Cocaine use as a predictor of outcome in aneurysmal subarachnoid hemorrhage

View More View Less
  • 1 Department of Neurosurgery, Louisiana State University Health Sciences Center, New Orleans, Louisiana; and Department of Social and Preventive Medicine, Division of Biostatistics, University at Buffalo, State University of New York, Buffalo, New York
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00
Print or Print + Online

Object. The goal of this study was to analyze the relationship between cocaine use and outcomes of aneurysmal subarachnoid hemorrhage (SAH).

Methods. A retrospective review was performed of the medical records of patients with intracranial aneurysms treated at a single institution between January 1996 and December 2001. Only patients who presented with SAH were included in the study. The covariates chosen for the statistical analysis included the following: patient age, sex, and race; systolic and mean arterial blood pressure measurements on hospital admission; Hunt and Hess and Fisher grades; preexistent major systemic disease; and history of alcohol, tobacco, or cocaine use. The Glasgow Outcome Scale (GOS) was used to standardize outcome and was dichotomized such that a score between 1 and 3 was considered a poor outcome and a score of 4 or 5 was considered a favorable outcome.

The records of 151 patients were reviewed and 108 of these presented with aneurysmal SAH. Of these 108 patients, 36 (33.3%) had used cocaine within 24 hours before presentation. A Hunt and Hess grade of IV or V was assigned to 20 (55.6%) of 36 patients who used cocaine, compared with eight (11.1%) of 72 patients who did not; this difference was found to be statistically significant (p < 0.0001). Twenty-eight patients (77.8%) in the cocaine user group and 20 patients (27.8%) in the non—cocaine user group experienced clinically significant, angiographically confirmed vasospasm during their hospital course (p < 0.0001). Cocaine use was associated with a 2.8-fold greater risk of developing vasospasm (95% confidence interval [CI] 1.86–4.22). A GOS score of 1, 2, or 3 was assigned to 33 patients (91.7%) in the cocaine user group and to 20 patients (27.8%) in the non—cocaine user group (p < 0.0001). Cocaine use was associated with a 3.3-fold greater risk of poor outcome (95% CI 2.24–4.85). This association was found to be independent of Hunt and Hess grade as well as of vasospasm.

Conclusions. Cocaine adversely affects both the presentation of and outcome in patients with aneurysmal SAH who are undergoing treatment for this disease. The vasoactive properties of the drug appear to aggravate the already tenuous situation of SAH and increase both the occurrence and influence of cerebral vasospasm. Statistical analysis demonstrates that cocaine directly affects both presentation and outcome in a significant manner. It is the authors' interpretation of the results of this retrospective review that cocaine use negatively affects outcome to such an extent that it should be considered equal to the presence of a major systemic illness when determining Hunt and Hess grade.

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $505.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $600.00

Contributor Notes

Address reprint requests to: Deepak Awasthi, M.D., Department of Neurosurgery, Louisiana State University Health Sciences Center, 1542 Tulane Avenue, New Orleans, Louisiana 70112. email: dawast@lsuhsc.edu.
  • 1.

    Anonymous: National Household Survey on Drug Abuse: Population Estimates 1990. Rockville, MD: US Department of Health and Human Services, 1991 Anonymous: National Household Survey on Drug Abuse: Population Estimates 1990. Rockville, MD: US Department of Health and Human Services, 1991

    • Search Google Scholar
    • Export Citation
  • 2.

    Black BK, & Hicks SP: Relation of hypertension to arterial aneurysms of the brain. US Armed Forces Med J 3:18131818, 1952 Black BK, Hicks SP: Relation of hypertension to arterial aneurysms of the brain. US Armed Forces Med J 3:1813–1818, 1952

    • Search Google Scholar
    • Export Citation
  • 3.

    Caplan LR, , Hier DB, & Banks G: Current concepts of cerebrovascular disease—stroke: stroke and drug abuse. Stroke 13:869872, 1982 Caplan LR, Hier DB, Banks G: Current concepts of cerebrovascular disease—stroke: stroke and drug abuse. Stroke 13:869–872, 1982

    • Search Google Scholar
    • Export Citation
  • 4.

    Cregler LL, & Mark H: Cardiovascular dangers of cocaine abuse. Am J Cardiol 57:11851186, 1986 Cregler LL, Mark H: Cardiovascular dangers of cocaine abuse. Am J Cardiol 57:1185–1186, 1986

    • Search Google Scholar
    • Export Citation
  • 5.

    De La Lande IS, & Waterson JG: Site of action of cocaine on the perfused artery. Nature 214:313314, 1967 De La Lande IS, Waterson JG: Site of action of cocaine on the perfused artery. Nature 214:313–314, 1967

    • Search Google Scholar
    • Export Citation
  • 6.

