Aneurysmal Subarachnoid Hemorrhage

Intracranial Pressure Monitoring in Poor-Grade Patients with Aneurysmal Subarachnoid Hemorrhage Treated by Coiling

OBJECTIVE

The main objective of the present study was to analyze the intracranial pressure (ICP) and cerebral perfusion pressure (CPP) changes during coiling. We also evaluated the prevalence of rebleeding and outcomes for patients monitored before and after coiling.

METHODS

Ninety-nine consecutive poor-grade patients with aneurysmal subarachnoid hemorrhage (aSAH; World Federation of Neurological Surgeons grade IV and V) were enrolled in our prospective observational study. For 31 patients, ICP and CPP monitoring was started immediately after the diagnosis of aSAH, and the values were recorded every 15 minutes during coiling (early ICP group). For 68 patients, ICP and CPP monitoring began after coiling (late ICP group). The outcomes were evaluated at 90 days using the modified Rankin scale.

RESULTS

At the beginning of coiling, the ICP was >20 mm Hg in 10 patients (35.7%). The median ICP was 18 mm Hg (range, 5-60 mm Hg). The CPP was <60 mm Hg in 6 patients (24%). The median CPP was 70 mm Hg (range, 30-101 mm Hg). Despite medical treatment and/or cerebrospinal fluid drainage, 51.6% of the patients monitored during coiling had at least one episode of intracranial hypertension (defined as ICP >20 mm Hg), and 51.6% had at least one episode of reduced CPP (defined as CPP <60 mm Hg). Early monitoring (before aneurysm repair) was not associated with rebleeding. At 90 days, the functional recovery was better in the early ICP group (P = 0.004).

CONCLUSIONS

During coiling, patients with poor-grade aSAH can experience episodes of intracranial hypertension and reduced CPP. Early and appropriate treatment of elevated ICP was not associated with rebleeding and might have improved the outcomes.

MicroRNAs as Biomarkers for Predicting Complications following Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a high mortality hemorrhagic stroke that affects nearly 30,000 patients annually in the United States. Approximately 30% of aSAH patients die during initial hospitalization and those who survive often carry poor prognosis with one in five having permanent physical and/or cognitive disabilities. The poor outcome of aSAH can be the result of the initial catastrophic event or due to the many acute or delayed neurological complications, such as cerebral ischemia, hydrocephalus, and re-bleeding. Unfortunately, no effective biomarker exists to predict or diagnose these complications at a clinically relevant time point when neurologic injury can be effectively treated and managed. Recently, a number of studies have demonstrated that microRNAs (miRNAs) in extracellular biofluids are highly associated with aSAH and complications. Here we provide an overview of the current research on relevant human studies examining the correlation between miRNAs and aSAH complications and discuss the potential application of using miRNAs as biomarkers in aSAH management.

Association Between Hospital Volumes and Clinical Outcomes for Patients With Nontraumatic Subarachnoid Hemorrhage

Background

Previous studies of patients with nontraumatic subarachnoid hemorrhage (SAH) suggest better outcomes at hospitals with higher case and procedural volumes, but the shape of the volume‐outcome curve has not been defined. We sought to establish minimum volume criteria for SAH and aneurysm obliteration procedures that could be used for comprehensive stroke center certification.

Methods and Results

Data from 8512 discharges in the National Inpatient Sample (NIS) from 2010 to 2011 were analyzed using logistic regression models to evaluate the association between clinical outcomes (in‐hospital mortality and the NIS‐SAH Outcome Measure [NIS‐SOM]) and measures of hospital annual case volume (nontraumatic SAH discharges, coiling, and clipping procedures). Sensitivity and specificity analyses for the association of desirable outcomes with different volume thresholds were performed. During 8512 SAH hospitalizations, 28.7% of cases underwent clipping and 20.1% underwent coiling with rates of 21.2% for in‐hospital mortality and 38.6% for poor outcome on the NIS‐SOM. The mean (range) of SAH, coiling, and clipping annual case volumes were 30.9 (1–195), 8.7 (0–94), and 6.1 (0–69), respectively. Logistic regression demonstrated improved outcomes with increasing annual case volumes of SAH discharges and procedures for aneurysm obliteration, with attenuation of the benefit beyond 35 SAH cases/year. Analysis of sensitivity and specificity using different volume thresholds confirmed these results. Analysis of previously proposed volume thresholds, including those utilized as minimum standards for comprehensive stroke center certification, showed that hospitals with more than 35 SAH cases annually had consistently superior outcomes compared with hospitals with fewer cases, although some hospitals below this threshold had similar outcomes. The adjusted odds ratio demonstrating lower risk of poor outcomes with SAH annual case volume ≥35 compared with 20 to 34 was 0.82 for the NIS‐SOM (95% CI, 0.71–094; P=0.0054) and 0.80 (95% CI, 0.68–0.93; P=0.0055) for in‐hospital mortality.

Conclusions

Outcomes for patients with SAH improve with increasing hospital case volumes and procedure volumes, with consistently better outcomes for hospitals with more than 35 SAH cases per year.

Dry Mouth Caused by Facial Nerve Ischemia due to Subarachnoid Hemorrhage: An Experimental Study

OBJECTIVE

Parasympathetic network damage results in facial nerve damage, sublingual ganglion degeneration, sublingual gland dysfunction, and dry mouth. In this study, subarachnoid hemorrhage (SAH) was considered to be the cause of dry mouth.

METHODS

We assessed 23 hybrid rabbits, including 5 control (group 1, Control). One milliliter of serum saline was injected into the cisterna magna of 5 animals (group 2). SAH was induced by injecting 1 mL of autologous blood into the cisterna magna of 13 animals (group 3). The animals were killed after 3 weeks of induction. The animals' sublingual ganglion and sublingual gland were excised for histopathological examination. The number of degenerated cells in the sublingual ganglion, secretory vesicles, and secretory granules in the sublingual gland that contain salivary components were estimated using Sequential Window Acquisition of All Theoretical Mass Spectra data analysis. The values were compared by the Mann-Whitney U-test.

RESULTS

The numbers of secretory vesicles in the sublingual gland were 5.3 ± 1.1 × 10³ (group 1), 4.23 ± 0.45 × 10³ (group 2), and 1.56 ± 0.22 × 10³ (group 3); the numbers of secretory vesicles containing saliva in the sublingual gland were 324 ± 12.18 (group 1), 263 ± 36.23 (group 2), and 114 ± 23.14 (group 3); and the numbers of degenerated cells in the sublingual ganglion were 11 ± 3/mm³ (group 1), 98.43 ± 15.54/mm³ (group 2), and 346 ± 12.28/mm³ (group 3) (P < 0.05).

CONCLUSIONS

Clinical findings in infection and diseases such as Sjögren syndrome, aseptic meningitis, and SAH are similar. However, until now, SAH has not been demonstrated experimentally to cause dry mouth. Discovering that SAH might cause dry mouth might prevent unnecessary use of antibiotics and decrease morbidity due to the wrong or late diagnosis.

Long-term survival outcomes and prognostic factors related to ruptured intracranial aneurysms: A comparison of surgical and endovascular options in a propensity score-matched, nationwide population-based cohort study

BACKGROUND AND PURPOSE

To determine the long-term survival outcomes of and prognostic factors for survival in patients with a ruptured intracranial aneurysm (RIA) who underwent endovascular coil embolization or surgical clipping.

METHODS

We selected patients who had received a diagnosis of RIA between January 1, 2011 and December 31, 2017. Propensity score matching was performed, and Cox proportional hazards model curves were plotted to analyze all-cause mortality in patients undergoing different treatments.

