Introduction

Subarachnoid Hemorrhage (SAH) is the cause of
5-10 percent of cerebrovascular accidents. Mortality and morbidity due to subarachnoid hemorrhage are significant.

On the other hand, cardiovascular complications are frequently seen in the course of SAH. Relatively high mortality due to cardiovascular complications has been reported.

There are some reports that show SAH can result in electrocardiographic changes similar those caused by ischemic heart diseases, but without tissue pathologic changes in the heart.

The pathophysiology of these changes is not fully known (1, 2, 3, 4, 5, 6, 7) and are commonly believed to be caused by a catecholamine surge following SAH.

The relationship between electrocardiogram changes and clinical and radiographic findings in SAH is an issue that requires further review.

Considering that Ghaem Hospital's neurologic ward is the sole center accepting patients with non-traumatic SAH from northeastern Iran, its information can serve as a valuable source of regional epidemiologic characteristics. Also, our study provides an analytical review of electrocardiographic changes in patients and clinical and radiological findings in comparison with a control group.

According to past research mainly performed in western countries, electrocardiography changes are seen frequently in SAH. However, it is not well known how these changes affect patient prognosis.

This study is designed to meet the above challenge.

When considering the importance of the analytical study of SAH patients' clinical and radiographic characteristics compared with Electrocardiography (ECG) changes, this research should prove to be of great assistance.

Materials and Methods

The study population consists of SAH patients without a history of Ischemic Heart Disease (IHD) who had been referred to Mashhad's Ghaem hospital. The control group was selected from among patients without heart problems who had been admitted to the hospital's surgery wards.

Study and control groups were matched based on age and sex. This study is cross-sectional and shows the epidemiological, clinical, radiographic and ECG findings in SAH patients who were admitted to Ghaem Hospital. In this research, ECG findings in SAH patients and the control group were compared and the relationship between the epidemiological, clinical and radiographic findings with the ECG changes was analyzed. In this study, an easy sampling method was employed.

Hunt and Hess grading system were employed.

Grade 1: Asymptomatic or mild headache and slight nuchal rigidity

Grade 2: Moderate to severe headache, stiff neck, no neurologic deficit except cranial nerve palsy

Grade 3: Drowsy or confused, mild focal neurologic deficit

Grade 4: Stupor, moderate or severe hemiparesis

Grade 5: Deep coma, decerebrate posturing

The grade is advanced one level for the presence of grave systemic disease (hypertension, diabetes, severe arteriosclerosis, chronic pulmonary disease) or angiographically confirmed vasospasm.

ECG abnormalities are divided into five main groups in patients:

(1) Atrial disorders (2) Conduction disorders (3) Repolarization disorders (4) rhythm disorders (5) Pathological Q Wave.  In this study a QTc of more than 0.44 sec was considered as a long QTc, A heart rate of more than 100 minutes as Sinus Tachycardia, and a heart rate of less than 60 minute as Sinus Bradycardia.

A questionnaire was prepared based on the study, Clinical symptoms, the brain CT scan and conventional angiography findings were recorded as patients entered the emergency room. If a patient had had multiple Computed Tomography (CT) scans or multiple angiographic evaluations, the first brain CT scan and the last angiography were evaluated.

For each patient, three ECGs were performed. A cardiologist interpreted the ECGs. ECG changes were recorded based on cardiologist point of view. The findings of these electrocardiograms were recorded on the questionnaire. A Chi-square test was used for statistical analysis.

Results

In this study, 102 patients with SAH were investigated. A brain CT scan was performed in all cases, but an angiography was performed in only 65 patients. 16 patients died within 72 hours of hospitalization. In the study, 47 (46.1%) patients were males and 55(53.9%) patients were females. The mean age of patients was (51.7±17.4) years. The youngest patient was 17 years and the oldest was 87 years.

The mean age of patients with and without ECG changes was (53.4±14.2) and (49.1±14.9) years respectively.

Table 1 shows the distribution of clinical grading, mean age and the sex of the patients with SAH.

The clinical signs and symptoms of 102 patients include:

Headache in (80.4%) of patients, vomiting in (72.5%), decreased consciousness in 53.9%, seizure in (15.7%), aphasia in (12.7%), hemiparesis in (6.9%) and visual disturbances in (4.9%).

Subarachnoid hemorrhage was diagnosed in 100 patients via a brain CT scan.  The brain CT scans of two patients were normal or suspicious and so the diagnosis of SAH was established by lumbar puncture.

CT scan findings in these patients include: unilateral bleeding in the Sylvian sulcus in 28 patients (27.5%), bilateral bleeding in the Sylvian sulcus in 55 patients (53.9%), bleeding in other sulcuses in 32 patients (31.4%),bleeding in the anterior interhemispheric sulcus  in 55 patients (53.9%), bleeding in the posterior interhemispheric sulcus in 29 patients (28.4%), bleeding in  basal cisterns in 61 patients(59.8%), SAH with IVH in 10 patients (9.8%), SAH with Intra Cranial Hemorrhage (ICH) in 7 patients (6.9%) and Hydrocephaly in 10 patients (9.8%). Angiography was performed in 60 of the cases within 72 hours of the occurrence of SAH.

In five patients, this performed later because of the

delay in referring these patients to the hospital. A second angiography was done after 10 to 14 days when the first angiography was normal.

In the angiography study, an aneurysm reported in 44 patients. Angiogram was normal in 15 patients while another disorder, such as AVM and vasospasm was reported in six patients.  Among the 44 patients with aneurysms, 10 had multiple aneurysms.