 days.

495 patients were included; 220 received NRT. NRT was not a predictor of radiological/ultrasonological VS or DCI-related infarction. Poor outcome was more frequent in light smokers when they had received NRT (12.49% vs 29.31%) and their length of hospitalization was longer. Moderate to heavy smokers that had received NRT developed less frequently atrial fibrillation (3.4% vs 11.7%) and their length of stay at the ICU was shorter. There was no difference in thromboembolic or epileptic events, or respiratory failure between groups. There was no difference in smoking cessation at 90 days with or without NRT.

NRT had no impact on vasospasm or DCI-related infarction and it did not increase the frequency of complications. It seems advisable to abstain from NRT in light smokers.