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Original Investigation |

Loss of Consciousness at Onset of Subarachnoid Hemorrhage as an Important Marker of Early Brain Injury

Sureerat Suwatcharangkoon, MD1,2; Emma Meyers, BA1; Cristina Falo, PhD1; J. Michael Schmidt, PhD1; Sachin Agarwal, MD, MPH1; Jan Claassen, MD, PhD1; Stephan A. Mayer, MD1,3
[+] Author Affiliations
1The Neurological Intensive Care Unit, Department of Neurology, Columbia University Medical Center, New York, New York
2Division of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
3The Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
JAMA Neurol. 2016;73(1):28-35. doi:10.1001/jamaneurol.2015.3188.
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Importance  Loss of consciousness (LOC) is a common presenting symptom of subarachnoid hemorrhage (SAH) that is presumed to result from transient intracranial circulatory arrest.

Objective  To clarify the association between LOC at onset of SAH, complications while in the hospital, and long-term outcome after SAH.

Design, Setting, and Participants  A retrospective analysis was conducted of 1460 consecutively treated patients with spontaneous SAH who were part of a prospective observational cohort study at a large urban academic medical center (the Columbia University SAH Outcomes Project or SHOP). Patients were enrolled between August 6, 1996, and July 23, 2012. Analysis was conducted from December 1, 2013, to February 28, 2015.

Exposures  Loss of consciousness at onset was identified by structured interview of the patient and first responders. Patients (80.5%) were observed for up to 1 year to assess functional recovery.

Main Outcomes and Measures  Modified Rankin scale scores were assigned based on telephone or in-person interviews of the patient, family members, or caregivers. Complications while in the hospital were predefined and adjudicated by the study team.

Results  Five hundred ninety patients (40.4%) reported LOC at onset of SAH. Loss of consciousness was associated with poor clinical grade, more subarachnoid and intraventricular blood seen on admission computed tomographic scan, and a higher frequency of global cerebral edema (P < .001). Loss of consciousness was also associated with more prehospital tonic-clonic activity (22.7% vs 4.2%; P < .001) and cardiopulmonary arrest (9.7% vs 0.5%, P < .001) vs patients who did not experience LOC. In multivariable analysis, death or severe disability at 12 months was independently associated with LOC after adjusting for established risk factors for poor outcome, including poor admission clinical grade (adjusted odds ratio, 1.94; 95% CI, 1.38-2.72; P < .001). There was no association between LOC at onset and delayed cerebral ischemia or aneurysm rebleeding.

Conclusions and Relevance  Loss of consciousness at symptom onset is an important manifestation of early brain injury after SAH and a predictor of death or poor functional outcome at 12 months.

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Distribution of Scores on the Modified Rankin Scale at Discharge and at 12 Months

A, Scores at discharge. B, Scores 12 months after discharge. A score of 6 represents death; a score of 0 represents full recovery with no residual symptoms or disability. Loss of consciousness was associated with higher rates of death and severe disability at discharge and at 12 months.

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