Cannabis Use Is Not Associated With Aneurysmal Subarachnoid Hemorrhage Complications or Outcomes

HomeStrokeVol. 53, No. 8Cannabis Use Is Not Associated With Aneurysmal Subarachnoid Hemorrhage Complications or Outcomes Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplementary MaterialsFree AccessResearch ArticlePDF/EPUBCannabis Use Is Not Associated With Aneurysmal Subarachnoid Hemorrhage Complications or Outcomes Feras Akbik, MD, PhD, Heather-Destiny Konan, Kayla P. Williams, Leelt M. Ermias, Yuyang Shi, Obai Takieddin, DDS, Jonathan A. Grossberg, MD, MPH, Brian M. Howard, MD, Frank Tong, MD, C. Michael Cawley, MD, Yajun Mei, PhD, Owen B. Samuels, MD and Ofer Sadan, MD, PhD Feras AkbikFeras Akbik Correspondence to: Feras Akbik, MD, PhD, Neurocritical Care, Neurology, Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322. Email E-mail Address: [email protected] https://orcid.org/0000-0002-1255-1622 Department of Neurology and Neurosurgery, Division of Neurocritical Care (F.A., O.T., O.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , Heather-Destiny KonanHeather-Destiny Konan Emory College, Atlanta, GA (H.-D.K., K.P.W., L.M.E.). Search for more papers by this author , Kayla P. WilliamsKayla P. Williams Emory College, Atlanta, GA (H.-D.K., K.P.W., L.M.E.). Search for more papers by this author , Leelt M. ErmiasLeelt M. Ermias Emory College, Atlanta, GA (H.-D.K., K.P.W., L.M.E.). Search for more papers by this author , Yuyang ShiYuyang Shi https://orcid.org/0000-0002-0178-7082 H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.). Search for more papers by this author , Obai TakieddinObai Takieddin https://orcid.org/0000-0002-2618-8545 Department of Neurology and Neurosurgery, Division of Neurocritical Care (F.A., O.T., O.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , Jonathan A. GrossbergJonathan A. Grossberg https://orcid.org/0000-0002-1152-8826 Department of Neurosurgery (J.A.G., B.M.H., F.T., C.M.C., O.B.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , Brian M. HowardBrian M. Howard Department of Neurosurgery (J.A.G., B.M.H., F.T., C.M.C., O.B.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , Frank TongFrank Tong Department of Neurosurgery (J.A.G., B.M.H., F.T., C.M.C., O.B.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , C. Michael CawleyC. Michael Cawley Department of Neurosurgery (J.A.G., B.M.H., F.T., C.M.C., O.B.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author , Yajun MeiYajun Mei H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.). Search for more papers by this author , Owen B. SamuelsOwen B. Samuels Department of Neurosurgery (J.A.G., B.M.H., F.T., C.M.C., O.B.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author and Ofer SadanOfer Sadan https://orcid.org/0000-0002-0050-3025 Department of Neurology and Neurosurgery, Division of Neurocritical Care (F.A., O.T., O.S.), Emory University School of Medicine, Atlanta, GA. Search for more papers by this author Originally published22 Jun 2022https://doi.org/10.1161/STROKEAHA.122.038951Stroke. 2022;53:e375–e376Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: June 22, 2022: Ahead of Print As cannabis decriminalization efforts progress across the United States, questions remain regarding potential public health consequences. Vasoactive metabolites of cannabis have been invoked as a risk factor for ischemic stroke, although this is contested.1 Registry data suggest cannabis use is associated with increased incidence of aneurysmal subarachnoid hemorrhage (aSAH), although not with cerebral vasospasm (CV) or clinical outcomes.2,3 Conversely, recent single-center data suggest increased delayed cerebral ischemia (DCI) after aSAH with cannabis use.4,5Using a retrospective cohort study of all aSAH patients presenting to Emory University between January 1, 2012 through December 31, 2019, we present the largest single-center series analyzing the impact of cannabis on aSAH complications and outcomes. The Emory University institutional review board approved this study. All data are available upon reasonable request. Patients were grouped based on the results of urine toxicology testing.1 Patient demographics, clinical characteristics, and clinical outcomes were analyzed. CV was defined as clinical or radiographic evidence of CV that prompted an intervention, as previously defined.6 Radiographic DCI was defined per consensus criteria.6 The data that support the findings of this study are available from the corresponding author upon reasonable request. The institutional review board at Emory University, Atlanta, GA, approved the data collection and quality assurance analysis, and waived the need for patient consent.Six hundred eighty-five (57.5%) of the 1190 aSAH patients underwent urine toxicology testing (Table S1). One hundred thirty-four (19.6%) patients tested positive for recent cannabis use. Cannabis using patients were significantly younger, less likely to be female or diabetic, and more likely to smoke or use amphetamines, cocaine, and barbiturates (Table S2). Clinical severity on presentation was less severe in cannabis users (Hunt and Hess grade 3, 2–4 versus 3, 1–3, P<0.025) but were otherwise similar in terms of modified Fisher scale and surgical interventions offered. In unadjusted analysis, there was