Role of ABO blood type in delayed cerebral ischemia onset and clinical outcomes after aneurysmal subarachnoid hemorrhage in an ethnic minority urban population
- Departments of Neurological Surgery, Weill Cornell, Bronx, New York, United States.
- Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, United States.
David J. Altschul
Department of Neurosurgery, Montefiore Medical Center, Bronx, New York, United States.
DOI:10.25259/SNI_10_2020Copyright: © 2020 Surgical Neurology International This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-Share Alike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Santiago René Unda, Tarini Vats, Rafael De la Garza Ramos, Phillip Cezaryirli, David J. Altschul. Role of ABO blood type in delayed cerebral ischemia onset and clinical outcomes after aneurysmal subarachnoid hemorrhage in an ethnic minority urban population. 16-May-2020;11:108
How to cite this URL: Santiago René Unda, Tarini Vats, Rafael De la Garza Ramos, Phillip Cezaryirli, David J. Altschul. Role of ABO blood type in delayed cerebral ischemia onset and clinical outcomes after aneurysmal subarachnoid hemorrhage in an ethnic minority urban population. 16-May-2020;11:108. Available from: https://surgicalneurologyint.com/surgicalint-articles/10049/
Background: In recent years, the role of ABO blood type moved into focus through the discovery of different hemostaseologic properties with importance in many diseases including subarachnoid hemorrhage (SAH). However, the role of ABO blood type in delayed cerebral ischemia (DCI) onset, clinical progress, and outcome after SAH is to date largely unexplored. Our aim was to explore the role of ABO blood group in DCI and clinical outcomes after aneurysmal SAH (aSAH).
Methods: A retrospective analysis was made with data collected from patients who presented aSAH at our single- academic center from 2015 to 2018. We included demographic, clinical, and imaging variables in the univariate analysis and in the subsequent multivariate analysis.
Results: A total of 204 patients were included in this study. About 17.9% of “O” type patients developed a DCI while DCI was reported in only 8.2% of non-O type patients (P = 0.04). “O” type was an independent risk after in the logistic regression after adjusting for significant factors in the univariate analysis (OR=2.530, 95% CI: 1.040- 6.151, P = 0.41). Compared to “non-O” type patients, “O” type patients had a trend to have poorer outcomes at discharge (25.5% vs. 21.3%, P = 0.489) and at 12–18 months (21.1% vs. 19.5%, P = 0.795). However, there were no significant differences.
Conclusion: Our study evidenced that patients with “O” blood type have higher risk of DCI onset after aSAH. Although these findings need to be confirmed, they may aid to improve DCI prevention and outcome predictions.
Keywords: ABO blood type, Aneurysm, Delayed cerebral ischemia, Subarachnoid hemorrhage
Subarachnoid hemorrhage (SAH) caused by aneurysmal rupture (aSAH) is a devastating condition causing the 2–5% of all new strokes[
Recently, ABO blood type has been related with hemorrhagic pathologies, because plasma vWF levels are 25–35% lower in subjects with type O blood group than in individuals without type O blood group and that has been established as the cause of excessive bleeding.[
In this context, ABO blood type linkage with SAH outcomes is possible. However, only few studies had assessed the relation of clinical status at admission and DCI after SAH with blood types but, any of these studies had found a significant influence of ABO blood type.[
A retrospective analysis was made with data collected from patients who presented aSAH at a single academic center located in the Bronx, New York, between 2016 and 2018. Institutional review board approved the protocol before study initiation. Informed consent was waived due to the nature of the research.
The principal inclusion criteria were patients over 18 years of age with aSAH. Exclusion criteria comprised nonaneurysmal etiology, patients with incomplete follow-up, and patients with infectious aneurysms.
ABO type was classified between “O” type and “non-O” type. Patient socio-demographics (sex, age, ethnicity, BMI, hypertension, and smoke status), procedure-related factors (microsurgical clipping, coiling, and EVD placement), aneurysms characteristics (location in anterior or posterior circulation and size <7 mm or 37 mm), and clinical variables (Hunt Hess Score, mFG, DCI, and modified Rankin Scale (mRS) at discharge and at outpatient follow-up between 12 and 18 months) were included.