RESULTS

The matching process yielded a final cohort of 8102 patients (4051 and 4051 in endovascular coil embolization and surgical clipping groups, respectively) who were eligible for inclusion. In multivariate Cox regression analyses, the adjusted hazard ratio (aHR) and 95% confidence interval (CI) for endovascular coil embolization compared with surgical clipping were 0.87 (95% CI, 0.79-0.97). The aHRs for the ages of 65 to 74, 75 to 84, and ≥85 years compared with the ages of 20 to 64 years were 1.82 (95% CI, 1.60-2.07), 3.35 (95% CI, 2.93-3.84), and 6.99 (95% CI, 5.51-8.86), respectively. Surgical clipping; old age; male sex; treatment during 2011 to 2013; presence of diabetes, congestive heart failure, hypertension, chronic kidney disease, or end-stage renal disease; history of stroke or transient ischemic attack; Charlson Comorbidity Index ≥2; attendance of nonacademic hospitals; and low income were significant independent prognostic factors for poor survival.

CONCLUSIONS

Compared with surgical clipping, endovascular coil embolization led to more favorable survival outcomes in patients with RIAs.

Aneurysmal Subarachnoid Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series

Objective

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a pressing public health issue. Although most cases do not result in severe illness requiring hospitalization, there is increasing evidence that SARS-CoV-2–induced inflammation can exacerbate pre-existing diseases. We sought to describe the characteristics of patients with aneurysmal subarachnoid hemorrhage who were actively or very recently infected with SARS-CoV-2.

Methods

We reviewed subarachnoid hemorrhage cases of patients who also were positive for SARS-CoV-2 at 5 high-volume cerebrovascular centers in the United States from March 2020 to January 2021. Cases of aneurysmal subarachnoid hemorrhage were analyzed.

Results

A total of 10 patients were identified, consisting of 5 women (50%) and 5 men (50%). Median age was 38.5 years. Four of the 10 patients (40%) were asymptomatic with respect to SARS-CoV-2–related symptoms, 3 patients (30%) had mild-to-moderate symptoms, and 3 patients (30%) had severe coronavirus disease 2019 (COVID-19), with pneumonia and sepsis. Of the 10 cases, 4 had dissecting pseudoaneurysms (40%), 3 in the posterior circulation and 1 in the anterior circulation. Among 6 saccular/blister aneurysms, 4 (67%) were ≤4 mm in largest diameter.

Conclusions

Our experience with aneurysmal subarachnoid hemorrhage in patients positive for COVID-19 reveals a possibly distinct pattern compared with traditional aneurysmal subarachnoid hemorrhage, namely a high frequency of small aneurysms, dissecting pseudoaneurysms, and young patients.

Long non-coding RNAs mediate cerebral vascular pathologies after CNS injuries

Central nervous system (CNS) injuries are one of the leading causes of morbidity and mortality worldwide, accompanied with high medical costs and a decreased quality of life. Brain vascular disorders are involved in the pathological processes of CNS injuries and might play key roles for their recovery and prognosis. Recently, increasing evidence has shown that long non-coding RNAs (lncRNAs), which comprise a very heterogeneous group of non-protein-coding RNAs greater than 200 nucleotides, have emerged as functional mediators in the regulation of vascular homeostasis under pathophysiological conditions. Remarkably, lncRNAs can regulate gene transcription and translation, thus interfering with gene expression and signaling pathways by different mechanisms. Hence, a deeper insight into the function and regulatory mechanisms of lncRNAs following CNS injury, especially cerebrovascular-related lncRNAs, could help in establishing potential therapeutic strategies to improve or inhibit neurological disorders. In this review, we highlight recent advancements in understanding of the role of lncRNAs and their application in mediating cerebrovascular pathologies after CNS injury.

Circulating MicroRNAs as Potential Molecular Biomarkers for Intracranial Aneurysmal Rupture

INTRODUCTION

Diagnosis of the rupture of an intracranial aneurysm (IA) relies on sophisticated neuro-imaging studies, and molecular biomarkers to identify an IA or predict its rupture are still unavailable.

OBJECTIVE

Our objective was to determine the plasma microRNA (miRNA) expression profile in patients with ruptured IA presenting as aneurysmal subarachnoid hemorrhage (aSAH) and identify potential biomarkers of aneurysmal rupture.

METHODS

Plasma miRNA profiling was carried out using quantitative real-time polymerase chain reaction (qRT-PCR) in 20 patients with aSAH and 20 age- and sex-matched healthy controls. Eight differentially expressed miRNAs were validated by qPCR in a larger cohort of 88 patients with aSAH and 110 healthy controls. A receiver operating characteristic (ROC) curve was constructed to evaluate the overall performance of the miRNA-based assay. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analysis was used to determine the potential pathway of miRNA-target genes.

RESULTS

The miRNA profiles were clearly distinct in patients compared with controls. Validation studies showed that three upregulated miRNAs (miR-15a-5p, miR-34a-5p, miR-374a-5p) and five downregulated miRNAs (miR-146a-5p, miR-376c-3p, miR-18b-5p, miR-24-3p, miR-27b-3p) could distinguish patients with aSAH from healthy controls with high predicted probability (0.865 and 0.995, respectively). Further, the expression levels of the eight candidate miRNAs were significantly dysregulated only in aSAH cases and not in patients with SAH due to other causes. Plasma miR-146a-5p and miR-27b-3p were associated with clinical outcomes in patients with aSAH. Functional analysis of the eight differentially expressed miRNA showed that the target genes involved in signaling pathways were related to inflammation.

CONCLUSIONS

Our study determined the plasma miRNA signature of ruptured IAs and identified eight candidate miRNAs that could be useful biomarkers for this condition. We hypothesize that these differentially expressed miRNAs may play pivotal roles in IA pathology.

Enigma of what is Known about Intracranial Aneurysm Occlusion with Endovascular Devices

Aneurysmal subarachnoid Hemorrhage is a major cause of neurological morbidity and mortality. Over the years vascular neurosurgery has witnessed technological advances aimed to reduce the morbidity and mortality. Several endovascular devices have been used in clinical practice to achieve this goal in the management of ruptured and unruptured cerebral aneurysms. Recurrence due to recanalization is encountered in all of these endovascular devices as well as illustrated by Barrow Ruptured Aneurysm Trial. Histological and molecular characterization of the aneurysms treated with endovascular devices is an area of active animal and human research studies. Yet, the pathobiology illustrating the mechanisms of aneurysmal occlusion and healing lacks evidence. The enigma of aneurysmal healing following treatment with endovascular devices needs to be de-mystified to understand the biological interaction of endovascular device and aneurysm and thereby guide the future development of endovascular devices aimed at better aneurysm occlusion. We performed a comprehensive and detailed literature review to bring all the known facts of the pathobiology of intracranial aneurysm healing, the knowledge of which is of paramount importance to neurosurgeons, an interventional neuroradiologist, molecular biologist, geneticists, and experts in animal studies. This review serves as a benchmark of what is known and platform for future studies basic science research related to intracranial aneurysms.

Vascular Macrophages as Therapeutic Targets to Treat Intracranial Aneurysms

Aneurysmal subarachnoid hemorrhage (aSAH) is a highly fatal and morbid type of hemorrhagic strokes. Intracranial aneurysms (ICAs) rupture cause subarachnoid hemorrhage. ICAs formation, growth and rupture involves cellular and molecular inflammation. Macrophages orchestrate inflammation in the wall of ICAs. Macrophages generally polarize either into classical inflammatory (M1) or alternatively-activated anti-inflammatory (M2)-phenotype. Macrophage infiltration and polarization toward M1-phenotype increases the risk of aneurysm rupture. Strategies that deplete, inhibit infiltration, ameliorate macrophage inflammation or polarize to M2-type protect against ICAs rupture. However, clinical translational data is still lacking. This review summarizes the contribution of macrophage led inflammation in the aneurysm wall and discuss pharmacological strategies to modulate the macrophageal response during ICAs formation and rupture.

Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH.

METHODS

This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment.

RESULTS

A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay.

CONCLUSIONS

The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.

The physiopathology of spontaneous hemorrhagic stroke: a systematic review

Hemorrhagic stroke (HS) is a major cause of death and disability worldwide, despite being less common, it presents more aggressively and leads to more severe sequelae than ischemic stroke. There are two types of HS: Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH), differing not only in the site of bleeding, but also in the mechanisms responsible for acute and subacute symptoms. This is a systematic review of databases in search of works of the last five years relating to the comprehension of both kinds of HS. Sixty two articles composed the direct findings of the recent literature and were further characterized to construct the pathophysiology in the order of events. The road to the understanding of the spontaneous HS pathophysiology is far from complete. Our findings show specific and individual results relating to the natural history of the disease of ICH and SAH, presenting common and different risk factors, distinct and similar clinical manifestations at onset or later days to weeks, and possible complications for both.

