Effect of stress-induced hyperglycemia after non-traumatic non-aneurysmal subarachnoid hemorrhage on clinical complications and functional outcomes

Abstract

Background: Despite having an overall benign course, non-traumatic non-aneurysmal subarachnoid hemorrhage (naSAH) is still accompanied by a risk of clinical complications and poor outcomes. Risk factors and mechanisms of complications and poor outcomes after naSAH remain unknown. Our aim was to explore the effect of stress-induced hyperglycemia (SIH) on complication rates and functional outcomes in naSAH patients.

Methods: We retrospectively reviewed patients with naSAH admitted to our institution between 2013 and 2018. SIH was identified according to previous criterion. Symptomatic vasospasm, delayed cerebral infarction, and hydrocephalus were identified as main complications. Outcomes were reviewed using a modified Rankin Scale (mRS) at discharge, 3 months, and 12 months. A statistical analysis was conducted to reveal the associations of SIH with complications and outcomes.

Results: A total of 244 naSAH patients were included in the cohort with 74 (30.3%) SIH. After adjusting for age, gender, hypertension, Hunt and Hess (HH) grade, modified Fisher Scale (mFS), intraventricular hemorrhage (IVH), and subarachnoid blood distribution, SIH was significantly associated with symptomatic vasospasm (p < 0.001, 12.176 [4.904-30.231]), delayed cerebral infarction (p < 0.001, 12.434 [3.850-40.161]), hydrocephalus (p = 0.008, 5.771 [1.570-21.222]), and poor outcome at 12 months (p = 0.006, 5.506 [1.632-18.581]), whereas the correlation between SIH and poor outcome at discharge (p = 0.064, 2.409 [0.951-6.100]) or 3 months (p = 0.110, 2.029 [0.852-4.833]) was not significant. Incorporation of SIH increased the area under curve (AUC) of ROC in the combined model for predicting symptomatic vasospasm (p = 0.002), delayed cerebral infarction (p = 0.024), hydrocephalus (p = 0.037), and 12-month poor outcome (p = 0.087).

Conclusions: SIH is a significant and independent risk factor for symptomatic vasospasm, delayed cerebral infarction, hydrocephalus, and long-term poor outcome in naSAH patients. Identifying SIH early after naSAH is important for decision-making and treatment planning.

Keywords: complication; functional outcome; hyperglycemia; neuroendocrine; stress; subarachnoid hemorrhage.

FIGURE 1

Unadjusted and adjusted OR for SIH to evaluate the effect of SIH on clinical complications and functional outcomes. After adjusting for age, gender, hypertension, HH grade, mFS, IVH, and subarachnoid blood distribution characteristic, SIH was still significantly associated with symptomatic vasospasm (A, p < 0.001), delayed cerebral infarction (B, p < 0.001), hydrocephalus (C, p = 0.008), and 12‐month poor outcome (F, p = 0.006), but was not significantly associated with discharge poor outcome (D, p = 0.064) and 3‐month poor outcome (E, p = 0.110). ^aAdjusted for age, gender, hypertension, and subarachnoid blood distribution characteristic. ^bAdjusted for HH grade, mFS, IVH, and subarachnoid blood distribution characteristic. ^cAdjusted for age, gender, hypertension, HH grade, mFS, IVH, and subarachnoid blood distribution characteristic. HH, Hunt and Hess; IVH, intraventricular hemorrhage; mFS, modified Fisher scale; OR, odds ratio; SIH, stress‐induced hyperglycemia

FIGURE 2

ROC curve for combined model to predict clinical complications and functional outcomes. In predicting symptomatic vasospasm (A, p = 0.002), delayed cerebral infarction (B, p = 0.024), and hydrocephalus (C, p = 0.037), model 1 had a significantly higher AUC than model 2. In predicting discharge poor outcome (D, p = 0.775) and 3‐month poor outcome (E, p = 0.659), the AUC of model 1 was not higher than that of model 2. In the prediction of 12‐month poor outcome (F, p = 0.087), the AUC of model 1 was higher than that of model 2, although it was not statistically significant. AUC, area under curve; ROC, receiver operating curve