Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association

The relationship between intraoperative surrogates of vascular stiffness, cerebral aneurysms, and surgical outcomes

OBJECTIVE

Increased arterial stiffness has been linked to aneurysm formation in the systemic and cerebral circulations, though the role played by arterial stiffness in the cerebral vasculature continues to be refined. This study assesses whether intraoperative surrogates of arterial stiffness differ between patients with cerebral aneurysms and controls, and the extend that these indices relate to outcomes following open surgical treatment.

METHODS

We evaluated patients in a prospectively maintained database who underwent cerebral aneurysm surgery, and compared them to controls without cerebral aneurysms. Arterial stiffness was estimated using the intraoperative ambulatory arterial stiffness index (AASI) and average pulse pressure (PP).

RESULTS

We analyzed 214 cerebral aneurysm patients and 234 controls. Patients in the aneurysm group were predominantly female and had a higher incidence of hypertension, diabetes mellitus, and vascular disease. They also demonstrate elevated AASI and average PP. When stratified by the occurrence of subarachnoid hemorrhage (SAH) or unfavorable neurological outcome, the AASI and average PP were not highly associated with the occurrence of SAH but were highly associated with unfavorable neurological outcomes. After multivariable analysis, both the AASI and average PP were no longer associated with unfavorable neurological outcomes, however elevated age, strongly linked with arterial stiffness, became a key predictive variable.

CONCLUSION

Readily obtained intraoperative surrogates of arterial stiffening demonstrates its presence in those with cerebral aneurysm disease and the extent that it does it may meaningfully direct their clinical course. However, multivariable analysis demonstrates limitations of using arterial stiffness measures to predict clinical outcomes.

Admission albumin-globulin ratio associated with delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage

Background

Despite the widespread use in ischemic stroke, cancer, and malnutrition, the predictive ability of serum albumin to globulin ratio (A/G) among patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. This study aimed to determine if serum A/G ratio is associated with the occurrence of delayed cerebral ischemia (DCI) after aSAH.

Methods

We retrospectively viewed the medical records of aSAH patients from 08/2017 to 08/2022. Serum albumin and globulin laboratory test results were collected within 24 hours after admission. Serum A/G were dichotomized based on whether the DCI occurred. Logistic regression was used to determine the predictors of DCI. The relationship between serum A/G and the occurrence of DCI was analyzed with receiver operating characteristic(ROC) curve.

Results

A total of 363 eligible patients with aSAH were included in the study, among which DCI occurred in 87 patients(23.97%). Serum A/G[OR=2.720, 95%CI (1.190-6.270), P=0.018], non-surgical[OR=0.228, 95%CI (0.065-0.621), P=0.008], lactate dehydrogenase[OR=1.004, 95%CI (1.000-1.008), P=0.029], P[OR=0.354, 95%CI (0.130-0.926), P=0.038], plasma fibrinogen[OR=1.266, 95%CI (1.019-1.583), P=0.035] were associated with the occurrence of DCI. ROC showed that serum A/G, non-surgical, LDH, P, plasma fibrinogen could predict the occurrence of DCI in aSAH patients with values 0.575, 0.560, 0.602, 0.571 and 0.539 for serum A/G, non-surgical, LDH, P, plasma fibrinogen, respectively.

Conclusions

In conclusion, serum A/G levels are correlated with DCI in individuals with aSAH, and high serum A/G levels on admission may be associated with the occurrence of DCI.

Cerebrolysin in Patients Diagnosed with Subarachnoid Hemorrhage-The Results of an Observational Cohort Study

Background: Subarachnoid hemorrhage (SAH) is associated with high mortality and a high level of disability. Progress in surgical and endovascular techniques has lowered the mortality rate in patients with SAH. However, many patients are left with neurological impairment. Objectives: In our study we wanted to examine the impact of Cerebrolysin on treatment results in patients with SAH diagnosis. Methods: The data of 47 patients, divided into Cerebrolysin (26) and non-Cerebrolysin (21) group were included. We examined the correlation between Cerebrolysin administration and additional Amantadine treatment or neuromonitoring, craniectomy, and endovascular treatment and its impact on the Glasgow Outcome Scale (GOS) score, length of stay (LOS), and mortality. Results: Our study shows that Cerebrolysin improves the mortality rate in combination with neuromonitoring in a group of patients with severe SAH. It does not affect the raw values of GOS or LOS in patients with SAH. Conclusions: Further studies with larger patient groups are needed to investigate the role of Cerebrolysin as an additional treatment in SAH.

Role of clipping in aneurysmal subarachnoid hemorrhage: a post hoc analysis of the Earlydrain trial

The choice between clipping and coiling of ruptured cerebral aneurysms in subarachnoid hemorrhage (SAH) remains controversial. The recently published Earlydrain trial provides the opportunity to analyze the latest clip-to-coil ratio in German-speaking countries and to evaluate vasospasm incidence and explorative outcome measures in both treatment modalities. We performed a post hoc analysis of the Earlydrain trial, a multicenter randomized controlled trial investigating the use of an additional lumbar drain in aneurysmal SAH. The decision whether to clip or to coil the ruptured aneurysm was left to the discretion of the participating centers, providing a real-world insight into current aneurysm treatment strategies. Earlydrain was performed in 19 centers in Germany, Switzerland, and Canada, recruiting 287 patients with aneurysmal SAH of all severity grades. Of these, 140 patients (49%) received clipping and 147 patients (51%) coiling. Age and clinical severity based on Hunt-Hess/WFNS grades and radiological criteria were similar. Clipping was more frequently used for anterior circulation aneurysms (55%), whereas posterior circulation aneurysms were mostly coiled (86%, p < 0.001). In high-volume recruiting centers, 56% of patients were treated with clipping, compared to 38% in other centers. A per-year analysis showed a stable and balanced clipping/coiling ratio over time. Regarding vasospasm, 60% of clipped versus 43% of coiled patients showed elevated transcranial Doppler criteria (p = 0.007), reflected in angiographic vasospasm rates (51% vs. 38%, p = 0.03). In contrast to the Earlydrain main results establishing the superiority of an additional lumbar drain, explorative outcomes after clipping and coiling measured by secondary infarctions, mortality, modified Rankin Score, Glasgow Outcome Scale Extended, or Barthel-Index showed no significant differences after discharge and at six months. In clinical practice, aneurysm clipping is still a frequently used method in aneurysmal SAH. Apart from a higher rate of vasospasm in the clipping group, an exploratory outcome analysis showed no difference between the two treatment methods. Further development of periprocedural treatment modalities for clipped ruptured aneurysms to reduce vasospasm is warranted.

