Spontaneous subarachnoid haemorrhage as a cause of out-of-hospital cardiac arrest
Introduction
Spontaneous subarachnoid haemorrhage is the most frequent neurological disorder leading to out-of-hospital cardiac arrest [1], [2], [3]. In subarachnoid haemorrhage, the spontaneous rupture of a cerebral aneurysm causes a sudden increase in intracranial pressure, leading to sympathetic hyperstimulation with release of catecholamines, which may produce cardiac arrhythmias [4], [5], [6], [7]. Direct mechanical compression of the brainstem centres seems to be another probable cause of cardiac and respiratory arrest [2], [8], [9].
There are no reliable data about the number of deaths due to subarachnoid haemorrhage in the out-of-hospital setting, and how many patients with cardiac arrest due to subarachnoid haemorrhage are admitted to hospital after restoration of a spontaneous circulation. It is estimated that 30% of patients overall with subarachnoid haemorrhage not complicated by cardiac arrest die in the first 24 h, many of them before arriving at the hospital [10]. As the clinical presentation of subarachnoid haemorrhage complicated by cardiac arrest is obscure, a precise diagnosis is often difficult, although it may be important for further medical management of the patient.
To enable better recognition of subarachnoid haemorrhage as a cause of cardiac arrest, we analysed the clinical presentation, diagnosis, therapy and outcome of patients with cardiac arrest caused by subarachnoid haemorrhage retrospectively.
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Materials and methods
Data from patients admitted after out-of-hospital cardiac arrest to the emergency department of an urban tertiary care university hospital were recorded according to the Utstein protocol [11]. Cardiac arrest was defined according to the criteria of the American Heart Association as sudden collapse followed by loss of consciousness and the absence of both spontaneous respiration and pulse requiring cardiopulmonary resuscitation (CPR) [12], [13]. The following data were documented on arrival: sex
Results
During the 8.5-year period, 765 patients were admitted to the emergency department after successful resuscitation from out-of-hospital cardiac arrest. Spontaneous subarachnoid haemorrhage was identified as the immediate cause of cardiac arrest in 27 (4%) patients. The median time to return of spontaneous circulation was 22 min (IQR: 15–26). In 23 of the 27 patients, subarachnoid haemorrhage was suspected clinically and confirmed by cranial computerized tomography. In four patients where
Discussion
We found that out-of-hospital cardiac arrest caused by spontaneous subarachnoid haemorrhage has an extremely poor prognosis. Only one of 27 patients survived to hospital discharge with a favourable neurology. We were able to identify several factors suggesting subarachnoid haemorrhage as cause of out-of-hospital cardiac arrest.
Subarachnoid haemorrhage leading to cardiac arrest affected women more often than men, which confirms prior studies [1], [3], [17]. Our population of patients with
Acknowledgements
We thank Dr Marcus Müllner for critically reading the manuscript and for constructive advice.
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