Health  Vol.5 No.7 E , July 2013
Predicting vasospasm after aneurismal subarachnoid hemorrhage with C reactive protein levels

Aim: The interest of inflammatory marker increased in the last years, even in preventing clinical outcome after subarachnoid hemorrhage (SAH). Our objective was to study the relationships between C-reactive protein levels and clinical outcome and the development of cerebral vasospasm after aneurismal SAH. Methods: One hundred adult patients with aneurismal SAH were prospectively evaluated. Glasgow Coma Scale (GCS) score, Hunt and Hess grade, Fisher grade, CT scans, digital subtraction angiography studies, transcranial doppler (TCD) and daily neurological examinations were recorded. Serial serum CRP measurements were obtained on daily between admission and 10th days. Glasgow Outcome Scale (GOS) and the modified Rankin Scale (mRS) were used to predict outcome. Results: A progressive increase in the CRP levels from the admission to the 3rd postictal day was observed, followed by a slow decrease until the 9th day. Hemodynamic changes in TCD were associated with higher serum CRP levels. Patients with lower GCS scores presented with increased CRP levels. Patients with higher Hunt and Hess grades on admission developed significantly higher CRP serum levels. Patients with higher admission Fisher grades showed increased levels of CRP. A statistically significant inverse correlation was established in our series between CRP serum levels and GOS and mRS scores on discharge and CRP levels. Conclusion: Increased CRP levels were strongly associated with poor clinical outcome. CRP levels can predict cerebral vasospasm and delayed ischemic deficits with higher statistic significance. There are relationships between hemodynamic chances in TCD and higher CRP levels.

Cite this paper: Romero, F. , Ducati, L. , Zanini, M. , Cataneo, D. , Cataneo, A. and Gabarra, R. (2013) Predicting vasospasm after aneurismal subarachnoid hemorrhage with C reactive protein levels. Health, 5, 1-6. doi: 10.4236/health.2013.57A5001.

[1]   Bengzon, J., Grubb, A., Bune, A., Heillstrom, K., Lindstrom, V. and Brandt, L. (2003) C-reactive protein levels following standard neurosurgical procedures. Acta Neurochirurgica, 145, 667-671. doi:10.1007/s00701-003-0083-5

[2]   Romero, F.R., Bertolini, E.G., Figueiredo, E.G. and Teixeira, M.J. (2012) Serum C-reactive protein levels predict neurological outcome after aneurysmal subarachnoid hemorrhage. Arq Neuropsiquiatr, 70, 202-205.

[3]   Fountas, K.N., Tasiou, A., Kapsalaki, E.Z., Paterakis, K.N., Grigorian, A.A. and Lee, G.P. (2009) Serum and cerebrospinal fluid C-reactive protein levels as predictors of vasospasm in aneurysmal subarachnoid hemorrhage. Neurosurgical Focus, 26, 22-31. doi:10.3171/2009.2.FOCUS08311

[4]   Kramer, A.H., Gurka, M.J., Nathan, B., Dumont, A.S., Kassell, N.F. and Bleck, T.P. (2008) Statin use was not associated with less vasospasm or improved outcome after subarachnoid hemorrhage. Neurosurgery, 62, 422-430. doi:10.1227/01.neu.0000316009.19012.e3

[5]   Suzuki, R., Masaoka, H., Hirata, Y., Marumo, F., Isotani, E. and Hirakawa, K. (1992) The role of endothelin-1 in the origin of cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. Journal of Neurosurgery, 77, 96-100. doi:10.3171/jns.1992.77.1.0096

[6]   Vajkoczy, P., Meyer, B., Weidauer, S., Raabe, A., Thome, C., Ringel, F., et al. (2005) Clazosentan (AXV-034343), a selective endothelin A receptor antagonist, in the prevention of cerebral vasospasm following severe aneurysmal subarachnoid hemorrhage: Results of a randomized, double-blind, placebo-controlled, multicenter Phase IIa study. Neurosurgery, 103, 9-17. doi:10.3171/jns.2005.103.1.0009

[7]   Goddard, A.J.P., Raju, P.P.J. and Gholkar, A. (2004) Does the method of treatment of acutely ruptured intracranial aneurysms influence the incidence and duration of cerebral vasospasm and clinical outcome? Journal of Neurology, Neurosurgery & Psychiatry, 75, 868-872. doi:10.1136/jnnp.2003.033068

[8]   Berk, B.C., Weintraub, W.S. and Alexander, R.W. (1990) Elevation of C-reactive protein in ‘‘active’’ coronary artery disease. American Journal of Cardiology, 65, 168-172. doi:10.1016/0002-9149(90)90079-G

[9]   Carr, W.P. (1983) The role of the laboratory in rheumatology. Acute-phase proteins. Rheumatic Diseases Clinics of North America, 9, 227-239.