Can the radiomics features of intracranial aneurysms predict the prognosis of aneurysmal subarachnoid hemorrhage?

Objectives

This study attempted to determine potential predictors among radiomics features for poor prognosis in aneurysmal subarachnoid hemorrhage (aSAH), develop models for prediction, and verify their predictive power.

Methods

In total, 252 patients with aSAH were included in this study and categorized into favorable and poor outcome groups based on the modified Rankin Scale score 3 months after event. Radiomics features of the ruptured intracranial aneurysm extracted from computed tomography angiography images were selected using least absolute shrinkage and selection operator regression and 10-fold cross-validation. A radiomics score was created by selecting the optimal features. Other risk factors for a poor prognosis were screened using multivariate regression analysis. Three models (clinical, aneurysm, and clinical-aneurysm combined models) were developed. The performance of the models was assessed using receiver operating characteristic (ROC) curves. A clinical-aneurysm combined nomogram was constructed to forecast the risk of poor prognosis in patients with aSAH.

Results

A total of three clinical variables and six radiomics features were shown to have a significant association with poor prognosis in patients with aSAH. In the training cohort, the clinical, aneurysm, and clinical-aneurysm combined models had areas under the ROC curves of 0.846, 0.762, and 0.893, respectively. In the testing cohort, these models had areas under the ROC curves of 0.848, 0.753, and 0.869, respectively.

Conclusion

The radiomics characteristics of ruptured intracranial aneurysms are valuable to predict prognosis after aSAH. The clinical-aneurysm combined model exhibited the best among the three models. The clinical-aneurysm combined nomogram is a reliable and effective tool for predicting poor prognosis in patients with aSAH.

Treatment of Cerebral Vasospasm after Aneurysmal Subarachnoid Hemorrhage Using the Compliant Manually Adjustable Mesh Comaneci

Background and purpose: Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Compliant and noncompliant balloons and manually adjustable mesh may be used in this indication. We describe our initial experience with the Comaneci (Rapid Medical, Yokneam, Israel) in cerebral vasospasm treatment following aSAH. Methods: All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Comaneci device for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details, and outcomes were obtained from electronic medical records. Results: Between February 2022 and June 2023, seven consecutive patients underwent CV treatment with the Comaneci. Angioplasty of 37 arterial segments (supraclinoid internal carotid artery, A1, A2, and A3 segments of the anterior cerebral artery and M1 and M2 segments of the middle cerebral artery) was attempted, and 35/37 (95%) were performed. The vessel diameter improved significantly following angioplasty (+64%), while brain hypoperfusion decreased (-45% of the mean T Max). There was no long-term clinical complication, and 6% per-procedural complications occurred. Conclusions: The Comaneci is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device in the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Guideline-recommended basic parameter adherence in neurocritical care stroke patients: Observational multicenter individual participant data analysis

INTRODUCTION

Neurocritical care patients with neurovascular disease often face poor long-term outcomes, highlighting the pivotal role of evidence-based interventions. Although International Guidelines emphasize managing basic physiological parameters like temperature, blood glucose, blood pressure, and oxygen levels, physician adherence to these targets remains uncertain. This study aimed to assess adherence to guideline-based treatment targets for basic physiological parameters in neurocritical care.

PATIENTS AND METHODS

This multicenter observational study was conducted across eight tertiary University Hospitals in Germany analyzed 474 patients requiring mechanical ventilation (between January 1st and December 31st, 2021). Adherence was defined as the rate of measurements within therapeutic ranges for systolic blood pressure (situation-adapted), mean blood pressure (MAP, 60-90 mmHg), glucose levels (80-180 mg/dl), body temperature (<37.5°C), partial arterial pressure of oxygen (PaO2) 80-120 mmHg und partial arterial pressure of carbon dioxide (PaCO2) 35-45 mmHg during the initial 96 h of hospitalization in 4 hour-intervals.

RESULTS

Overall, 70.7% of all measurements were within the predetermined therapeutic ranges including SBP (71.3%), temperature (68.3%), MAP (71.4%), PaO2 (65.2%), PaCO2 (75.0%) and blood glucose (80.7%).

DISCUSSION AND CONCLUSION

This multicenter study demonstrates adherence to guideline-based treatment targets, underscoring the high standards maintained by neurological intensive care units. Our study offers valuable insights into adherence to guideline-based treatment targets for neurocritical care patients in Germany. To improve patient care and optimize therapeutic strategies in neurovascular diseases, further research is needed to examine the impact of these adherence parameters on long-term outcomes.

Brain hypoxia and metabolic crisis are common in patients with acute brain injury despite a normal intracranial pressure

Patients with acute brain injury are vulnerable to secondary deterioration, which may go undetected by traditional monitoring. However, multimodal neuromonitoring of brain tissue oxygen tension (PbtO2) and energy metabolism may be able to detect such episodes. We report a retrospective, observational study of 94 patients with aneurysmal subarachnoid haemorrhage (SAH) or traumatic brain injury (TBI) who underwent multimodal neuromonitoring during admission. We examined the co-occurrence of pathological neuromonitoring values: elevated intracranial pressure (ICP, > 20 mmHg), inadequate cerebral perfusion pressure (CPP, < 60 mmHg), brain hypoxia (PbtO2 < 20 mmHg), and metabolic crisis (lactate/pyruvate ratio > 40 and a glucose level < 0.2 mmol/L in cerebral microdialysate). Mixed effects linear regression demonstrated significant associations between abnormal ICP/CPP, cerebral hypoxia and metabolic crisis. However, brain hypoxia occurred in 40% and 31% of observations in patients with SAH and TBI, respectively, despite normal concurrent values of ICP. Similarly, metabolic crisis was observed in 8% and 16% of measurements for SAH and TBI, respectively, despite a normal ICP. The pattern was identical for CPP. In conclusion, although all neuromonitoring variables are interrelated, brain hypoxia and metabolic crisis are common despite an absence of abnormalities in conventional monitoring. Multimodal neuromonitoring may help identify such episodes and guide individualised treatment.

