PPROXIMATELY 30,000 people per year in the US suffer aneurysmal SAH. Most of these patients will undergo induction of general anesthesia followed by craniotomy and clip placement or endovascular coil embolization of their aneurysm. Electrocardiographic ab- normalities, regional or focal wall-motion abnormalities on echocardiograms, and/or increased levels of CK-MB have been observed in some patients with SAH. 2,12,15,29,30,41 These findings can raise concern about ongoing cardiac ischemia and may thus cause a delay in treatment. The pathophysiol- ogy of these changes is not well understood and, therefore, the operative risk to the patient is unknown. Although some of these patients have underlying CAD, many of these ab- normalities appear to be caused by sympathetic activation. 23 More recently, cTnI has been shown to be a more sensitive and specific marker for cardiac dysfunction in patients with SAH than CK-MB. 16,33 In this study, we prospectively evaluated cardiac function and enzyme levels to compare the sensitivity and specifici- ty of both cTnI and CK-MB in the prediction of left ventric- ular dysfunction in patients with nontraumatic SAH. In ad- dition, those patients in whom echocardiograms appeared abnormal and an elevated cTnI level was detected were fur- ther evaluated for CAD and to determine whether the left ventricular dysfunction was reversible. Clinical Material and Methods Patient Population Patients 18 years or older who were admitted to the neu- rology–neurosurgery ICU with nontraumatic SAH between January 1998 and August 2000 were eligible for enrollment in this study. Exclusion criteria included previously known cardiac disease such as MI, previous coronary artery bypass surgery, angina, previously abnormal cardiac catheteriza- tion, and abnormal findings on echocardiograms or EKGs. Patients with a recent history of dyspnea on exertion or ex- ertional chest pain were also excluded. This study was re- viewed and approved by the Washington University School of Medicine Human Studies Committee and each patient or surrogate gave informed consent. J. Neurosurg. / Volume 98 / April, 2003 J Neurosurg 98:741–746, 2003 Clinical significance of elevated troponin I levels in patients with nontraumatic subarachnoid hemorrhage ELLEN DEIBERT , M.D., BENICO BARZILAI, M.D., ALAN C. BRAVERMAN, M.D., DOROTHY F ARRAR EDWARDS, PH.D., VENKATESH AIYAGARI, M.D., RALPH DACEY , M.D., AND MICHAEL DIRINGER, M.D. Departments of Neurology, Cardiology, Neurosurgery, and Program in Occupational Therapy, Washington University School of Medicine, St. Louis, Missouri Object. Aneurysmal subarachnoid hemorrhage (SAH) is associated with electrocardiographic abnormalities, region- al or focal wall-motion abnormalities on echocardiograms, and/or increased creatine kinase MB isoenzyme (CK-MB) or cardiac troponin I (cTnI). The goal of this prospective study was to compare the sensitivity and specificity of cTnI with those of CK-MB in the prediction of left ventricular dysfunction on echocardiograms in patients with nontraumat- ic SAH. In addition, those patients with abnormal findings on their echocardiograms and elevated cTnI levels were fur- ther evaluated for the presence of coronary artery disease (CAD) by a cardiologist and to determine whether any left ventricular dysfunction that had been detected was reversible. Methods. The authors obtained electrocardiograms and echocardiograms, and measured serial levels of cardiac en- zymes (CK-MB and cTnI) in 43 patients with nontraumatic SAH. Patients with known CAD were excluded. Those patients found to have elevated enzyme levels and abnormal findings on their echocardiograms underwent additional evaluation for CAD. The sensitivity and specificity of both cTnI and CK-MB for detecting left ventricular function were determined. Twenty-eight percent of patients with SAH in the study had elevated cTnI levels within the first 24 hours after hem- orrhage. Seven of the 12 patients had evidence of left ventricular dysfunction on echocardiograms. In all these patients a return to baseline function was found during follow-up examinations. The authors found that cTnI is much more sen- sitive than CK-MB (100% compared with 29%) in the detection of left ventricular dysfunction in patients with SAH. Conclusions. An elevated level of cTnI is a good indicator of left ventricular dysfunction in patients with SAH. In this study cardiac dysfunction was reversible and should not necessarily preclude these patients from undergoing oper- ative interventions or becoming heart donors. Clinical management may require more aggressive hemodynamic mon- itoring until cardiac function returns to normal. KEY WORDS • troponin • subarachnoid hemorrhage • ventricular dysfunction A 741 Abbreviations used in this paper: CAD = coronary artery disease; CK-MB = creatine kinase MB isoenzyme; CT = computerized to- mography; cTnI = cardiac troponin I; EKG = electrocardiogram; ICH = intracerebral hemorrhage; ICU = intensive care unit; IVH = intraventricular hemorrhage; MI = myocardial infarction; SAH = subarachnoid hemorrhage.