A Propensity Score Analysis of the Impact of Dexamethasone Use on Delayed Cerebral Ischemia and Poor Functional Outcomes After Subarachnoid Hemorrhage

Nathaniel Mohney; Craig A Williamson; Edward Rothman; Ron Ball; Kyle M Sheehan; Aditya S Pandey; Jeffrey J Fletcher; Teresa L Jacobs; B Gregory Thompson; Venkatakrishna Rajajee

doi:10.1016/j.wneu.2017.10.051

A Propensity Score Analysis of the Impact of Dexamethasone Use on Delayed Cerebral Ischemia and Poor Functional Outcomes After Subarachnoid Hemorrhage

World Neurosurg. 2018 Jan:109:e655-e661. doi: 10.1016/j.wneu.2017.10.051. Epub 2017 Oct 20.

Authors

Affiliations

¹ Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA.
² Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA; Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA.
³ Department of Statistics, University of Michigan, Ann Arbor, Michigan, USA.
⁴ Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
⁵ Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA; Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA. Electronic address: vrajajee@yahoo.com.

PMID: 29061461
DOI: 10.1016/j.wneu.2017.10.051

Abstract

Objective: An inflammatory response occurs after aneurysmal subarachnoid hemorrhage (aSAH) and predicts poor outcomes. Glucocorticoids suppress inflammation and promote fluid retention. Dexamethasone is often administered after aSAH for postoperative cerebral edema and refractory headache. Our objective was to examine the impact of dexamethasone use on functional outcomes and delayed cerebral ischemia (DCI) after aSAH.

Methods: Patients with aSAH admitted between 2010 and 2015 were included; the data source was a single-center subarachnoid hemorrhage registry. The intervention of interest was a dexamethasone taper used <7 days from ictus. The primary outcome was poor discharge functional outcome, with a modified Rankin Scale score >3. Other outcomes included DCI and infection. A propensity score for use of dexamethasone was calculated using a logistic regression model that included potential predictors of dexamethasone use and outcome. The impact of dexamethasone on outcomes of interest was calculated and the propensity score was controlled for.

Results: A total of 440 patients with subarachnoid hemorrhage were admitted during the study period and 309 met eligibility criteria. Dexamethasone was administered in 101 patients (33%). A total of 127 patients (41%) had a discharge modified Rankin Scale score >3, 105 (34%) developed DCI, and 94 (30%) developed an infection. After propensity score analysis, dexamethasone use was associated with a significant reduction in poor functional outcomes (odds ratio [OR], 0.35; 95% confidence interval [CI], 0.19-0.66) but showed no significant association with DCI (OR, 0.93; 95% CI, 0.53-1.64) or infection (OR, 0.60; 95% CI, 0.34-1.06).

Conclusions: Dexamethasone use after aSAH was associated with a reduction in poor functional outcomes at discharge but not DCI, controlling for predictors of dexamethasone use.

Keywords: Cerebral ischemia; Cerebral vasospasm; Corticosteroids; Dexamethasone; Glucocorticoids; Subarachnoid hemorrhage.

MeSH terms

Aged
Brain Edema / drug therapy*
Brain Ischemia / epidemiology*
Dexamethasone / therapeutic use*
Female
Glucocorticoids / therapeutic use*
Humans
Logistic Models
Male
Middle Aged
Neurosurgical Procedures
Odds Ratio
Postoperative Complications / epidemiology*
Propensity Score
Registries*
Retrospective Studies
Risk Factors
Subarachnoid Hemorrhage / therapy*
Treatment Outcome
Vasospasm, Intracranial / epidemiology*

Substances

Glucocorticoids
Dexamethasone