The impact of sleep problems on cerebral aneurysm risk is mediated by hypertension: a mediated Mendelian randomization study

Introduction

Cerebral aneurysm (CA) is a common vascular disease. The risk factors of CA include hypertension, smoking, and a family history of genetic predisposition. Although sleep-related problems have been found to have a strong association with cardiovascular disease, there is a lack of research regarding the causal relationship with cerebral aneurysms.

Methods

In this study, we investigated the causal relationship between four sleep-related problems, including snoring, insomnia, narcolepsy, and napping during the day, and CA using a two-sample Mendelian randomization (MR) analysis. Moreover, the potential confounders before sleep problems and CA were further analyzed by multivariate MR (MVMR).

Results

The causal relationship between insomnia and CA was obtained analytically by means of six MR analyses. There was a strong causal effect relationship between insomnia and CA, which suggests this as a potential risk factor [odds ratio (OR) = 8.35, 95% confidence interval (CI) = 2.422-28.791, p = 7.772e-04]. On this basis, hypertension was identified as a mediator between insomnia and CA by MVMR, with a mediating effect of 52.538% (OR = 3.05, 95% CI = 1.549-4.55, p = 0.015).

Conclusion

The causal relationship between insomnia and CA was predicted using genetic variance data, and insomnia was found to be a potential risk factor. Furthermore, hypertension is a mediator between insomnia and CA. Therefore, focusing on sleep problems and improving sleep quality may be an active and effective strategy to prevent CA.

Transcription factor EB (TFEB) promotes autophagy in early brain injury after subarachnoid hemorrhage in rats

Subarachnoid hemorrhage (SAH) has high mortality. Early brain injury (EBI) is responsible for unfavorable outcomes for patients with SAH. The protective involvement of autophagy in hemorrhagic stroke has been proposed. The transcription factor EB (TFEB) can increase autophagic flux by promoting autophagosome formation and autophagosome-lysosome fusion, and dysregulation of TFEB activity might induce the development of several diseases. However, the biological functions of TFEB in EBI after SAH remain unknown. We established an animal model of SAH by the modified endovascular perforation method. Expression of TFEB and autophagy required genes was measured by western blotting and immunofluorescence staining. SAH grading, brain water content and neurobehavioral functions were evaluated at 24 h post-SAH. Neuronal apoptosis in cerebral cortex was assessed by TUNEL staining and Fluoro Jade B staining. TFEB was downregulated in SAH rats, and its overexpression reduced brain edema and ameliorated neurological deficits of SAH rats. Additionally, the neuronal apoptosis induced by SAH was inhibited by TFEB overexpression. Moreover, TFEB overexpression promoted autophagy after SAH. TFEB overexpression promotes autophagy to inhibit neuronal apoptosis, brain edema and neurological deficits post-SAH.

Real-world evaluation of CYP2C19 guided antiplatelet therapy in patients undergoing intracranial aneurysm repair

Aim: To evaluate the feasibility and impact of using CYP2C19 genotype to guide selection of antiplatelet therapy in patients undergoing intracranial aneurysm treatment with a flow diversion stent in a real-world clinical setting.Patients & methods: A single-center, retrospective, observational cohort study was conducted in 112 patients undergoing intracranial aneurysm repair with flow-diversion stenting from 2014 to 2021. Data were abstracted from health records. The frequency of clopidogrel or alternative therapy (ticagrelor or prasugrel) use was compared across CYP2C19 status (intermediate or poor metabolizer [IM/PM] vs. normal, rapid, or ultrarapid metabolizer [NM/RM/UM]).Results: In the study population, CYP2C19 genotype testing was performed on 110 (98.2%) patients; of these, 106 (97.2%) had results available prior to the stent procedure and 28 (25.5%) were IM/PMs. Alternative therapy was used more frequently in IM/PMs compared with NM/RM/UMs (57.1 vs. 8.5%, respectively, p < 0.0001). The frequency of thromboembolic events over 12 months did not significantly differ across clopidogrel-treated IM/PMs, clopidogrel-treated NM/RM/UMs and patients on alternative therapy (p = 0.352); although, event numbers were low.Conclusion: A pre-emptive CYP2C19 genotyping strategy to guide antiplatelet therapy selection in intracranial aneurysm repair patients is feasible in a real-world clinical setting. Larger studies are needed to assess the impact on clinical outcomes.

Association Between Early Mobilization and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter Retrospective Propensity Score-Matched Study

BACKGROUND

Early mobilization has been shown to promote functional recovery and prevent complications in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, the efficacy of early mobilization in patients with aSAH remains unclear. This study aimed to investigate the association between early mobilization and functional outcomes in patients with aSAH.

METHODS

This multicenter retrospective study was conducted in Japan and included patients with aSAH who received physical therapy with or without occupational therapy from April 2014 to March 2019. The primary outcome was the modified Rankin Scale (mRS) score, with a favorable functional outcome defined as an mRS score of 0-2 and an unfavorable outcome with an mRS score of 3-5. Patients initiating walking training within 14 days of aSAH onset were classified into the early mobilization group, whereas those initiating training after 14 days were classified into the delayed mobilization group. Propensity score matching analysis was performed to assess the association between early mobilization and favorable outcomes.

RESULTS

A total of 718 patients were screened, and 450 eligible patients were identified. Before matching, 229 patients (50.9%) were in the early mobilization group and 221 (49.1%) were in the delayed mobilization group. After matching, each group consisted of 122 patients, and the early mobilization group exhibited a higher proportion of favorable outcomes than did the delayed mobilization group (81.1% vs. 52.5%, risk difference 28.7%, 95% confidence interval 17.4-39.9, p < 0.001).

CONCLUSIONS

This multicenter retrospective study suggests that initiating walking training within 14 days of aSAH onset is associated with favorable outcomes.