    Fisher CM, , Kistler JP, & Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:19, 1980 Fisher CM, Kistler JP, Davis JM: Relation of cerebral vasospasm to subarachnoid hemorrhage visualized by computerized tomographic scanning. Neurosurgery 6:1–9, 1980

    • Search Google Scholar
    • Export Citation
  • 7.

    Gawin FH, & Ellinwood EH Jr: Cocaine and other stimulants. Actions, abuse, and treatment. N Engl J Med 318:11731182, 1988 Gawin FH, Ellinwood EH Jr: Cocaine and other stimulants. Actions, abuse, and treatment. N Engl J Med 318:1173–1182, 1988

    • Search Google Scholar
    • Export Citation
  • 8.

    Golbe LI, & Merkin MD: Cerebral infarction in a user of free-base cocaine (“crack”). Neurology 36:16021604, 1986 Golbe LI, Merkin MD: Cerebral infarction in a user of free-base cocaine (“crack”). Neurology 36:1602–1604, 1986

    • Search Google Scholar
    • Export Citation
  • 9.

    Goldfrank LR, & Hoffman RS: The cardiovascular effects of cocaine. Ann Emerg Med 20:165175, 1991 Goldfrank LR, Hoffman RS: The cardiovascular effects of cocaine. Ann Emerg Med 20:165–175, 1991

    • Search Google Scholar
    • Export Citation
  • 10.

    Grabowski J (ed): Cocaine: Pharmacology, Effects, and Treatment of Abuse. Rockville, MD: US Department of Health and Human Services, 1984 Grabowski J (ed): Cocaine: Pharmacology, Effects, and Treatment of Abuse. Rockville, MD: US Department of Health and Human Services, 1984

    • Search Google Scholar
    • Export Citation
  • 11.

    Hunt WE, & Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:1420, 1968 Hunt WE, Hess RM: Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg 28:14–20, 1968

    • Search Google Scholar
    • Export Citation
  • 12.

    Isner JM, & Chokshi SK: Cocaine and vasospasm. N Engl J Med 321:16041606, 1989 Isner JM, Chokshi SK: Cocaine and vasospasm. N Engl J Med 321:1604–1606, 1989

    • Search Google Scholar
    • Export Citation
  • 13.

    Jacobs IG, , Roszler MH, & Kelly JK, et al: Cocaine abuse: neurovascular complications. Radiology 170:223227, 1989 Jacobs IG, Roszler MH, Kelly JK, et al: Cocaine abuse: neurovascular complications. Radiology 170:223–227, 1989

    • Search Google Scholar
    • Export Citation
  • 14.

    Jaffe JH: Drug addiction and drug abuse, in Gilman AG, , Rall TW, & Nies AS, et al (eds): Goodman and Gilman's The Pharmacological Basis of Therapeutics, ed 8. New York: Pergamon Press, 1990, pp 539545 Jaffe JH: Drug addiction and drug abuse, in Gilman AG, Rall TW, Nies AS, et al (eds): Goodman and Gilman's The Pharmacological Basis of Therapeutics, ed 8. New York: Pergamon Press, 1990, pp 539–545

    • Search Google Scholar
    • Export Citation
  • 15.

    Jennett B, & Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480484, 1975 Jennett B, Bond M: Assessment of outcome after severe brain damage. A practical scale. Lancet 1:480–484, 1975

    • Search Google Scholar
    • Export Citation
  • 16.

    Kassell NF, & Torner JC: The International Cooperative Study on Timing of Aneurysm Surgery—an update. Stroke 15:566570, 1984 Kassell NF, Torner JC: The International Cooperative Study on Timing of Aneurysm Surgery—an update. Stroke 15:566–570, 1984

    • Search Google Scholar
    • Export Citation
  • 17.

    Kittner SJ, , Stern BJ, & Wozniak M, et al: Cerebral infarction in young adults: the Baltimore-Washington Cooperative Young Stroke Study. Neurology 50:890894, 1998 Kittner SJ, Stern BJ, Wozniak M, et al: Cerebral infarction in young adults: the Baltimore-Washington Cooperative Young Stroke Study. Neurology 50:890–894, 1998

    • Search Google Scholar
    • Export Citation
  • 18.

    Levine SR, , Brust JC, & Futrell N, et al: Cerebrovascular complications of the use of the “crack” form of alkaloidal cocaine. N Engl J Med 323:699704, 1990 Levine SR, Brust JC, Futrell N, et al: Cerebrovascular complications of the use of the “crack” form of alkaloidal cocaine. N Engl J Med 323:699–704, 1990

    • Search Google Scholar
    • Export Citation
  • 19.