Long-Term Independence in Older Patients with Aneurysmal Subarachnoid Hemorrhage in the Barrow Ruptured Aneurysm Trial

OBJECTIVE

Older patients have a higher risk for poor neurological outcomes following aneurysmal subarachnoid hemorrhage (aSAH). This study compared functional independence in older versus younger patients with aSAH and compared endovascular coiling with microsurgical clipping in the older cohort.

METHODS

Patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) with confirmed aSAH were analyzed. Patients were grouped by age: older (≥65 years old) or younger (<65 years old). The primary outcome analyzed was functional independence at long-term follow-up, defined as Barthel index >80 at 6-year follow-up. A second analysis was performed comparing functional independence in older patients treated with endovascular coiling versus microsurgical clipping.

RESULTS

Of 405 patients with aSAH enrolled in BRAT, 77 (19%) were ≥65 years old, and 328 (81%) were <65 years old. A lower percentage of older versus younger patients was functionally independent (Barthel index >80) at 6-year follow-up (42.0% [29/69] vs. 82.2% [217/264]; P < 0.001). A higher percentage of younger patients (69.7% [184/264]) had good neurological outcomes (modified Rankin Scale score <3) at 6-year follow-up compared with older patients (31.9% [22/69]; P < 0.001). A greater percentage of older patients treated with microsurgical clipping (51.0% [18/47]) versus endovascular coiling (22.7% [5/22]) had functional independence at 6-year follow-up (P < 0.04).

CONCLUSIONS

Patients ≥65 years old with aSAH are at increased risk for poor neurological outcomes compared with younger patients. Greater independence was observed in older patients after microsurgical clipping than after endovascular coiling at long-term follow-up.

Prognostic factors of delayed cerebral ischemia after subarachnoid hemorrhage including CT perfusion: a prospective cohort study

Background

Delayed cerebral ischemia (DCI) is the worst sequel following subarachnoid hemorrhage (SAH), representing a challenge in prediction and prevention. The current study aims to identify the optimum predictors of DCI including CT perfusion (CTP) and to determine the best prognostic thresholds.

This prospective study included 49 SAH patients. All patients were treated with the standard therapy and underwent non-contrast CT, CTP, and CTA within 3 days after SAH. Hunt and Hess and Fisher scales were assessed besides quantitative CTP parameters. The primary endpoint was DCI within 21 days after SAH, defined as clinical deterioration or infarction.

Results

Out of 49 eligible patients with SAH, 9 patients developed DCI. Univariate analysis revealed that Hunt and Hess scale, Fisher scale, the presence of a cerebral aneurysm, and mean transit time (MTT) were predictive for DCI. Diagnostic threshold values by ROC curve analysis with optimal sensitivity and specificity were Hunt and Hess scale > 2, Fisher scale > 2, and MTT of 4.65 s.

Conclusion

MTT is a sensitive and specific predictor of DCI. However, Hunt and Hess scale has the optimal sensitivity and specificity to distinguish between patients who developed DCI and clinically stable patients.

Failed Neuroprotection of Combined Inhibition of L-Type and ASIC1a Calcium Channels with Nimodipine and Amiloride

Effective pharmacological neuroprotection is one of the most desired aims in modern medicine. We postulated that a combination of two clinically used drugs-nimodipine (L-Type voltage-gated calcium channel blocker) and amiloride (acid-sensing ion channel inhibitor)-might act synergistically in an experimental model of ischaemia, targeting the intracellular rise in calcium as a pathway in neuronal cell death. We used organotypic hippocampal slices of mice pups and a well-established regimen of oxygen-glucose deprivation (OGD) to assess a possible neuroprotective effect. Neither nimodipine (at 10 or 20 µM) alone or in combination with amiloride (at 100 µM) showed any amelioration. Dissolved at 2.0 Vol.% dimethyl-sulfoxide (DMSO), the combination of both components even increased cell damage (p = 0.0001), an effect not observed with amiloride alone. We conclude that neither amiloride nor nimodipine do offer neuroprotection in an in vitro ischaemia model. On a technical note, the use of DMSO should be carefully evaluated in neuroprotective experiments, since it possibly alters cell damage.

Diagnostic and prognostic potential of circulating miRNAs for intracranial aneurysms

Intracranial aneurysm (IA) is an abnormal focal dilation of an artery in the brain that results from a weakening of the inner muscular layer of a blood vessel wall. IAs represent the most common etiology of nontraumatic subarachnoid hemorrhage (SAH). Despite technological advances in the treatment and use of new diagnostic methods for IAs, they continue to pose a significant risk of mortality and disability. Thus, early recognition of IA with a high risk of rupture is crucial for the stratification of patients with such a formidable disease. MicroRNAs (miRNA) are endogenous noncoding RNAs of 18-22 nucleotides that regulate gene expression at the post-transcriptional level through interaction with 3'-untranslated regions (3'UTRs) of the target mRNAs. MiRNAs are involved in the pathogenesis of IAs, including in the mechanisms of formation, growth, and rupture. It is known that in many biological fluids of the human body, such as blood or cerebrospinal fluid (CSF), numerous miRNAs, called circulating miRNAs, have been detected. The expression profile of circulating miRNAs represents a certain part of the cells in which they are modified and secreted in accordance with the physiological or pathological conditions of these cells. Circulating miRNAs can be secreted from cells into human biological fluids in extracellular vesicles or can be bound to Ago2 protein, which makes them resistant to the effects of RNAse. Therefore, circulating miRNAs are considered as new potential biomarkers of interest in many diseases, including IA.

Efficacy and safety of cilostazol-nimodipine combined therapy on delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a prospective, randomised, double-blinded, placebo-controlled trial protocol

INTRODUCTION

Delayed cerebral ischaemia (DCI) due to cerebral vasospasm (cVS) remains the foremost contributor to morbidity and mortality following aneurysmal subarachnoid haemorrhage (aSAH). Past efforts in preventing and treating DCI have failed to make any significant progress. To date, our most effective treatment involves the use of nimodipine, a calcium channel blocker. Recent studies have suggested that cilostazol, a platelet aggregation inhibitor, may prevent cVS. Thus far, no study has evaluated the effect of cilostazol plus nimodipine on the rate of DCI following aSAH.

METHODS AND ANALYSIS

This is a multicentre, double-blinded, randomised, placebo-controlled superiority trial investigating the effect of cilostazol on DCI. Data concerning rates of DCI, symptomatic and radiographic vasospasm, length of intensive care unit stay, and long-term functional and quality-of-life (QoL) outcomes will be recorded. All data will be collected with the aim of demonstrating that the use of cilostazol plus nimodipine will safely decrease the incidence of DCI, and decrease the rates of both radiographic and symptomatic vasospasm with subsequent improvement in long-term functional and QoL outcomes when compared with nimodipine alone.

ETHICS AND DISSEMINATION

Ethical approval was obtained from all participating hospitals by the Ascension Providence Hospital Institutional Review Board. The results of this study will be submitted for publication in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04148105.

Impact of Ruptured Aneurysm Circulation on Mortality: A Nationwide Inpatient Sample Analysis

OBJECTIVE

This study investigates the effect of aneurysm circulation on mortality and patient outcomes after aneurysmal subarachnoid hemorrhage (SAH) within the United States.

METHODS

A retrospective cohort study was conducted using the Nationwide Inpatient Sample (NIS), a part of the Healthcare Cost and Utilization Project (HCUP), with ICD-10 codes for non-traumatic SAH between 2015-2016. Aneurysms were stratified as either anterior or posterior circulation. Multivariate logistic regression was used to find the impact of selected variables on the odds of mortality.