Enteral Cilostazol and High-Dose Intravenous Albumin in Aneurysmal Subarachnoid Hemorrhage Patients With Refractory Cerebral Ischemia

Cerebral ischemia associated with vasospasm in patients with aneurysmal subarachnoid hemorrhage (aSAH) requires a multifaceted approach. We report the use of the combination of enteral cilostazol and intravenous (IV) high-dose albumin in aSAH patients with cerebral ischemia refractory to other accepted pharmacologic and endovascular treatments. Three aSAH patients who developed cerebral ischemic symptoms despite treatment with oral nimodipine and endovascular measures (i.e., intraarterial vasodilators and balloon angioplasty) were treated with enteral cilostazol (200 mg/day) and one or more doses of IV (25%) albumin (1.25 g per kg over eight hours). The patients were monitored by serial neurological examinations, transcranial Doppler imaging (TCDI) ultrasound, computed tomographic angiography (CTA), and perfusion (CTP) scans. Three patients (ages 58, 67, and 56 years) developed symptomatic cerebral ischemia and vasospasm following an aSAH. Due to limited angiographic response to endovascular treatment, including intraarterial vasodilators with or without balloon angioplasty, IV (25%) albumin and enteral cilostazol were administered. CT angiogram and perfusion 2-3 days post-treatment demonstrated resolution of the perfusion deficits and angiographic vasospasm. Concurrently, TCDI demonstrated improved vasospasm and clinical examination demonstrated resolution of neurological deficits. None of the patients required any additional treatments for cerebral ischemia. A combination of oral cilostazol and IV high dose (25%) albumin was associated with amelioration of angiographic vasospasm, reduction of tissue perfusion deficits, and clinical improvement of aSAH patients with severe refractory cerebral ischemia.

Analysis of Cerebral Spinal Fluid Drainage and Intracranial Pressure Peaks in Patients with Subarachnoid Hemorrhage

BACKGROUND

After aneurysmal subarachnoid hemorrhage (aSAH), elevated intracranial pressure (ICP) due to disrupted cerebrospinal fluid (CSF) dynamics is a critical concern. An external ventricular drainage (EVD) is commonly employed for management; however, optimal strategies remain debated. The randomized controlled Earlydrain trial showed that an additional prophylactic lumbar drainage (LD) after aneurysm treatment improves neurological outcome. We performed a post hoc investigation on the impact of drainage volumes and critical ICP values on patient outcomes after aSAH.

METHODS

Using raw patient data from Earlydrain, we analyzed CSF drainage amounts and ICP measurements in the first 8 days after aSAH. Outcomes were the occurrence of secondary infarctions and the score on the modified Rankin scale after 6 months, dichotomized in values of 0-2 as favorable and 3-6 as unfavorable. Repeated measurements were considered with generalized estimation equations.

RESULTS

Earlydrain recruited 287 patients, of whom 221 received an EVD and 140 received an LD. Higher EVD volumes showed a trend to more secondary infarctions (p = 0.09), whereas higher LD volumes were associated with less secondary infarctions (p = 0.009). The mean total CSF drainage was 1052 ± 659 mL and did not differ concerning infarction and neurological outcome. Maximum ICP values were higher in patients with poor outcomes but not related to drainage volumes via EVD. After adjustment for aSAH severity and total CSF drainage, higher LD volume was linked to favorable outcome (per 100 mL: odds ratio 0.61 (95% confidence interval 0.39-0.95), p = 0.03), whereas higher EVD amounts were associated with unfavorable outcome (per 100 mL: odds ratio 1.63 (95% confidence interval 1.05-2.54), p = 0.03).

CONCLUSIONS

Findings indicate that effects of CSF drainage via EVD and LD differ. Higher amounts and higher proportions of LD volumes were associated with better outcomes, suggesting a potential quantity-dependent protective effect. Optimizing LD volume and mitigating ICP spikes may be a strategy to improve patient outcomes after aSAH.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01258257.

Intravenous milrinone for delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage: a systematic review

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is a major contributor to mortality worldwide, with delayed cerebral ischaemia (DCI) contributing significantly to morbidity in these patients. There are limited evidence-based therapies for DCI. A 2012 case series first recommended the use of intravenous (IV) milrinone in this patient population, stating the need for formal prospective trials. However, uptake of this therapy into clinical practice has proceeded without adequate studies for efficacy and safety.

METHODS

We sought to determine the effect of IV milrinone on DCI in patients with aSAH in terms of functional outcome through a systematic review using Embase, MEDLINE, and Cochrane Library databases. Quality assessment was performed using MINORS criteria.

RESULTS

A total of 2429 studies were screened, with ten studies included in the review. Of these, no randomized trials were identified. Three observational comparative studies were included, and the remaining seven studies were non-comparative in nature, and mainly retrospective. Overall, the quality of evidence for non-comparative studies was poor.

CONCLUSIONS

This study reveals a paucity of evidence in the literature and highlights the need for high-quality randomized trials to investigate the safety and efficacy of IV milrinone, a commonly utilized treatment in critically ill aSAH patients with DCI. Ultimately, without evidence of efficacy and absence of harm, we caution continued use of intravenous milrinone for the treatment of DCI.

A Narrative Review of Interhospital Transfers for Intracerebral Hemorrhage

Of the 750,000 strokes in the United States every year, 15% patients suffer from hemorrhagic stroke. Intracerebral hemorrhage (ICH) is a subtype of hemorrhagic stroke. Despite advances in acute management, patients with hemorrhagic stroke continue to suffer from high mortality and survivors suffer from multidomain impairments in the physical, cognitive, and mental health domains which could last for months to years from their index stroke. Long-term prognosis after ICH is critically dependent on the quality and efficacy of care a patient receives during the acute phase of care. With ongoing care consolidation in stroke systems of care, the number of ICH patients who need to undergo interhospital transfers (IHTs) is increasing. However, the associations between IHT and ICH outcomes have not been well described in literature. In this review, we describe the epidemiology of IHT for ICH, the relationship between IHT and ICH patient outcomes, and proposed improvements to the IHT process to ensure better long-term patient outcomes. Our review indicates that evidence regarding the safety and benefit of IHT for ICH patients is conflicting, with some studies reporting poorer outcomes for transferred patients compared to direct admissions via emergency rooms and other studies showing no effect on outcomes. The American Heart Association guidelines for ICH provide recommendations for timely blood pressure control and anticoagulation reversal to improve patient outcomes. The American Heart Association stroke systems of care guidelines provide recommendations for transfer agreements and but do not provide details on how patients should be managed while undergoing IHT. Large, prospective, and multicenter studies comparing outcomes of IHT patients to direct admissions are necessary to provide more definitive guidance to optimize IHT protocols and aid clinical decision-making.

The Impact of Enteral Nimodipine on Endothelial Cell Apoptosis in an Animal Subarachnoid Hemorrhage Model

BACKGROUND

Enteral nimodipine is the most evidence-based and widely used drug for the treatment of delayed cerebral ischemia and is known to have various neuroprotective functions. However, the neuroprotective mechanism of nimodipine still remains unclear, and the effects of nimodipine remain ambiguous. Herein, we studied the effect of enteral nimodipine on endothelial apoptosis after subarachnoid hemorrhage (SAH).