increased CV with cannabis use (51.0% versus 61.2%, P=0.042) but no significant difference in DCI (12.3% versus 14.2%, P=0.564).Propensity score matching was used to adjust for baseline differences (Table S2). In univariable regression analysis, cannabis use was associated with a nonsignificant trend towards increased CV (adjusted odds ratio, 1.39 [0.94–2.08]; P=0.098), but patients were more likely to go home (1.72 [1.15–2.58]; P=0.009) without increased DCI (1.38 [0.79–2.41]; P=0.263, Tables S3 through S5). Using multivariable logistic regression of the propensity core matched cohorts, cannabis use was not associated with CV, DCI, or home discharge (Tables S6 through S8).We find no association of cannabis use with complications and outcomes after aSAH. Although univariable weighted analysis suggested a nonsignificant trend towards increased CV (without increased DCI), discharge outcomes were paradoxically better. These trends dissipated under multivariable assumptions, likely due to accounting for a skewed population of younger cannabis using patients that could not be entirely age-matched using propensity score methods (Table S2). Given the age dependency of CV and DCI, the skewed age distribution in cannabis users may explain why our study differs from 2 reports that did not include age in multivariable analyses and agrees with larger registry studies that did.2–5 Strengths of our study include the largest single-center cohort of cannabis using aSAH patients to date, rigorous accounting of age differences between cohorts, and primary review of all radiographic and clinical data to adjudicate events. Nevertheless, our results have several limitations. First, DCI rates in our cohort are significantly lower than registry rates, potentially due to the use intrathecal nicardipine.6 This low baseline DCI rate may reduce the power to detect small differences. Second, urine toxicology was not uniformly checked, with a sampling bias towards younger patients who were more likely to smoke. Furthermore, urine toxicology does not differentiate the acuity of ingestion, as metabolites can be detected days to weeks after last use.1 Finally, this is the experience of a single Southeastern center, limiting generalizability in terms of local patterns of clinical practice and cannabis use.Limited data suggest that like tobacco use, cannabis use may increase the incidence of aSAH.2 In contrast to tobacco use, however, the totality of data thus far argues against an association with aSAH complications and outcomes. Our data suggest that in terms of aSAH, ongoing efforts to assess the public health impact of increased cannabis use should be focused on managing the risk of incident hemorrhage rather than complications thereof.Article InformationSources of FundingNone.Supplemental MaterialSupplemental MethodsTables S1–S8Disclosures Dr Grossberg reports grants from Georgia Research Alliance; compensation from Cognition for consultant services; and grants from Emory Medical Care Foundation. The other authors report no conflicts.FootnotesSupplemental Material is available at https://www.ahajournals.org/doi/suppl/10.1161/STROKEAHA.122.038951.For Sources of Funding and Disclosures, see page e376.Correspondence to: Feras Akbik, MD, PhD, Neurocritical Care, Neurology, Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA 30322. Email feras.[email protected]comReferences1. Akbik F, Sadan O. Can marijuana use lead to cerebral ischemia?Stroke. 2022; 53:e44–e46. doi: 10.1161/STROKEAHA.121.037791LinkGoogle Scholar2. Rumalla K, Reddy AY, Mittal MK. Association of recreational marijuana use with aneurysmal subarachnoid hemorrhage.J Stroke Cerebrovasc Dis. 2016; 25:452–460. doi: 10.1016/j.jstrokecerebrovasdis.2015.10.019CrossrefMedlineGoogle Scholar3. Dandurand C, Ke JXC, Mekary RA, Prakash S, Redekop G, Gooderham P, Haw CS. Cannabis use and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide retrospective cohort study.J Clin Neurosci. 2020; 72:98–101. doi: 10.1016/j.jocn.2019.12.066CrossrefGoogle Scholar4. Behrouz R, Birnbaum L, Grandhi R, Johnson J, Misra V, Palacio S, Seifi A, Topel C, Garvin R, Caron JL. Cannabis use and outcomes in patients with aneurysmal subarachnoid hemorrhage.Stroke. 2016; 47:1371–1373. doi: 10.1161/STROKEAHA.116.013099LinkGoogle Scholar5. Catapano JS, Rumalla K, Srinivasan VM, Labib MA, Nguyen CL, Rutledge C, Rahmani R, Baranoski JF, Cole TS, Jadhav AP, et al. Cannabis use and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage.Stroke. 2022; 53:e42–e43. doi: 10.1161/STROKEAHA.121.035650LinkGoogle Scholar6. Sadan O, Waddel H, Moore R, Feng C, Mei Y, Pearce D, Kraft J, Pimentel C, Mathew S, Akbik F, et al. Does intrathecal nicardipine for cerebral vasospasm following subarachnoid hemorrhage correlate with reduced delayed cerebral ischemia? A retrospective propensity score-based analysis.J Neurosurg. 2021; 136:115–124. doi: 10.3171/2020.12.JNS203673Google Scholar Previous Back to top Next FiguresReferencesRelatedDetails August 2022Vol 53, Issue 8 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.122.038951PMID: 35730458 Originally publishedJune 22, 2022 Keywordsischemic strokepublic healthcannabishemorrhageaneurysmPDF download Advertisement SubjectsCerebral AneurysmCerebrovascular Disease/StrokeIntracranial Hemorrhage