RESULTS

The NIS reported 1,892 cases of non-traumatic SAH within the study period that were predominantly anterior circulation (82.6%), female (68.6%), white (57.7%), with mean age of 59.07 years, and in-hospital mortality of 21.4%. Anterior circulation aneurysms were associated with lower severity of initial illness (p = 0.014) but higher likelihood of vasospasm (p = 0.0006) than those of the posterior circulation. In a multivariate logistic regression analysis, mortality was associated with posterior circulation aneurysms (OR: 1.42; CI 95% 1.005-20.10, p = 0.047), increasing age (OR: 1.035; 95% CI 1.022-1.049; p < 0.0001), and shorter hospital stays (OR: 0.7838; 95% CI 0.758-0.811; p < 0.0001). Smoking history (OR: 0.825; 95% CI 0.573-1.187, p > 0.05) and vasospasm (OR: 1.005; 95% CI 0.648-1.558; p > 0.05) were not significantly associated with higher odds of mortality.

CONCLUSIONS

Mortality following aneurysmal SAH is associated with posterior circulation aneurysms, and increasing age, but not smoking history or vasospasm. These findings may be useful for prognostication and counseling patients and families.

Sex differences in aneurysmal subarachnoid haemorrhage (aSAH): aneurysm characteristics, neurological complications, and outcome

BACKGROUND

Women are over-represented in aSAH cohorts, but whether their outcomes differ to men remains unclear. We examined if sex differences in neurological complications and aneurysm characteristics contributed to aSAH outcomes.

METHODS

In a retrospective cohort (2010-2016) of all aSAH cases across two hospital networks in Australia, information on severity, aneurysm characteristics and neurological complications (rebleed before/after treatment, postoperative stroke < 48 h, neurological infections, hydrocephalus, seizures, delayed cerebral ischemia [DCI], cerebral infarction) were extracted. We estimated sex differences in (1) complications and aneurysm characteristics using chi square/t-tests and (2) outcome at discharge (home, rehabilitation or death) using multinomial regression with and without propensity score matching on prestroke confounders.

RESULTS

Among 577 cases (69% women, 84% treated) aneurysm size was greater in men than women and DCI more common in women than men. In unadjusted log multinomial regression, women had marginally greater discharge to rehabilitation (RRR 1.15 95% CI 0.90-1.48) and similar likelihood of in-hospital death (RRR 1.02 95% CI 0.76-1.36) versus discharge home. Prestroke confounders (age, hypertension, smoking status) explained greater risk of death in women (rehabilitation RRR 1.13 95% CI 0.87-1.48; death RRR 0.75 95% CI 0.51-1.10). Neurological complications (DCI and hydrocephalus) were covariates explaining some of the greater risk for poor outcomes in women (rehabilitation RRR 0.87 95% CI 0.69-1.11; death RRR 0.80 95% CI 0.52-1.23). Results were consistent in propensity score matched models.

CONCLUSION

The marginally poorer outcome in women at discharge was partially attributable to prestroke confounders and complications. Improvements in managing complications could improve outcomes.

The Role of Long Non-Coding RNAs in Intracranial Aneurysms and Subarachnoid Hemorrhage

Intracranial aneurysms (IAs) represent the most complex and relevant problem of modern neurology and neurosurgery. They serve as one of the main causes of non-traumatic subarachnoid hemorrhage (SAH), causing up to 85% of all cases of intracranial hemorrhage, which is associated with frequent disability and high mortality among patients. Unfortunately, the molecular mechanisms of the development and rupture of IAs are still under study. Long non-coding RNAs (lncRNAs) are non-coding RNAs that typically have a length of more than 200 nucleotides. It is known that lncRNAs regulate many processes, such as transcription, translation, cell differentiation, regulation of gene expression, and regulation of the cell cycle. In recent years, a lot of evidence has established their role in human diseases from oncology to cardiovascular disease. Recent studies have shown that lncRNAs may be involved in the pathogenesis of IAs. The study of lncRNAs and its targets in various pathological conditions of a person is a rapidly developing field, and it is likely that the knowledge obtained from these studies regarding the pathogenesis of intracranial aneurysms will have the potential to use lncRNAs in therapy, as well as in the diagnosis and prediction of high aneurysms risk of rupture.

Epidemiology of spontaneous subarachnoid hemorrhage in the state of Qatar

Background: Spontaneous subarachnoid hemorrhage (SAH) is one of the significant etiologies for stroke. SAH causes higher morbidity and mortality with loss of productivity, resulting in increased disease burden. Only few studies in Qatar have reported on SAH, and the epidemiological features of SAH and aneurysmal SAH (aSAH) have not been comprehensively studied before in Qatar. Our study aimed to describe the epidemiological profile of patients with SAH and aSAH in the State of Qatar.

Methods: We reviewed the medical records of all patients with SAH and/or ruptured aneurysm who were consecutively admitted to Hamad General Hospital (600-bed tertiary care facility) from January 1, 2007 to December 31, 2016. We performed a quantitative analysis of demographics, clinical characteristics, diagnostic findings, interventions, and overall mortality. We used SPSS version 18 for data entry. We used chi-square and student t tests to compare the groups. We considered p < 0.05 as statistically significant.

Results: The study included 323 patients with aneurysmal and non-aneurysmal SAH. The mean age at presentation was 47.4 ± 12.2 years. Men comprised 68.7% of the cases. Further, 86.6% of the patients presented with acute-onset headache. Additionally, 217 patients had 1 aneurysm, and 32 patients had multiple aneurysms. Anterior communicating artery aneurysm has been found to be the most common aneurysm. Non-aneurysmal SAH occurred in 74 patients (22.9%), with male predominance. Moreover, 23.7% and 52.6% of the patients underwent microsurgical clipping and coiling of the aneurysm, respectively. The overall mortality in World Federation of Neurosurgeon Score (WFNS) grades 1 and 2 SAH was lesser than that in higher grades (28.6% vs 71.4%). Of 323 patients, 69 died within 1 month post-ictus, accounting for an overall mortality rate of 21.2% in our study.

Conclusions: The annual incidence of aneurysmal SAH in Qatar has been increasing. Men had a higher incidence of aSAH. Internal carotid aneurysms have been found to be more common in Qatari women, which may have a genetic basis. Lower WFNS grades of aSAH have been associated with better prognosis. The overall mortality associated with aSAH in Qatar has declined over the last 3 years.

Posterior Reversible Encephalopathy Syndrome Caused by Induced Hypertension to Treat Cerebral Vasospasm Secondary to Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

The aim of the present study was to describe the case of a patient who had presented to a university hospital with induced-hypertension (IH) posterior reversible encephalopathy syndrome (PRES). We also reviewed all other reports of such patients.

METHODS

We have described the clinical course of a patient who had presented to the university hospital neurosurgical department. We also performed a systematic review of studies related to the incidence of PRES caused by the use of IH in the treatment of cerebral vasospasm after aneurysmal subarachnoid hemorrhage.

RESULTS

The patient had presented with an acute-onset headache and found to have a subarachnoid hemorrhage due to anterior communicating artery aneurysm rupture. She underwent coiling the next day. During the subsequent days, she demonstrated fluctuating clinical examination findings, aphasia, and decreased levels of arousal. Digital subtraction angiography was performed, and the findings were concerning for mild vasospasm of the anterior and middle cerebral arteries. The systolic blood pressure goal was increased to 180-220 mm Hg for an IH trial, which had initially resulted in some transient clinical improvements in her level of arousal. However, the improvement was not sustained. During the next 36 hours, the patient worsened, and she developed left middle cerebral artery syndrome. Given the concern for a possible ischemic event, magnetic resonance imaging was performed, which demonstrated interval development of multiple areas of cortical-based fluid-attenuated inversion recovery hyperintensity consistent with PRES. The systolic blood pressure goal was relaxed to normotension, and ~48 hours later, the patient's clinical status had significantly improved.