METHODS

SAH was experimentally introduced in white rabbits (n = 42) that were grouped as follows: enteral nimodipine (SAH-nimodipine group, n = 14), a control that received normal saline (SAH-saline group, n = 13), and a control without hemorrhage (control group, n = 15). On the third day after SAH induction, the brain stem, including the vertebrobasilar vascular system, was extracted. The effects of enteral nimodipine were analyzed by group using histopathologic analysis, including immunohistochemical staining of apoptosis-related proteins (Bcl2 [anti-apoptotic] and Bax [pro-apoptotic]).

RESULTS

Cytoplasmic vacuolation of smooth muscle cells was observed in two SAH hemorrhagic groups and was more prominent in the SAH-saline group. Endothelial desquamation was observed only in the SAH-saline group. For the basilar artery, expression of Bcl2 and Bax in the SAH-nimodipine group was lower than that in the SAH-saline group, but significant differences were not observed (pBcl2 = 0.311 and pBax = 0.720, respectively). In penetrated arterioles, the expression of Bax in the SAH-nimodipine group was significantly lower than that of the SAH-saline group (p < 0.001). The thickness of the tunica media in the basilar artery was thinner in the SAH-nimodipine group than in the SAH-saline group (p < 0.001).

CONCLUSIONS

This study suggests that enteral nimodipine may have a neuroprotective function by inhibiting endothelial apoptosis in small arterioles and preventing smooth muscle cell proliferation in large arteries.

A Longitudinal Model for a Dynamic Risk Score to Predict Delayed Cerebral Ischemia after Subarachnoid Hemorrhage

BACKGROUND

Accurate longitudinal risk prediction for DCI (delayed cerebral ischemia) occurrence after subarachnoid hemorrhage (SAH) is essential for clinicians to administer appropriate and timely diagnostics, thereby improving treatment planning and outcome. This study aimed to develop an improved longitudinal DCI prediction model and evaluate its performance in predicting DCI between day 4 and 14 after aneurysm rupture.

METHODS

Two DCI classification models were trained: (1) a static model based on routinely collected demographics and SAH grading scores and (2) a dynamic model based on results from laboratory and blood gas analysis anchored at the time of DCI. A combined model was derived from these two using a voting approach. Multiple classifiers, including Logistic Regression, Support Vector Machines, Random Forests, Histogram-based Gradient Boosting, and Extremely Randomized Trees, were evaluated through cross-validation using anchored data. A leave-one-out simulation was then performed on the best-performing models to evaluate their longitudinal performance using time-dependent Receiver Operating Characteristic (ROC) analysis.

RESULTS

The training dataset included 218 patients, with 89 of them developing DCI (41%). In the anchored ROC analysis, the combined model achieved a ROC AUC of 0.73 ± 0.05 in predicting DCI onset, the static and the dynamic model achieved a ROC AUC of 0.69 ± 0.08 and 0.66 ± 0.08, respectively. In the leave-one-out simulation experiments, the dynamic and voting model showed a highly dynamic risk score (intra-patient score range was 0.25 [0.24, 0.49] and 0.17 [0.12, 0.25] for the dynamic and the voting model, respectively, for DCI occurrence over the course of disease. In the time-dependent ROC analysis, the dynamic model performed best until day 5.4, and afterwards the voting model showed the best performance.

CONCLUSIONS

A machine learning model for longitudinal DCI risk assessment was developed comprising a static and a dynamic sub-model. The longitudinal performance evaluation highlighted substantial time dependence in model performance, underscoring the need for a longitudinal assessment of prediction models in intensive care settings. Moreover, clinicians need to be aware of these performance variations when performing a risk assessment and weight the different model outputs correspondingly.

Cerebrospinal fluid markers of neuroinflammation and coagulation in severe cerebral edema and chronic hydrocephalus after subarachnoid hemorrhage: a prospective study

BACKGROUND

Early severe cerebral edema and chronic hydrocephalus are the primary cause of poor prognosis in patients with subarachnoid hemorrhage (SAH). This study investigated the role of cerebrospinal fluid (CSF) inflammatory cytokines and coagulation factors in the development of severe cerebral edema and chronic hydrocephalus in patients with SAH.

METHODS

Patients with SAH enrolled in this study were categorized into mild and severe cerebral edema groups based on the Subarachnoid Hemorrhage Early Brain Edema Score at admission. During long-term follow-up, patients were further classified into hydrocephalus and non-hydrocephalus groups. CSF samples were collected within 48 h post-SAH, and levels of inflammatory cytokines and coagulation factors were measured. Univariate and multivariate logistic regression analyses were performed to identify independent factors associated with severe cerebral edema and chronic hydrocephalus. The correlation between inflammatory cytokines and coagulation factors was further investigated and validated in a mouse model of SAH.

RESULTS

Seventy-two patients were enrolled in the study. Factors from the extrinsic coagulation pathway and inflammatory cytokines were associated with both severe cerebral edema and chronic hydrocephalus. Coagulation products thrombin-antithrombin complexes (TAT) and fibrin, as well as inflammatory cytokines IL-1β, IL-2, IL-5, IL-7, and IL-4, were independently associated with severe cerebral edema. Additionally, Factor VII, fibrin, IL-2, IL-5, IL-12, TNF-α, and CCL-4 were independently associated with chronic hydrocephalus. A positive correlation between extrinsic coagulation factors and inflammatory cytokines was observed. In the SAH mouse model, tissue plasminogen activator was shown to alleviate neuroinflammation and cerebral edema, potentially by restoring glymphatic-meningeal lymphatic function.

CONCLUSIONS

Elevated levels of inflammatory cytokines and extrinsic coagulation pathway factors in the CSF are associated with the development of early severe cerebral edema and chronic hydrocephalus following SAH. These factors are interrelated and may contribute to post-SAH glymphatic-meningeal lymphatic dysfunction.

Brain plasticity and neuroinflammatory protein biomarkers with circulating MicroRNAs as predictors of acute brain injury outcome - A prospective cohort study

BACKGROUND

Brain recovery mechanisms after injuries like aneurysmal subarachnoid hemorrhage (aSAH), ischemic stroke (IS), and traumatic brain injury (TBI) involve brain plasticity, synaptic regeneration, and neuroinflammation. We hypothesized that serum levels of the p75 neurotrophic receptor (p75NTR) and associated signaling proteins, as well as differentially expressed (DE) microRNAs, could predict recovery outcomes irrespective of injury type.