[10]   Dumont, A.S., Dumont, R.J., Chow, M.M., Lin, C., Calisaneller, T., Ley, K.F., et al. (2003) Cerebral vasospasm after subarachnoid hemorrhage: Putative role of inflammation. Neurosurgery, 53, 123-135. doi:10.1227/01.NEU.0000068863.37133.9E

[11]   Hansen-Schwartz, J. (2004) Cerebral vasospasm: A consideration of the various cellular mechanisms involved in the pathophysiology. Neurocritical Care, 1, 235-246. doi:10.1385/NCC:1:2:235

[12]   Hergenroeder, G., Redell, J.B., Moore, A.N., Dubinsky, W.P., Funk, R.T., Crommett, J., et al. (2008) Identification of serum biomarkers in brain-injured adults: Potential for predicting elevated intracranial pressure. Journal of Neurotrauma, 25, 79-93. doi:10.1089/neu.2007.0386

[13]   Hoshi, T., Shimizu, T., Kito, K., Yamasaki, N., Takahashi, K., Takahashi, M., et al. (1984) Immunological study of late cerebral vasospasm in subarachnoid hemorrhage: Detection of immunoglobulins, C3, and fibrinogen in cerebral arterial walls by immunofluorescence method. Neurologia Medico-Chirurgica, 24, 647-654. doi:10.2176/nmc.24.647

[14]   Rothoerl, R.D., Schebesch, K.M., Kubitza, M., Woertgen, C., Brawanski, A. and Pina, A.L. (2006) ICAM-1 and VCAM-1 expression following aneurysmal subarachnoid hemorrhage and their possible role in the pathophysiology of subsequent ischemic deficits. Cerebrovascular Diseases, 22, 143-149. doi:10.1159/000093243

[15]   Rankin, J. (1957) Cerebral vascular accidents in patients over the age of 60. Scottish Medical Journal, 2, 200-215.

[16]   Bonita, R. and Beaglehole, R. (1988) Modification of rankin scale: Recovery of motor function after stroke. Stroke, 19, 1497-1500. doi:10.1161/01.STR.19.12.1497

[17]   Van Swieten, J.C., Koudstaal, P.J., Visser, M.C., Schouten, H.J. and van Gijn, J. (1988) Interobserver agreement for the assessment of handicap in stroke patient. Stroke, 19, 604-607. doi:10.1161/01.STR.19.5.604

[18]   Lynch, J.R., Blessing, R., White, W.D., Gracott, H.P., Newman, M.F. and Laskowitz, D.T. (2004) Novel diagnostic test for acute stroke. Stroke, 35, 57-63. doi:10.1161/01.STR.0000105927.62344.4C

[19]   Suzuki, H., Kanamaru, K., Tsunoda, H., Inada, H., Kuroki, M., Sun, H., et al. (1999) Heme oxygenase-1 gene induction as an intrinsic regulation against delayed cerebral vasospasm in rats. Journal of Clinical Investigation, 104, 59-66. doi:10.1172/JCI5357

[20]   Pluta, R.M. (2005) Delayed cerebral vasospasm and nitric oxide: review, new hypothesis, and proposed treatment. Pharmacology & Therapeutics, 105, 23-56. doi:10.1016/j.pharmthera.2004.10.002

[21]   Mazlam, M.Z. and Hodgson, H.J. (1994) Interrelations between interleukin-6, interleukin-1 beta, plasma C-reactive protein values, and in vitro C-reactive protein generation in patients with inflammatory bowel disease. Gut, 35, 77-83. doi:10.1136/gut.35.1.77

[22]   Kassell, N.F., Sasaki, T., Colohan, A.R.T. and Nazar, G. (1985) Cerebral vasospasm following aneurysmal subarachnoid hemorrhage. Stroke, 16, 562-572. doi:10.1161/01.STR.16.4.562

[23]   Kasuya, H., Weir, B.K., Nakane, M., Pollock, J.S., Johns, L., Marton, L.S., et al. (1995) Nitric oxide synthase and guanylate cyclase levels in canine basilar artery after subarachnoid hemorrhage. Journal of Neurosurgery, 82, 250-255. doi:10.3171/jns.1995.82.2.0250

[24]   Hung, M.J., Cherng, W.J., Yang, N.I., Cheng, C.W. and Li, L.F. (2005) Relation of high-sensitivity C-reactive protein level with coronary vasospastic angina pectoris in patients without hemodynamically significant coronary artery disease. American Journal of Cardiology, 96, 1484-1490. doi:10.1016/j.amjcard.2005.07.055

[25]   Deshmukh, V.R., Kakarla, U.K., Figueiredo, E.G., Zabramski, J.M. and Spetzler, R.F. (2006) Long-term clinical and angiographic follow-up of unclippable wrapped intracranial aneurysms. Neurosurgery, 58, 434-442.

[26]   Mayberg, M.R., Batjer, H.H., Dacey, R.G. Jr, Diringer, M., Haley, E.C., Heros, R.C., et al. (1994) Guidelines for the management of aneurysmal subarachnoid hemorrhage: A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke, 25, 2315-2328. doi:10.1161/01.STR.25.11.2315

[27]   Kasuya, H., Weir, B.K., Nakane, M., Pollock, J.S., Johns, L., Marton, L.S., et al. (1995) Nitric oxide synthase and guanylate cyclase levels in canine basilar artery after subarachnoid hemorrhage. Journal of Neurosurgery, 82, 250-255. doi:10.3171/jns.1995.82.2.0250

[28]   Cecon, A.D., Figueiredo, E.G., Bor-Seng-Shu, E., Scaff, M. and Teixeira, M.J. (2008) Extremely delayed cerebral vasospasm after subarachnoid hemorrhage. Arq Neuropsiquiatr, 66, 554-556. doi:10.1590/S0004-282X2008000400024