CONCLUSION

IH-PRES is a rare complication that should be remembered in the differential diagnosis for at-risk patients.

lncRNA Signature for Predicting Cerebral Vasospasm in Patients with SAH: Implications for Precision Neurosurgery

Subarachnoid hemorrhage (SAH) patients’ surgery is performed to prevent extravasation of blood into the subarachnoid space. Cerebral vasospasm (CVS; narrowing of cerebral arteries) occurs following SAH and represents a major cause of associated mortality and morbidity. To improve postsurgery care of SAH patients and their prognosis, the ability to predict CVS onset is critical. We report a long noncoding RNA (lncRNA) signature to distinguish SAH patients with CVS from SAH patients without CVS. Cerebrospinal fluid (CSF) was obtained from SAH patients without CVS (n = 10) and SAH patients with CVS (n = 10). lncRNAs ZFAS1 and MALAT1 were significantly upregulated (p < 0.05), whereas lncRNAs LINC00261 and LINC01619 were significantly downregulated in SAH patients with CVS (p < 0.05) compared to SAH patients without CVS. We applied this lncRNA signature to retrospectively predict CVS in SAH patients (n = 38 for SAH patients without CVS, and n = 27 for SAH patients with CVS). The 4-lncRNA signature was found to be predictive in >40% of samples and the 2-lncRNA comprising MALAT1 and LINC01619 accurately predicted CVS in ∼90% cases. These results are initial steps toward personalized management of SAH patients in clinics and provide novel CSF biomarkers that can substantially improve the clinical management of SAH patients.

The impact of statin therapy after surgical or endovascular treatment of cerebral aneurysms

OBJECTIVE

Cerebral aneurysms represent the most common cause of spontaneous subarachnoid hemorrhage. Statins are lipid-lowering agents that may expert multiple pleiotropic vascular protective effects. The authors hypothesized that statin therapy after coil embolization or surgical clipping of cerebral aneurysms might improve clinical outcomes.

METHODS

This was a retrospective cohort study using the National Health Insurance Service-National Sample Cohort Database in Korea. Patients who underwent coil embolization or surgical clipping for cerebral aneurysm between 2002 and 2013 were included. Based on prescription claims, the authors calculated the proportion of days covered (PDC) by statins during follow-up as a marker of statin therapy. The primary outcome was a composite of the development of stroke, myocardial infarction, and all-cause death. Multivariate time-dependent Cox regression analyses were performed.

RESULTS

A total of 1381 patients who underwent coil embolization (n = 542) or surgical clipping (n = 839) of cerebral aneurysms were included in this study. During the mean (± SD) follow-up period of 3.83 ± 3.35 years, 335 (24.3%) patients experienced the primary outcome. Adjustments were performed for sex, age (as a continuous variable), treatment modality, aneurysm rupture status (ruptured or unruptured aneurysm), hypertension, diabetes mellitus, household income level, and prior history of ischemic stroke or intracerebral hemorrhage as time-independent variables and statin therapy during follow-up as a time-dependent variable. Consistent statin therapy (PDC > 80%) was significantly associated with a lower risk of the primary outcome (adjusted hazard ratio 0.34, 95% CI 0.14-0.85).

CONCLUSIONS

Consistent statin therapy was significantly associated with better prognosis after coil embolization or surgical clipping of cerebral aneurysms.

Adenosine-induced transient asystole to control intraoperative rupture of intracranial aneurysms: institutional experience and systematic review of the literature

BACKGROUND

Intraoperative rupture of an intracranial aneurysm is a life-threatening situation that carries a high risk of morbidity and mortality. Since 2000, adenosine has been used successfully to induce transient hypotension and/or asystole to control bleeding and facilitate surgical clipping of aneurysms that rupture intraoperatively. Given the paucity of reports describing this method in a limited number of patients, we performed a systematic review of the literature detailing the use and outcomes of this technique.

METHODS

The authors performed a systematic review and identified all studies in which adenosine was used in the setting of an intracranial aneurysm that ruptured intraoperatively. We then determined overall morbidity and mortality rates, adding an additional six of our own patients.

RESULTS

Data was analyzed for a total of 29 patients, including 23 previously reported patients from the literature and 6 additional cases from our own experience (mean age 54.8 years, 58.6% female). Most patients (82.8%, 24/29) presented with subarachnoid hemorrhage (SAH). Overall mean dose of adenosine was 51.8 mg. Successful clipping was achieved in 100% of patients. Transient or permanent morbidity was reported in 5/29 (17.2%) and the overall mortality rate was 31% (9/29), which occurred primarily due to an initial severe SAH and its resultant complications.

CONCLUSIONS

Adenosine-induced circulatory arrest appears to safely control intraoperative bleeding and facilitate the clipping of ruptured intracranial aneurysms based on the limited published literature available. Further studies comparing patient outcomes using this technique to traditional approaches are required to validate the safety and efficacy of adenosine in this high-risk setting.

Clinical Prognosis for SAH Consistent with Redox Imbalance and Lipid Peroxidation

Subarachnoid hemorrhage (SAH) accounts for 3% of all strokes. As more and more data indicates the role of oxidative stress in acute brain damage caused by SAH, an attempt was made to correlate the clinical status of patients with systemic level of antioxidants and lipid peroxidation products. The hemorrhage was diagnosed with brain computed tomography (CT) and aneurysm with angio-CT and angiography, while the vasospasm was monitored with transcranial Doppler. Plasma glutathione peroxidase activity (GSH-Px) and vitamin A, E, and C levels were determined spectrophotometrically and by HPLC, respectively. The levels of polyunsaturated fatty acids (PUFAs) cyclization products were determined by GC–MS, while F₂-isoprostanes and neuroprostanes (NP) were determined by LC–MS. SAH was accompanied by changes in antioxidant capacity in blood plasma, including initially (day 1) an increase in GSH-Px activity, followed by its decrease and a progressive decrease in glutathione (GSH) levels and vitamins A, E, and C. On the other hand, levels of PUFAs cyclization products, F₂-isoprostanes, and neuroprostanes were highest on day 1 (two and eight times higher, respectively) and decreased over time. The levels of 4-HNE (4-hydroxynonenal), 4-ONE (4-oxononenal), and MDA (malondialdehyde) changed similarly. In contrast, the 4-HHE (4-hydroxyhexenal) level reduced after SAH increased significantly after a week. It was found that the deterioration of the overall clinical and neurological condition of SAH patients due to cerebral edema, intracranial hemorrhage, or vasoconstriction corresponded to reduced antioxidant defense and, as a consequence, increased lipid peroxidation and slower observed changes in regression. It can be concluded that monitoring the level of lipid peroxidation products (neuroprostanes, 4-ONE, and MDA) can support the monitoring of the clinical status of patients, especially with regard to the assessment of vasospasm.

The role of Toll-like receptor signaling pathways in cerebrovascular disorders: the impact of spreading depolarization

Cerebral vascular diseases (CVDs) are a group of disorders that affect the blood supply to the brain and lead to the reduction of oxygen and glucose supply to the neurons and the supporting cells. Spreading depolarization (SD), a propagating wave of neuroglial depolarization, occurs in different CVDs. A growing amount of evidence suggests that the inflammatory responses following hypoxic-ischemic insults and after SD plays a double-edged role in brain tissue injury and clinical outcome; a beneficial effect in the acute phase and a destructive role in the late phase. Toll-like receptors (TLRs) play a crucial role in the activation of inflammatory cascades and subsequent neuroprotective or harmful effects after CVDs and SD. Here, we review current data regarding the pathophysiological role of TLR signaling pathways in different CVDs and discuss the role of SD in the potentiation of the inflammatory cascade in CVDs through the modulation of TLRs.

The burden of headache following aneurysmal subarachnoid hemorrhage: a prospective single-center cross-sectional analysis

Background

Aneurysmal subarachnoid hemorrhage (SAH) as a serious type of stroke is frequently accompanied by a so-called initial thunderclap headache. However, the occurrence of burdensome long-term headache following SAH has never been studied in detail so far. The aim of this study was to determine the prevalence and characteristics of long-term burdensome headache in good-grade SAH patients as well as its relation to health-related quality of life (HR-QOL).