    Levine SR, , Brust JC, & Futrell N, et al: A comparative study of the cerebrovascular complications of cocaine: alkaloidal versus hydrochloride—a review. Neurology 41:11731177, 1991 Levine SR, Brust JC, Futrell N, et al: A comparative study of the cerebrovascular complications of cocaine: alkaloidal versus hydrochloride—a review. Neurology 41:1173–1177, 1991

    • Search Google Scholar
    • Export Citation
  • 20.

    Lichtenfeld PJ, , Rubin DB, & Feldman RS: Subarachnoid hemorrhage precipitated by cocaine snorting. Arch Neurol 41:223224, 1984 Lichtenfeld PJ, Rubin DB, Feldman RS: Subarachnoid hemorrhage precipitated by cocaine snorting. Arch Neurol 41:223–224, 1984

    • Search Google Scholar
    • Export Citation
  • 21.

    Macdonald RL, & Weir B: Pathophysiology and clinical evaluation of subarachnoid hemorrhage, in Youmans JR (ed): Neurological Surgery, ed 4. Philadelphia: WB Saunders, 1996, Vol 2, pp 12241242 Macdonald RL, Weir B: Pathophysiology and clinical evaluation of subarachnoid hemorrhage, in Youmans JR (ed): Neurological Surgery, ed 4. Philadelphia: WB Saunders, 1996, Vol 2, pp 1224–1242

    • Search Google Scholar
    • Export Citation
  • 22.

    Madden JA, & Powers RH: Effect of cocaine and cocaine metabolites on cerebral arteries in vitro. Life Sci 47:11091114, 1990 Madden JA, Powers RH: Effect of cocaine and cocaine metabolites on cerebral arteries in vitro. Life Sci 47:1109–1114, 1990

    • Search Google Scholar
    • Export Citation
  • 23.

    McNagny SE, & Parker RM: High prevalence of recent cocaine use and the unreliability of patient self-report in an inner-city walk-in clinic. JAMA 267:11061108, 1992 McNagny SE, Parker RM: High prevalence of recent cocaine use and the unreliability of patient self-report in an inner-city walk-in clinic. JAMA 267:1106–1108, 1992

    • Search Google Scholar
    • Export Citation
  • 24.

    Oyesiku NM, , Colohan AR, & Barrow DL, et al: Cocaine-induced aneurysmal rupture: an emergent negative factor in the natural history of intracranial aneurysms? Neurosurgery 32:518526, 1993 Oyesiku NM, Colohan AR, Barrow DL, et al: Cocaine-induced aneurysmal rupture: an emergent negative factor in the natural history of intracranial aneurysms? Neurosurgery 32:518–526, 1993

    • Search Google Scholar
    • Export Citation
  • 25.

    Sacco RL, , Wolf PA, & Bharucha NE, et al: Subarachnoid and intracerebral hemorrhage: natural history, prognosis, and precursive factors in the Framingham Study. Neurology 34:847854, 1984 Sacco RL, Wolf PA, Bharucha NE, et al: Subarachnoid and intracerebral hemorrhage: natural history, prognosis, and precursive factors in the Framingham Study. Neurology 34:847–854, 1984

    • Search Google Scholar
    • Export Citation
  • 26.

    Salom JB, , Torregrosa G, & Barbera MD, et al: Effects of cocaine on human and goat isolated cerebral arteries. Drug Alcohol Depend 42:6571, 1996 Salom JB, Torregrosa G, Barbera MD, et al: Effects of cocaine on human and goat isolated cerebral arteries. Drug Alcohol Depend 42:65–71, 1996

    • Search Google Scholar
    • Export Citation
  • 27.

    Simpson RK Jr, , Fischer DK, & Narayan RK, et al: Intravenous cocaine abuse and subarachnoid haemorrhage: effect on outcome. Br J Neurosurg 4:2730, 1990 Simpson RK Jr, Fischer DK, Narayan RK, et al: Intravenous cocaine abuse and subarachnoid haemorrhage: effect on outcome. Br J Neurosurg 4:27–30, 1990

    • Search Google Scholar
    • Export Citation
  • 28.

    Weiss RD, & Gawin FH: Protracted elimination of cocaine metabolites in long-term high-dose cocaine abusers. Am J Med 85:879880, 1988 Weiss RD, Gawin FH: Protracted elimination of cocaine metabolites in long-term high-dose cocaine abusers. Am J Med 85:879–880, 1988

    • Search Google Scholar
    • Export Citation
  • 29.

    Wojak JC, & Flamm ES: Intracranial hemorrhage and cocaine use. Stroke 18:712715, 1987 Wojak JC, Flamm ES: Intracranial hemorrhage and cocaine use. Stroke 18:712–715, 1987

    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 587 160 11
Full Text Views 192 18 2
PDF Downloads 79 6 0
EPUB Downloads 0 0 0