Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage: The Impact of Cocaine Use, Hunt-Hess Grade, and Other Risk Factors

Introduction : Cerebral vasospasm (CV) is a common complication following aneurysmal subarachnoid hemorrhage (aSAH) that contributes to significant morbidity and mortality. While numerous identified CV risk factors exist, illicit substance use’s influence, particularly cocaine, remains controversial. This study aims to elucidate relationships between known risk factors and CV’s incidence, severity, and refractoriness. Methods : A retrospective chart review was conducted on all aSAH patients between 2014-2023 with inclusion criteria of confirmed aneurysms on digital subtraction angiography (DSA) and available urine drug screens (UDS). Demographic data, Hunt-Hess (HH), modified Fisher Scale (mFS), comorbidities, and vasospasm grades were collected. Outcomes, including vasospasm treatment counts, length of stay (LOS), and 3-month modified Rankin Scale (mRS) scores, were recorded. Results : Of 88 patients, 43% experienced CV. Cocaine use was significantly more prevalent in the CV group (26% vs. 8%, p=0.04) and increased CV risk (OR=4.11, 95% CI: 1.25–16.13, p=0.03), independent of other factors. Higher HH grades were associated with increased CV incidence (OR=1.75, p=0.01), severity (β=0.271, p=0.02), and 3-month mRS scores (β=0.81, p<0.001). Female sex also predicted vasospasm incidence (OR=4.78, p=0.01). Older age was associated with worse long-term outcomes (β=0.05, p=0.004). In the multivariable analysis, cocaine revealed a significant increased risk of CV incidence (OR=5.79, p=0.02). Higher HH grades significantly impacted CV severity (OR=0.30, p=0.01) and worse long-term outcomes (OR=0.957, p<0.01) in the multivariable analysis. Conclusions : Females, those with positive cocaine use on UDS, and a history of T2DM were at an increased risk of CV with no impact on severity, recurrence, or 3-month outcomes. Older age was associated with worse long-term outcomes. HH grade was significantly associated with increased vasospasm severity, refractoriness to treatment, and worse long-term outcomes as per mRS scores.