Methods

All SAH cases treated between January 2014 and December 2016 with preserved consciousness at hospital discharge were prospectively interviewed regarding burdensome headache in 2018. Study participants were subsequently scrutinized by means of a standardized postal survey comprising validated pain and HR-QOL questionnaires. A retrospective chart review provided data on the initial treatment.

Results

A total of 93 out of 145 eligible SAH patients participated in the study (62 females). A total of 41% (38/93) of subjects indicated burdensome headache at follow-up (mean 32.6 ± 9.3 months). Comparison between patients with (HA+) and without long-term headache (HA-) revealed significantly younger mean age (47.9 ± 11.8 vs. 55.6 ± 10.3 years; p < .01) as well as more favorable neurological conditions (WFNS I/II: 95% vs. 75%; p = .03) in HA+ cases. The mean average headache of the HA+ group was 3.7 ± 2.3 (10-point numeric rating scale), and the mean maximum headache intensity was 5.7 ± 2.9. Pain and HR-QOL scores demonstrated profound alterations in HA+ compared to HA- patients.

Conclusions

Our results suggest that a considerable proportion of SAH patients suffers from burdensome headache even years after the hemorrhage. Moreover, long-term headache is associated with reduced HR-QOL in these cases.

Electronic supplementary material

The online version of this article (10.1007/s00701-020-04235-7) contains supplementary material, which is available to authorized users.

Intracranial hypertension in patients with aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating and life-threatening condition with high mortality and morbidity. Even though there is an association with intracranial pressure (ICP) raise and aSAH, there is a lack of recommendations regarding the indications for ICP monitoring in patients with aSAH. Defining what patients are at a higher risk to develop intracranial hypertension and its role in the functional outcome and mortality in patients with aSAH will be the purpose of the following systematic review and meta-analysis. The primary endpoint is to determine the prevalence and impact on mortality of ICP in patients with aSAH. Secondary endpoints aim to describe the variables related to the development of ICP and the relationship between traumatic and aneurysmal etiology of intracranial hypertension. PubMed, Embase, Central Cochrane Registry of Controlled Trials, and research meeting abstracts were searched up to August 2019 for studies that performed ICP monitoring, assessed the prevalence of intracranial hypertension and the mortality, in adults. Newcastle Ottawa scale (NOS) was used to assess study quality. The statistical analysis was performed using the Mantel-Haenszel methodology for the prevalence and mortality of intracranial hypertension for reasons with a randomized effect analysis model. Heterogeneity was assessed by I². A total of 110 bibliographic citations were identified, 20 were considered potentially eligible, and after a review of the full text, 12 studies were considered eligible and 5 met the inclusion criteria for this review. One study obtained 7 points in the NOS, another obtained 6 points, and the rest obtained 5 points. Five studies were chosen for the final analysis, involving 793 patients. The rate of intracranial hypertension secondary to aSAH was 70.69% (95% CI 56.79-82.84%) showing high heterogeneity (I² = 92.48%, p = < 0.0001). The results of the meta-analysis of mortality rate associated with intracranial hypertension after aSAH found a total of four studies, which involved 385 patients. The mortality rate was 30.3% (95% CI: 14.79-48.57%). Heterogeneity was statistically significant (I² = 90.36%; p value for heterogeneity < 0.001). We found that in several studies, they reported that a high degree of clinical severity scale (Hunt and Hess or WNFS) and tomographic (Fisher) were significantly correlated with the increase in ICP above 20 mmHg (P < 0.05). The interpretation of the results could be underestimated for the design heterogeneity of the included studies. New protocols establishing the indications for ICP monitoring in aSAH are needed. Given the high heterogeneity of the studies included, we cannot provide clinical recommendations regarding this issue.

Effectiveness of intrathecal nicardipine on cerebral vasospasm in non-traumatic subarachnoid hemorrhage: a systematic review

OBJECTIVE

The objective of this review was to determine the effectiveness of intrathecal nicardipine compared to usual care on cerebral vasospasm and its impact on the following outcome measures: mean flow velocities, angiographic and/or clinical vasospasm, and infection rates.

INTRODUCTION

The results of non-traumatic (aneurysmal) subarachnoid hemorrhage can have devastating effects on patients in terms of functional outcomes. Although other medications have been and continue to be used, Nimodipine is the only Food and Drug Administration-approved medication for treating and improving outcomes following non-traumatic subarachnoid hemorrhage, which may be caused by aneurysmal rupture or arteriovenous malformation. Cerebral vasospasm after non-traumatic subarachnoid hemorrhage is a major concern; cerebral vasospasm refers to the narrowing of the cerebral vessels, which can lead to stroke. Delayed ischemic neurological deficit, as a result of cerebral vasospasm, is the number one reason for death and disability following subarachnoid hemorrhage. This review will determine the effects that intrathecal nicardipine has on cerebral vasospam following non-traumatic subarachnoid hemorrhage.

INCLUSION CRITERIA

The participants of this review included adult patients (18 years and over) in intensive care units. The patients must have had a subarachnoid hemorrhage without history of trauma as cause of subarachnoid hemorrhage, along with the presence of an external ventricular drain. The intervention was administration of intrathecal nicardipine in patients with cerebral vasospasm as a result of non-traumatic subarachnoid hemorrhage. The comparator was usual care, which does not include use of intrathecal nicardipine as part of the treatment regimen. The current review considered both experimental and quasi-experimental study designs. The primary outcomes measured included presence of cerebral vasospasm (identified by mean flow velocities measured by transcranial Doppler and the presence of angiographic vasospasm identified on angiogram) and clinical/symptomatic vasospasm. Secondarily, infection rates as a result of intrathecal nicardipine administration were evaluated.

METHODS

The search strategy aimed to find both published and unpublished studies. Seven databases were searched with no date limitations due to the limited amount of research on this topic.Two independent reviewers assessed the methodological validity of the papers prior to inclusion in the review using the standardized critical appraisal instruments from Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI).Quantitative data was extracted from included studies using the standardized data extraction tool from JBI SUMARI.Statistical pooling was not possible; therefore findings were presented in a narrative form.

RESULTS

Two studies examined the effect that intrathecal nicardipine has on cerebral vasospasm, clinical/symptomatic vasospasm and safety concerns (i.e. infection). The studies indicate that intrathecal nicardipine has shown potential benefits and safety in the treatment of cerebral vasospasm.

CONCLUSIONS

Although intrathecal nicardipine has shown potential to be effective in treating cerebral vasospasm, variance existed among those who received intrathecal nicardipine. In terms of safety, one study had no occurrences of associated bacterial meningitis and the other study had two reported cases of bacterial meningitis out of 50 among those who received intrathecal nicardipine. Limited studies on the use of intrathecal nicardipine following non-traumatic subarachnoid hemorrhage and lack of pooling of results for this review demonstrate the need for more research in this field.

Role of ATP-sensitive potassium channels and inflammatory response of basilar artery smooth muscle cells in subarachnoid hemorrhage of rabbit and immune-modulation by shikonin

OBJECTIVE

To investigate the role of inflammatory response, oxidative damage and changes of ATP-sensitive potassium channels (sK_ATP) in basilar artery (BA) smooth muscle cells (SMCS) of rabbits in subarachnoid hemorrhage (SAH) model.

METHODS

Time course studies on inflammatory response by real-time PCR, oxidative process and function of isolated basilar artery after SAH in New Zealand White rabbits were performed. Basilar artery smooth muscle cells (BASMCs) in each group were obtained and whole-cell patch-clamp technique was applied to record cell membrane capacitance and K_ATP currents. The morphologies of basal arteries were analyzed. Protective effect of shikonin were also determine by same parameters.

RESULTS

Inflammatory cytokines levels were highest at 24h compare to 72h after SAH whereas the oxidative damage and cell death marker were at highest peak at 72h. Oxidative damage peak coincided with significant alterations in cell membrane capacitance, K_ATP currents and morphological changes in basilar arteries. Shikokin pretreatment attenuated early inflammatory response at 24h and associated oxidative damage at 72h. Finally, shikonin attenuated morphological changes in basilar arteries and dysfunction.