METHODS

A prospective patient cohort with ischemic stroke (IS, n = 30), aneurysmal subarachnoid hemorrhage (aSAH, n = 31), and traumatic brain injury (TBI, n = 13) were evaluated (total n = 74). Serum samples were collected at two post-injury intervals (early: 1-3 days, late: 4-8 days), and outcomes were assessed after three months using the modified Rankin Scale (mRS), categorizing outcomes as favorable (mRS 0-3) or unfavorable (mRS 4-6). Six proteins were measured using ELISAs: p75NTR, NGF, sortilin, IL1β, TNFα, and cyclophilin. DE microRNAs were identified using DESeq2, and their target genes were predicted. Serum molecules between patients with differing outcomes were compared using a Kolmogorov-Smirnov test, 2-tailed t-test and multivariate linear discriminant analysis (LDA).

RESULTS

Favorable (n = 46) and unfavorable (n = 28) outcome cohorts were balanced with age and sex (p = 0.25 and 0.63). None of the studied proteins correlated with age. Combinatory LDA of the six protein biomarkers indicated strong prognostic value for favorable outcomes (OR 2.09; AUC = 70.3%, p = 0.0058). MicroRNA expression changes over time were identified in the aSAH, TBI, and IS groups (p < 0.05, FDR corrected). Twenty-three microRNAs were commonly DE across all brain injury groups when comparing favorable and unfavorable outcomes (p < 0.05). LDA of four microRNAs targeting the studied proteins showed high prognostic accuracy (OR 11.7; AUC = 94.1%, p = 0.016).

CONCLUSIONS

The combined prognostic microRNA and protein biomarker models demonstrated accurate outcome prognostication across diverse injury types, implying the presence of a common recovery mechanism. DE microRNAs were found to target the studied molecules, suggesting a potential mechanistic role in recovery. Further investigation is warranted to study these molecules in prognostication, as well as therapeutic targets for enhancing recovery.

Safety and Outcomes of Valproic Acid in Subarachnoid Hemorrhage Patients: A Retrospective Study

Background and Purpose

Animal studies have suggested that valproic acid (VPA) is neuroprotective in aneurysmal subarachnoid hemorrhage (SAH). Potential mechanisms include an effect on cortical spreading depolarizations (CSD), apoptosis, blood-brain barrier integrity, and inflammatory pathways. However, the effect of VPA on SAH outcomes in humans has not been investigated.

Methods

We conducted a retrospective analysis of 123 patients with nontraumatic SAH. Eighty-seven patients had an aneurysmal source and 36 patients did not have a culprit lesion identified. We used stepwise logistic regression to determine the association between VPA and the following: delayed cerebral ischemia (DCI), radiographic vasospasm, and discharge modified Rankin Scale (mRS) score > 3.

Results

All 18 patients who received VPA underwent coil embolization of their aneurysm. VPA use did not have a significant association with DCI on adjusted analysis (Odds Ratio, OR = 1.07, 95% CI: 0.20 - 5.80). The association between VPA use and vasospasm was OR = 0.64 (0.19 - 1.98) and discharge mRS > 3 was OR = 0.45 (0.10 - 1.64). Increased age (OR = 1.04, 1.01 - 1.07) and Hunt and Hess (HH) grade > 3 (OR = 14.5, 4.31 - 48.6) were associated with an increased likelihood for poor discharge outcome (mRS > 3). Younger age (OR = 0.96, 0.93 - 0.99), mFS score = 4 (OR = 4.14, 1.81 - 9.45), and HH grade > 3 (OR = 2.92, 1.11 - 7.69) were all associated with subsequent development of radiographic vasospasm. There were no complications associated with VPA administration.

Conclusion

We did not observe an association between VPA and the rate of DCI. There may have been a protective association on discharge outcome and radiographic vasospasm that did not reach statistical significance. We found that VPA use was safe and is plausible to be used in a population of SAH patients who have undergone endovascular treatment of their aneurysm. Larger, prospective studies are needed to determine the effect of VPA on outcome after SAH.

Follow-Up Imaging in Angiography-Negative Spontaneous Subarachnoid Hemorrhage

BACKGROUND

The aim of this study was to assess the diagnostic yield of follow-up investigations in aneurysm-negative subarachnoid hemorrhage (SAH) patients.

METHODS

In 109 (25%) of 435 patients with SAH and initial negative digital subtraction angiography (DSA), the diagnostic yield of repeat DSA and magnetic resonance imaging (MRI) of the brain and craniocervical junction was reviewed.

RESULTS

Of the 109 patients with an initial negative DSA, 51 (47%) had perimesencephalic (PM), 54 (50%) had nonperimesencephalic (NPM) blood distribution, and 4 (3.7%) had computed tomography-negative SAH. A delayed bleeding source was determined in 3 of 82 (3.7%) patients who underwent repeat DSA and in 1 of 5 patients who underwent a third DSA. The bleeding patterns of these patients were all NPM (n = 4). Repeat DSA did not identify a bleeding source in patients with PM-SAH. MRI of the brain and craniocervical junction after 2 days revealed a bleeding source in 1 of 105 patients (1%) in a computed tomography-negative SAH. When all diagnostic modalities, including exploratory craniotomy and MRI of the spinal axis, were considered, the rate of delayed diagnosis of the bleeding source was 6.4% (7/109). In addition to the bleeding pattern, patients with delayed diagnosis of the bleeding source were characterized by worse disease severity parameters, worse radiological grading scales, and more in-hospital complications than patients without delayed diagnosis of a bleeding source.

CONCLUSIONS

The results of this study support the use of repeat DSA in patients with NPM-SAH; however, routine repeat DSA may not be indicated in PM-SAH patients. The routine use of MRI remains controversial.

Decreased timing to vasospasm prophylaxis improves outcomes among patients with aneurysmal subarachnoid hemorrhage (aSAH) on prehospital CCBs, ARBs, or ACE-inhibitors

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) patients are given calcium channel blockers (CCBs) to prevent brain vessel vasospasm. We hypothesized that preinjury antihypertensive use may protect against vasospasm. It remains unclear whether the timing of in-hospital CCB initiation affects the vasospasm risk in this population.

