Ocular fundus abnormalities as a prognostic marker in acute subarachnoid hemorrhage: The FOTO-ICU Study Público

Garza, Philip (2016)

Permanent URL: https://etd.library.emory.edu/concern/etds/tm70mw033?locale=es
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Abstract

Ocular fundus abnormalities, especially intraocular hemorrhage, are common among patients with acute subarachnoid hemorrhage (SAH) and may represent a clinically useful prognostic marker. We enrolled patients admitted to our neurointensive care unit (Neuro ICU) between 9/2014-4/2015 with a working diagnosis of SAH into a prospective cohort study. Handheld ocular fundus photography was performed once patients were deemed appropriate for pupillary dilation, and photographs were reviewed for intraocular hemorrhage and other neurologically-relevant fundus abnormalities. Multivariable logistic and Cox models were used to evaluate associations between fundus abnormalities and poor outcome (defined as inpatient death, care withdrawal, or discharge Glasgow Outcome Score < 4) and ICU and hospital lengths-of-stay, controlling for APACHE II score, respiratory failure at ICU admission, Hunt & Hess score, aneurysmal etiology, age, and sex. 79 consecutively enrolled patients had confirmed acute SAH. Twenty-eight of these 79 (28/79 [35.4%]) had an ocular fundus abnormality, and 20/79 (25.3%) had intraocular hemorrhage. In univariate analyses, poor outcomes were more likely in patients with fundus abnormalities vs. without (15/28 [53.6%] vs. 15/51 [29.4%], p=0.03), whereas median length of ICU stay was longer in patients with intraocular hemorrhage than without (18 days [IQR 12-25] vs. 11 [IQR 7-17], p=0.03). Logistic regression modeling with fundus abnormality as predictor of interest showed that male sex (OR 5.33 [95% CI 1.09-26.0], p=0.04), higher APACHE II (OR, per 1-point increase, 1.43 [95% CI 1.09-1.87, p=0.01], and aneurysmal etiology (OR 5.95 [95% CI 1.06-33.2], p=0.04), but not fundus abnormalities (OR 1.46 [95% CI 0.37-5.82], p=0.59), were associated with poor outcome. The results were similar using intraocular hemorrhage as the predictor (OR 1.13 [95% CI 0.23-5.53], p=0.88). Cox models stratified on respiratory failure at ICU admission identified aneurysmal SAH etiology, but not fundus abnormalities, as a strong independent predictor of length-of-stay (HRs for ICU and hospital discharge, aneurysmal vs. nonaneurysmal = 0.3 [95% CI 0.2-0.6], p<0.001). Therefore, although ocular fundus abnormalities are associated with markers of disease severity in SAH, they do not add value to patients' acute management beyond other risk factors already in clinical use.

Table of Contents

INTRODUCTION...........................................................................................1

BACKGROUND.............................................................................................3

METHODS...................................................................................................7

Research Goal.....................................................................................7
Study Design & Population....................................................................8
Measurements.....................................................................................8
Sample Size & Power...........................................................................11
Analytic Plan......................................................................................11

RESULTS....................................................................................................15

Cohort Characteristics.........................................................................15

Univariate Results...............................................................................16

Logistic Regression Modeling.................................................................17

Time-to-Event Analyses........................................................................20

DISCUSSION AND CONCLUSIONS..................................................................22

REFERENCES...............................................................................................30

TABLES AND FIGURES..................................................................................32

Figure 1.............................................................................................32

Figure 2.............................................................................................33

Figure 3.............................................................................................34

Table 1a.............................................................................................35

Table 1b.............................................................................................36

Table 2a.............................................................................................37

Table 2b.............................................................................................38

Figure 4.............................................................................................39

Figure 5.............................................................................................40

Figure 6.............................................................................................41

Figure 7.............................................................................................42

Figure 8.............................................................................................43

Table 3a.............................................................................................44

Table 3b.............................................................................................45

Table 3c.............................................................................................46

Table 3d.............................................................................................47

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