Higher modified Graeb scores were associated with a 7.0-fold increase in odds of substantial troponin elevation after aneurysmal subarachnoid hemorrhage.
Does the extent of intraventricular hemorrhage measured by radiographic scores predict neurocardiogenic injury in adults with aneurysmal subarachnoid hemorrhage?
The modified Graeb score for intraventricular hemorrhage strongly predicts neurocardiogenic injury following aneurysmal subarachnoid hemorrhage, outperforming early brain-edema scores.
Background: Aneurysmal subarachnoid hemorrhage (aSAH) frequently causes neurocardiogenic injury, a serious complication characterized by troponin elevation, EKG abnormalities, and reduced left ventricular ejection fraction (LVEF). This cardiac dysfunction is thought to result from an excessive catecholamine release following the initial brain injury. While radiographic scoring systems like the modified Graeb score (measuring intraventricular hemorrhage) and the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) assess early brain injury, their specific ability to predict cardiac complications is not well established. This study tested whether these scores predict neurocardiogenic injury in aSAH. Methods: We conducted a retrospective analysis of 318 adults with aSAH from a prospectively maintained database (REACH, NCT04189471) at the University of Maryland Medical Center (Jan 2020 – Dec 2024). Admission non-contrast head CTs were scored with modified Graeb, SEBES, and SEBES-6c by raters blinded to outcomes. Markers of cardiac injury included the peak troponin level within the first 72 hours, LVEF on echocardiogram, and EKG abnormalities. The association between radiographic scores and cardiac outcomes was analyzed using partial ordinal logistic regression. Results: Higher admission modified Graeb scores showed a significant association with markers of neurocardiogenic injury, specifically troponin elevation (p = 0.0015). Troponin elevation was also significantly associated with the secondary outcome of reduced LVEF (p = 0.004). Patients with modified Graeb scores in the highest quartile (mGraeb > 8) had a 7.0-fold higher odds of substantial troponin elevation (Ref: Troponin I < 0.2) compared to those in the lowest quartile (mGraeb = 0) 95% CI: 2.6–20.7. In contrast, the SEBES and SEBES-6c scores showed a trend toward correlation with troponin levels but did not reach statistical significance. These models accounted for established risk factors for poor outcomes after aSAH. Conclusion: Intraventricular hemorrhage extent, measured by modified Graeb, is a strong predictor of neurocardiogenic injury after aSAH, outperforming early brain-edema scores. Patients with large intraventricular hemorrhage warrant intensive cardiac monitoring. Utilizing modified Graeb at admission may help stratify high-risk patients and guide integrated neurocardiac care.
Shamsuddin et al. (2026) studied this question. Higher modified Graeb scores were associated with a 7.0-fold increase in odds of substantial troponin elevation after aneurysmal subarachnoid hemorrhage.