METHODS

This retrospective cohort study included aSAH patients (≥18 y/o) at a Comprehensive Stroke Center (1/18-11/21). Patients taking prehospital antihypertensives [CCBs, Angiotensin-converting enzyme (ACE) inhibitors or Angiotensin II receptor blockers (ARBs)] were compared to those who were not. Results were stratified by patients receiving vasospasm prophylaxis ('in-hospital CCBs') ≤1.2 h of arrival vs. >1.2 h from arrival. Outcomes included vasospasm, hospital length of stay (LOS), and mortality.

RESULTS

Of 251 patients, 18% were taking prehospital antihypertensives. Patients were comparable in baseline characteristics. There was no difference in the rate of vasospasm when compared by prehospital antihypertensive use. For those on prehospital antihypertensives, the time to in-hospital CCBs was significantly longer for patients who developed vasospasm than for those who did not (1.2 vs. 4.9 h, respectively, p = 0.02). For those on prehospital antihypertensives, receipt of in-hospital CCBs within 1.2 h of arrival was associated with a significantly lower vasospasm rate (6% vs. 39%, p = 0.03) and LOS (14 vs. 20 d, p = 0.01) when compared to receiving in-hospital CCBs > 1.2 h of arrival, respectively. The mortality rate (50% vs. 26%, p = 0.06) was statistically similar between groups, respectively. These results were not observed among patients who were not on prehospital antihypertensives. The timing to in-hospital CCB initiation had no effect on vasospasm (p = 0.23), death (p = 0.08), or LOS (p = 0.31) for patients not on prehospital antihypertensives.

CONCLUSIONS

Enhancing the efficiency of in-hospital CCB initiation for patients on prehospital antihypertensives may decrease the occurrence of vasospasm and lead to a shorter LOS.

The Link Between Vitamin D and the Risk of Aneurysmal Subarachnoid Hemorrhage: A Systematic Review

BACKGROUND

Vitamin D (VD) is one of the fat-soluble vitamins proposed to be associated with aSAH. According to the clinical evidence, this investigation explores the link between VD concentrations and clinical outcomes in aSAH patients.

METHODS

This systematic review was executed based on the PRISMA 2020 statement. Observational studies that evaluated the serum VD concentrations in aSAH patients were considered as included articles. Review articles, case reports, letters, commentaries, non-English papers, and conference abstracts were excluded. Five online databases-Scopus, PubMed, Web of Science, Embase, and Ovid-were searched up to November 23, 2023, and based on the Newcastle-Ottawa Scale, the risk of bias was assessed.

RESULTS

Out of 383 articles initially identified, eventually 7 studies were included in the systematic review. These studies were conducted between 2016 and 2023 and included a total of 333,907 patients. The varying results suggest that VD may impact clinical outcomes in aSAH patients.

CONCLUSIONS

This study highlights the complex association between VD concentration and the risk of aSAH. The observed inconsistencies in study outcomes suggest that the relationship between VD and aSAH is multifaceted and may be influenced by various factors, including study population, geographical location, and methodological approach.

Recurrent artery of Heubner aneurysms in focus: insights into occurrence and current treatment paradigms

INTRODUCTION

The recurrent artery of Heubner (RAH), also known as the medial striate artery, is the most clinically important perforator of the anterior cerebral artery. RAH aneurysm is relatively rare, with 11 cases found in the present literature review, but poses significant clinical challenges due to potential impact on cognitive and motor functions. This systematic review explored available case reports to comprehensively understand clinical presentation, diagnosis, management and outcome in RAH aneurysm.

MATERIALS AND METHODS

Following PRISMA guidelines, this systematic review extensively explored RAH aneurysms, covering demographics, symptoms, diagnosis, treatments and outcomes. Comprehensive searches on PubMed, Scopus, Google Scholar, and Science Direct employed keywords such as "recurrent artery of Heubner aneurysm" and "Heubner's artery."

RESULTS

After extensive screening, 9 qualifying studies were identified, with 11 patients diagnosed with rare RAH aneurysm. Median age was 55 years (standard deviation, 15.3 years), with 54.5% males. 45.5% of patients presented risk factors, including Moyamoya disease in 2 patients. The majority were classified as grade I/II on the Hunt and Hess (H&H) and World Federation of Neurological Societies (WFNS) systems. Aneurysms were predominantly located in the A1 segment, with a mean size of 4.7 mm. Treatments varied, with clipping being the most frequent (63.6%). The mortality rate was 18.2%. Clipping was associated with favorable outcomes but higher rates of infarction.

CONCLUSION

This analysis highlighted the various symptoms, therapy methods and outcomes of RAH aneurysm, with A1 being the predominant origin. Future research should explore potential genetic predisposition factors and novel therapeutic interventions to address gaps in our knowledge.

Spontaneous subarachnoid hemorrhage in a referral health Centre in Central Africa

Background

Spontaneous subarachnoid hemorrhage (sSAH) is a medicosurgical emergency with high morbidity and mortality. The aimed of this study was to describe the clinical features and outcome of sSAH in Cameroon.

Methods

We reviewed medical records of patients aged ≥15 years old, admitted for sSAH from Januray 2011 to December 2020 in the Douala General Hospital. The diagnosis of sSAH was confirmed by neuroimaging (CT scan or MRI). Clinical and radiological severities were assessed by the WFNS score and the modified Fisher score respectively. Factors associated to in-hospital mortality was identified using cross-table (RR and 95%CI).

Results

Among the 111 cases of sSAH reviewed in emergencies records, we included 70 patients. The mean age was of 55.6 ± 13.6 years. Female were predominant (57.1%). Altered consciousness was the main clinical feature (55.7%). The WFNS score was grade 4-5 in 54.3% of patients. And 75.7% of cases presented a modified Fisher score of 3-4. Ruptured of intracranial aneurysm was the most common etiology (46.2%). Endovascular treatment and/or surgical treatment were not avaible. Hospital-based mortality was 40% and factor associated with death were Altered consciousness (RR: 4.3, 95%CI:1.52-12.33, p = 0.004), coma (RR: 23.9, 95%CI:2.85-200.62, p = 0.004), WFNS grade 5 (RR: 18.2, 95%CI:3.7-92.3, p < 0.001), and hospital length ≤ 7 days (RR: 13.5, 95%CI:4.28-42.56, p < 0.001).

Conclusion

Mortality and disability of sSAH are still high in our setting. Further studies with prospective follow up of patients are needed to determine the long-term outcome of these patients.