After SAH diagnosis, four-vessel 3D angiography was performed in every patient. Selection of patients that underwent microsurgical clipping or coiling was done by the neurointerventional team of our institution that performs both procedures. TCDs were done for 15 days after the SAH routinely every 24 h and cerebral angiography for confirmation of clinically suspected vasospasm during the hospital stay.
All patients had a clinical and neurological examination by the neurovascular team at 24 h’ postprocedure, at discharge, and at 6 mo to 18 mo after treatment. mRS score was recorded in every follow-up by the physician in charge of the case.
The main outcome measure was development of DCI. Secondary outcomes included clinical functional outcomes at discharge and at 12–18 months with the mRS score. For this purpose, we used the following definitions: (1) DCI, the occurrence of focal neurological impairment that lasted more than 1 h (such as hemiparesis, aphasia, apraxia, hemianopia, or neglect), or a decrease of at least two points on the Glasgow Coma Scale (either on the total score or on one of its individual components [eye, motor on either side, and verbal]) and cannot be attributed to other cause[
The aim of this study was (1) to determine the role of ABO blood type in the development of DCI, and (2) to explore the association between ABO blood type with: (a) demographic characteristics, (b) clinical presentation with Hunt-Hess (HH) score at admission, (c) imaging severity with mFG, (d) DCI, and (e) clinical outcomes assessed with mRS.
SPSS v.24 software was used to perform the statistical analysis. In regard to demographic, treatment and clinical variables, comparisons of the distributions were made by the Chi-square test) or Student’s t-test as appropriate. Factors with P < 0.10 were included in a multiple logistic regression model to identify independent predictors of outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. P < 0.05 was considered as statistically significant.
A total of 204 patients met the inclusion criteria for this study. The baseline characteristics of the population are summarized in
Compared to “non-O” type patients, “O” type patients had a trend to have poorer outcomes at discharge (25.5% vs. 21.3%, P = 0.489) and at 12–18 months (21.1% vs. 19.5%, P = 0.795). However, there were no significant differences [
Our study explored the role of ABO blood type in DCI onset and clinical functional outcomes. The significant finding of this study is the association between “O” blood type and DCI onset. Unlike other studies that have not found any ABO blood type to be related to DCI,[
The increased prevalence of DCI in “O” type patients can be supported in recent evidence that showed lower levels of vWF and VIII factor in plasma lead to excessive bleeding in the subarachnoid space. Although some studies have shown that peripheral vasospasm is related to increase levels of VIII factor,[
We showed that there was no difference between “O” type and “non-O” type groups in the mFG at admission, similar to recent reports,[
The blood type is currently not assessed in the clinical setting to predict any kind of outcomes in SAH patients; however, our work provides evidence that the major complication after SAH, DCI is influenced by the blood type; therefore, patients with “O” blood type may need closer monitoring of vasospasm. Further studies that propose mechanisms by which cerebrovascular tone might be influenced by blood type in SAH conditions are needed to validate these results.
Although, short- and long-term clinical outcomes were not statistically significant between ABO blood types, the “O” type group had higher rates of poor clinical outcomes. These results could be explained by the fact that clinical outcomes are influenced by clinical, socio-economic, demographic, and many other factors, therefore, are expected that the contribution of the ABO blood type is not enough to produce a significant change in the patient’s functional recovery after aSAH.
The findings of this study have to be seen in light of some limitations inherent in a single-center retrospective design. Therefore, our study is subject to biases and confounding that may have influenced our study estimates. The sample size was a constraint for the assessment of patients to meet the inclusion and exclusion criteria in this study. The high representation of hispanics and African Americans makes another limitation to translate these findings to the general population. Finally, the relatively small amount of literature makes it difficult to compare the results, we present in this study; therefore, these results should be interpreted with caution for extrapolate or compare with other studies.
Our study evidenced that patients with “O” blood type have higher risk of DCI onset after aSAH. Although these findings need to be confirmed, they may aid to improve DCI prevention and outcome predictions.
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