CONCLUSION

Currents of ATP-sensitive potassium channels in basilar smooth muscle cells decreased after SAH by putative oxidative modification from immediate inflammatory response and can be protected by shikonin pretreatment.

Trends for in-hospital metrics in the treatment of intracranial aneurysms in Minas Gerais, Brazil

Background: Aneurysmal subarachnoid hemorrhage (ASAH) and unruptured aneurysm (URA) are particularly important because of the high mortality rates, and physical and cognitive impairment, which affect the economically active population. The present work aims at describing the scenario regarding in-hospital indicators related to the following therapeutic approaches: vascular microsurgery (VMS) and endovascular therapy (EVT) in the state of Minas Gerais, Brazil, in order to gather information to construct hypotheses and plan actions. Methods: The study has an ecological design and it is also analytical for the time trends of 2008-2014. Trends for VMS and EVT therapies and mortality are estimated using linear regression, followed by the Prais-Winsten procedure. Data were obtained through Hospital Information System (Sistema de Informações Hospitalares - SIH) of Brazilian Public Health System (Sistema Único de Saúde - SUS). Results: In 2014, 601 procedures were performed, and out of these, 373 (62%) were triggered by SAH and 228 (38%) by URA. The frequency of procedures performed in males and in females results in a ratio of 1:2 for SAH procedures and 1:3 for URA procedures. A heterogeneous distribution of therapeutic approaches was seen among the hospital studied, suggesting a technological preference, which determines the therapeutic approach. Conclusion: Technological bias was observed for aneurysm treatment in Minas Gerais's hospitals. EVT is seen to have a growing trend to detriment of VMS (β₁ = 0.024; p = 0.025), with a stable mortality for both therapeutics in both pathologies (SAH and URA). EVT has been associated with a shorter hospital stay, with higher expenses for both ASAH and URA treatment. EVT showed an inverse correlation with in-hospital fatality for ASAH treatment.

Prognostic significance of factor XIIIA promoter methylation status in aneurysmal subarachnoid haemorrhage (aSAH)

BACKGROUND

Aneurysmal subarachnoid hemorrhage is a life- threatening condition with high rate of disability and mortality. Apolipoprotein E (APOE) and Factor XIIIA (F13A) genes are involved in the pathogenetic mechanism of aneurysmal subarachnoid haemorrhage (aSAH). We evaluated the association of promoter methylation status of APOE and F13A gene and risk of aSAH.

METHODS

For evaluating the effect of hypermethylation in the promoter region of these genes with risk of aSAH, we conducted a case -control study with 50 aSAH patients and 50 healthy control. The methylation pattern was analysed using methylation specific PCR. The risk factors associated with poor outcome after aSAH was also analysed in this study. The outcome was assessed using Glasgow outcome score (GOS) after 3 months from the initial bleed.

RESULTS

The frequency of APOE and F13A methylation pattern showed insignificant association with risk of aSAH in this study. Gender stratification analysis suggests that F13A promoter methylation status was significantly associated with the risk of aSAH in male gender. Age, aneurysm located at the anterior communicating artery and diabetes mellitus showed significant association with poor outcome after aSAH.

CONCLUSION

There was no significant association with APOE promoter methylation with the risk as well as outcome of patients after aSAH. F13A promoter methylation status was significantly associated with risk of aSAH in male gender, with no significant association with outcome after aSAH.

An Investigation Into the Challenges of Using Metal Additive Manufacturing for the Production of Patient-Specific Aneurysm Clips

Cerebral aneurysm clips are biomedical implants applied by neurosurgeons to re-approximate arterial vessel walls and prevent catastrophic aneurysmal hemorrhages in patients. Current methods of aneurysm clip production are labor intensive and time-consuming, leading to high costs per implant and limited variability in clip morphology. Metal additive manufacturing is investigated as an alternative to traditional manufacturing methods that may enable production of patient-specific aneurysm clips to account for variations in individual vascular anatomy and possibly reduce surgical complication risks. Relevant challenges to metal additive manufacturing are investigated for biomedical implants, including material choice, design limitations, postprocessing, printed material properties, and combined production methods. Initial experiments with additive manufacturing of 316 L stainless steel aneurysm clips are carried out on a selective laser melting (SLM) system. The dimensions of the printed clips were found to be within 0.5% of the dimensions of the designed clips. Hardness and density of the printed clips (213 ± 7 HV1 and 7.9 g/cc, respectively) were very close to reported values for 316 L stainless steel, as expected. No ferrite and minimal porosity is observed in a cross section of a printed clip, with some anisotropy in the grain orientation. A clamping force of approximately 1 N is measured with a clip separation of 1.5 mm. Metal additive manufacturing shows promise for use in the creation of custom aneurysm clips, but some of the challenges discussed will need to be addressed before clinical use is possible.

Association between Circle of Willis Configuration and Rupture of Cerebral Aneurysms

Background and Objectives: Intracranial hemorrhage caused by the rupture of brain aneurysms occurs in almost 10 per 100,000 people whereas the incidence of such aneurysms is significantly higher, accounting for 4–9%. Linking certain factors to cerebral aneurysm rupture could help in explaining the significantly lower incidence of their rupture compared to their presence. The aim of this study is to determine the association between the corresponding circle of Willis configurations and rupture of cerebral aneurysms. Materials and Methods: A group of 114 patients treated operatively for aruptured cerebral aneurysm and a group of 56 autopsied subjects were involved in the study. Four basic types of the circle of Willis configurations were formed—two symmetric types A and C, and two asymmetric types B and D. Results: A statistically significantly higher presence of asymmetry of the circle of Willis was determined in the group of surgically-treated subjects (p = 0.001),witha significant presence of asymmetric Type B in this group (p < 0.001). The changeson the A1 segment in the group of surgically-treated subjects showed a statistically significant presence compared to the group of autopsied subjects (p = 0.001). Analyzing the presence of symmetry of the circle of Willis between the two groups, that is, the total presence of symmetric types A and C, indicated their statistically significant presence in the group of autopsied patients (p < 0.001). Conclusions: Changes such as hypoplasia or aplasia of A1 and the resulting asymmetry of the circle of Willis directly affect the possibility of the rupture of cerebral aneurysms. Detection of the corresponding types of the circle of Willis after diagnostic examination can be the basis for the development of a protocol for monitoring such patients.

Reconstrucción endovascular de aneurisma intracraneal mediante dispositivo diversor de flujo Pipeline®

El tratamiento endovascular para aneurismas intracraneales ha evolucionado sustancialmente en las últimas dos décadas, convirtiéndose en el tratamiento de elección en diversas situaciones clínicas. En el presente caso, el paciente fue tratado mediante un procedimiento de mínima invasión, con resultados satisfactorios y reducción en la estancia intrahospitalaria y recuperación, con alto grado de seguridad

Subarachnoid Hemorrhage in Hospitalized Renal Transplant Recipients with Autosomal Dominant Polycystic Kidney Disease: A Nationwide Analysis

BACKGROUND

This study aimed to evaluate the hospitalization rates for subarachnoid hemorrhage (SAH) among renal transplant patients with adult polycystic kidney disease (ADPKD) and its outcomes, when compared to non-ADPKD renal transplant patients.

METHODS

The 2005-2014 National Inpatient Sample databases were used to identify all hospitalized renal transplant patients. The inpatient prevalence of SAH as a discharge diagnosis between ADPKD and non-ADPKD renal transplant patients was compared. Among SAH patients, the in-hospital mortality, use of aneurysm clipping, hospital length of stay, total hospitalization cost and charges between ADPKD and non-ADPKD patients were compared, adjusting for potential confounders.

RESULTS

The inpatient prevalence of SAH in ADPKD was 3.8/1000 admissions, compared to 0.9/1000 admissions in non-ADPKD patients (p < 0.01). Of 833 renal transplant patients with a diagnosis of SAH, 30 had ADPKD. Five (17%) ADPKD renal patients with SAH died in hospitals compared to 188 (23.4%) non-ADPKD renal patients (p = 0.70). In adjusted analysis, there was no statistically significant difference in mortality, use of aneurysm clipping, hospital length of stay, or total hospitalization costs and charges between ADPKD and non-ADPKD patients with SAH.

