From the Division of Neurosurgery, Department of Surgery, University of British Columbia, Vancouver, Canada (O.G.S.A., P.A.G.)Division of Neurosurgery, Hospital for Sick Children (G.M.I.)Department of Surgery, Li Ka Shing Knowledge Institute (N.M.A., R.L.M.)Institute of Medical Science (N.M.A.), University of Toronto, CanadaDivision of Neurosurgery, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre for Biomedical Research, St. Michael’s Hospital, Toronto, Canada (N.M.A., R.L.M.).
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Background and Purpose—Anemia after aneurysmal subarachnoid hemorrhage is common and potentially modifiable. Here, we first evaluate the effect of anemia on neurological outcome and death and second, study the effects of packed red blood cell transfusion on outcome.Methods—A secondary analysis on 413 subjects in the CONSCIOUS-1 study (Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage). Multivariable logistic regression identified independent risk factors for anemia and determined the effect of anemia on neurological outcome and death, while adjusting for selected covariates. Optimal predictive thresholds for hemoglobin levels were determined using receiver operating characteristic curve analysis. Finally, patients were pseudorandomized to transfusion using propensity score matching to study the effect of transfusions on outcome.Results—Anemia, defined as hemoglobin <10 g/dL, was present in 5% of patients at presentation, in 29% of patients after aneurysm securing (days 1–3), and in 32% of patients during the peak delayed cerebral ischemia risk period (days 5–9). Anemia after aneurysm securing (odds ratio, 1.96; 95% confidence interval, 1.07–3.59; P=0.03) and during the delayed cerebral ischemia window (odds ratio, 2.63; 95% confidence interval, 1.46–4.76; P=0.0014) was independently associated with poor neurological outcome. Anemia postaneurysm securing (odds ratio, 3.50; 95% confidence interval, 1.15–10.62; P=0.027) but not during the delayed cerebral ischemia window was associated with death. Using propensity score-matched cohorts, we found that transfusion of anemic patients did not improve long-term outcome (P=0.8) or mortality rates (P=0.9). Transfusion of patients with a hemoglobin concentration >10 g/dL was associated with improved neurological outcomes (odds ratio, 0.09; 95% confidence interval, 0.002–0.72; P=0.015), with no differences in mortality.Conclusions—Anemia after aneurysmal subarachnoid hemorrhage is associated with poor long-term neurological outcome and death. Transfusion of packed red blood cells is beneficial for patients who are not considerably anemic beforehand, suggesting further work needs to define the threshold but also the time period of anemia that is sufficient and necessary to contribute to poor outcomes.Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT00111085.