CONCLUSION

Renal transplant patients with ADPKD had a 4-fold higher inpatient prevalence of SAH than those without ADPKD. Further studies are needed to compare the incidence of overall admissions in ADPKD and non-ADPKD patients. When renal transplant patients developed SAH, inpatient mortality rates were high regardless of ADPKD status. The outcomes, as well as resource utilization, were comparable between the two groups.

Endovascular Coiling Versus Neurosurgical Clipping for Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis

Background Aneurysmal subarachnoid hemorrhage is a frequently devastating condition with a reported incidence of between 10 and 15 people per 100,000 in the United States. Currently, according to the best of our knowledge, there are not enough meta-analyses available in the medical literature of the last five years which compare the risks and benefits of endovascular coiling with neurosurgical clipping. Methods Twenty-two studies were selected out of the short-listed studies. The studies were selected on the basis of relevance to the topic, sample size, sampling technique, and randomization. Data were analyzed on Revman software. Results Mortality was found to be significantly higher in the endovascular coiling group (odds ratio (OR): 1.17; confidence interval (CI): 95%, 1.04, 1.32). Re-bleeding was significantly higher in endovascular coiling (OR: 2.87; CI: 95%, 1.67, 4.93). Post-procedure complications were significantly higher in neurosurgical clipping compared to endovascular coiling (OR: 0.36; CI: 95%, 0.24, 0.56). Neurosurgical clipping was a 3.82 times better surgical technique in terms of re-bleeding (Z = 3.82, p = 0.0001). Neurosurgical clipping is a better technique requiring fewer re-treatments compared to endovascular coiling (OR: 4.64; CI: 95%, 2.31, 9.29). Endovascular coiling was found to be a better technique as it requires less rehabilitation compared to neurosurgical clipping (OR: 0.75; CI: 95%, 0.64,0.87). Conclusion Neurosurgical clipping provides better results in terms of mortality, re-bleeding, and re-treatments. Endovascular coiling is a better surgical technique in terms of post-operative complications, favorable outcomes, and rehabilitation.

Unexplained paraparesis following subarachnoid haemorrhage

Spinal arachnoid cysts (SAC) are rare in isolation and the exact aetiology is still debated. Primary (congenital) cysts are caused by structural abnormalities in the arachnoid layer and largely affect the thoracic region. Secondary cysts are induced by a multitude of factors, infection, trauma or iatrogenic response, and can affect any level of the spinal cord. While subarachnoid haemorrhage (SAH) is a relatively common condition with significant repercussions, it is extremely uncommonly associated with SAC. When present, it may develop in the months and years after the original bleed, giving rise to new neurological symptoms. Prompt treatment is needed to halt or reverse the worsening of symptoms and questions are still being asked about how best to approach this condition. A 42-year-old man presented with chronic back pain, severe worsening ataxia and numbness below the umbilicus, 7 months after treatment for a World Federation of Neurosurgical Societies grade five (WFNS V) SAH. Imaging revealed a SAC extending from T12 to L4 and causing thecal compression. This was treated with a L3 laminectomy andmarsupialisation. An improvement in neurological function was observed at 6 months. Aetiology of the SAC and its association with SAH are discussed and a review of the relevant literature is provided.

Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) is associated with a mortality of more than 30%. Only about 30% of patients with SAB recover sufficiently to return to independent living.

METHODS

This article is based on a selective review of pertinent literature retrieved by a PubMed search.

RESULTS

Acute, severe headache, typically described as the worst headache of the patient's life, and meningismus are the characteristic manifestations of SAH. Computed tomog raphy (CT) reveals blood in the basal cisterns in the first 12 hours after SAH with approximately 95% sensitivity and specificity. If no blood is seen on CT, a lumbar puncture must be performed to confirm or rule out the diagnosis of SAH. All patients need intensive care so that rebleeding can be avoided and the sequelae of the initial bleed can be minimized. The immediate transfer of patients with acute SAH to a specialized center is crucially important for their outcome. In such centers, cerebral aneurysms can be excluded from the circulation either with an interventional endovascular procedure (coiling) or by microneurosurgery (clipping).

CONCLUSION

SAH is a life-threatening condition that requires immediate diagnosis, transfer to a neurovascular center, and treatment without delay.

Laboratory biomarkers of delayed cerebral ischemia after subarachnoid hemorrhage: a systematic review

Delayed cerebral ischemia (DCI) is a severe complication of subarachnoid hemorrhage (SAH). Clinical and radiographic features of SAH may be helpful in identification of individuals prone to DCI. The aim of this systematic review was to analyze the present evidence on predictive value of blood and cerebrospinal fluid (CSF) biomarkers of DCI after SAH. We systematically searched in PubMed, Scopus, Web of Science, and Cochrane Library databases for publications before July 15, 2018, reporting correlations between blood/CSF biomarkers and occurrence of DCI and/or vasospasm in SAH patients. Included studies underwent quality assessment according to QUIPS and STARD guidelines. Level of evidence (I-IV) for each of tested biomarkers was assessed according to GRADE guidelines. Of 2181 unique records identified in four databases, 270 original articles and 5 meta-analyses were included to this review. Of 257 blood and CSF parameters analyzed in 16.914 SAH patients, there was no biomarker with positive association with DCI/vasospasm showing level I evidence. Twenty-one biomarkers achieved level II evidence and could be confirmed as predictive biomarkers. In this review, six single nucleotide polymorphisms (for EET metabolic pathways, COMT, HMGB1, ACE, PAI-1 promoter, and Hp genes) and 15 non-genetic biomarkers (pNF-H, ADAMTS13, NPY, Copeptin, HMGB1, GFAP, periostin, Tau, BNP, NT pro-BNP, hs-TnT, PA-TEGMA, MPV:PLT, NLR, and PLR) were selected as predictive DCI biomarkers. We propose that a panel analysis of the selected genetic and protein biomarker candidates would be needed for further validation in a large SAH cohort.

Evaluation of alpha-II-spectrin breakdown products as potential biomarkers for early recognition and severity of aneurysmal subarachnoid hemorrhage

This study assessed whether cytoskeletal protein alpha-II spectrin breakdown products (SBDP150, SBDP145, and SBDP120) would identify the presence of aSAH and be associated with severity (GCS score, WFNS grade and survival to hospital discharge). This prospective case-control study, conducted at a tertiary care Level I trauma center, enrolled adult patients with angiography confirmed aSAH who underwent ventriculostomy placement for cerebrospinal fluid (CSF) drainage. There were 40 patients enrolled in the study, 20 with aSAH and 20 control subjects. Patients with aSAH were a mean age of 54 (SD15) and 75% were female. There were significant differences in SBDP150, SBDP145, and SBDP120 CSF levels between patients with and without aSAH (p < 0.001), even in those presenting with a GCS Score of 15 and a WFNS Grade 1. The AUC for distinguishing aSAH from control subjects was 1.0 for SBDP150 and SBDP145, and 0.95 for SBDP120. SBDP150 and SBDP145 both yielded sensitivities and specificities of 100% and SBDP120 was 90% and 100% respectively. Moreover, there were significantly higher levels of SBDP150 and SBDP145 in the non-survivors than in the survivors (p < 0.001). This study demonstrates the potential that SBDP’s have as biomarkers for recognition and severity of aSAH. A larger prospective study is warranted.

Management of raised intracranial pressure in aneurysmal subarachnoid hemorrhage: time for a consensus?

Elevated intracranial pressure (ICP) is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Despite significant advances in clinical research into aSAH, there are no consensus guidelines devoted specifically to the management of elevated ICP in the setting of aSAH. To treat high ICP in aSAH, most centers extrapolate their treatment algorithms from studies and published guidelines for traumatic brain injury. Herein, the authors review the current management strategies for treating raised ICP within the aSAH population, emphasize key differences from the traumatic brain injury population, and highlight potential directions for future research in this controversial topic.