Reporting of Participant Race and Ethnicity in Cerebrovascular Randomized Controlled Trials

BACKGROUND

Randomized controlled trials (RCTs) provide information on appropriate management protocols in patients with cerebrovascular diseases. Despite growing evidence of race and ethnicity being independent predictors of outcomes, recent literature has drawn attention to inadequate reporting of these demographic profiles across RCTs. To our knowledge, the adherence to reporting race and/or ethnicity in cerebrovascular RCTs remains undescribed. Our study describes trends in the reporting of race and/or ethnicity across cerebrovascular RCTs.

METHODS

Web of Science was searched to identify the top 100-cited cerebrovascular RCTs. Additional articles were retrieved from guidelines issued by the American Heart Association for the management of ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Univariate and multivariate analyses were performed to assess for factors influencing reporting of race/ethnicity.

RESULTS

Sixty-five percent of cerebrovascular RCTs lacked reporting of participant race and/or ethnicity. Multivariate regression revealed that studies from North America had a 14.74- fold higher odds (95% CI: 4.574-47.519) of reporting race/ethnicity. Impact factor of the journal was associated with 1.007-fold odds of reporting race/ethnicity (95% CI: 1.000-1.013). Reporting of race and/or ethnicity did not increase with time, or vary according to the number of participating centers, median number of study participants, source of funding, or category of RCT. Among RCTs that reported race, Blacks and Asians were underrepresented compared to Whites.

CONCLUSIONS

Sixty-five percent of prominent cerebrovascular RCTs lack adequate reporting of participant race/ethnicity. Reasons for inadequate reporting of these variables remain unclear and warrant additional investigation.

An Association Between Prophylactic Hypervolemia-Augmented Blood Pressure and Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage Who Underwent Delayed Clipping

BACKGROUND

The prior trials investigating triple-H therapy for preventing delayed cerebral ischemia (DCI) enrolled patients with aneurysmal subarachnoid hemorrhage (aSAH) who underwent early aneurysm therapy within 3 days. However, surgical clipping might be performed during 4-7 days that high incidence cerebral vasospasm is likely. We examined effects of hypervolemia-augmented blood pressure (HV-ABP) protocol on DCI prevention when clipping was delayed.

METHODS

The study enrolled aSAH patients hospitalized during 2013-2019 who underwent clipping 4-7 days after rupture in a university hospital in Thailand. DCI and secondary outcomes were compared among patients who achieved the HV-ABP protocol (3-5 L/day fluid intake and 140-180 mmHg systolic blood pressure maintained for 72 hours postoperatively) and those who did not. The intervention-outcome associations were estimated using logistic regression for the whole group and a patient subgroup with similar propensity scores (PS) for protocol achievement.

RESULTS

One hundred seventy-seven aSAH patients were clipped 4-7 days after rupture; 97 patients (54.8%) achieved the HV-ABP protocol, while 80 patients (45.2%) did not. One hundred twenty-two patients with one-to-one PS matching reduced the originally unequal patient characteristics. The observed DCI was lower in patients with protocol-achieved (8.3%) than in their nonachieved counterparts (22.5%). This resulted in an association with the HV-ABP intervention with adjusted odds ratios of 0.201 (95% confidence interval, 0.066-0.613) in the whole sample and 0.228 (0.065-0.794) in the PS-matched subsample. No statistically significant differences in the secondary outcomes were found.

CONCLUSIONS

Achieving the targets recommended in the HV-ABP protocol was associated with reducing the DCI incidence in patients with aSAH who underwent delayed clipping.

Impact of time to start of tranexamic acid treatment on rebleed risk and outcome in aneurysmal subarachnoid hemorrhage

INTRODUCTION

The ULTRA-trial investigated effectiveness of ultra-early administration of tranexamic acid (TXA) in subarachnoid hemorrhage (SAH) and showed that TXA reduces the risk of rebleeding without concurrent improvement in clinical outcome. Previous trials in bleeding conditions, distinct from SAH, have shown that time to start of antifibrinolytic treatment influences outcome. This post-hoc analysis of the ULTRA-trial investigates whether the interval between hemorrhage and start of TXA impacts the effect of TXA on rebleeding and functional outcome following aneurysmal SAH.

PATIENTS AND METHODS

A post-hoc comparative analysis was conducted between aneurysmal SAH patients of the ULTRA-trial, receiving TXA and usual care to those receiving usual care only. We assessed confounders, hazard ratio (HR) of rebleeding and odds ratio (OR) of good outcome (modified Rankin Scale 0-3) at 6 months, and investigated the impact of time between hemorrhage and start of TXA on the treatment effect, stratified into time categories (0-3, 3-6 and >6 h).

RESULTS

Sixty-four of 394 patients (16.2%) in the TXA group experienced a rebleeding, compared to 83 of 413 patients (19.9%) with usual care only (HR 0.86, 95% confidence interval (CI): 0.62-1.19). Time to start of TXA modifies the effect of TXA on rebleeding rate (p < 0.001), with a clinically non-relevant reduction observed only when TXA was initiated after 6 h (absolute rate reduction 1.4%). Tranexamic acid treatment showed no effect on good outcome (OR 0.96, 95% CI: 0.72-1.27) with no evidence of effect modification on the time to start of TXA (p = 0.53).

DISCUSSION AND CONCLUSIONS

This study suggests that the effect of TXA on rebleeding is modified by time to treatment, providing a protective, albeit clinically non-relevant, effect only when started after 6 h. No difference in functional outcome was seen. Routine TXA treatment in the aneurysmal SAH population, even within a specified time frame, is not recommended to improve functional outcome.

CTA-based 3D virtual model for preoperative simulation and intraoperative neuronavigation in the surgical treatment of distal anterior cerebral artery aneurysms

OBJECTIVE

This study aims to assess the efficacy and limitations of Computed Tomography Angiography (CTA)-based 3D virtual models for preoperative simulation and intraoperative neuronavigation in the surgical treatment of Distal Anterior Cerebral Artery (DACA) Aneurysms.

METHODS

A retrospective observational study was conducted, analyzing patients who underwent surgical clipping of DACA aneurysms via an interhemispheric approach from 2016 to 2022. Outcomes measured included qualitative analyses of 3D reconstructions against actual intraoperative anatomy, neuronavigator accuracy, 6-month modified Rankin Scale (mRS), complete exclusion rates, and surgical complications. Patient demographics, clinical characteristics, surgical timing, and intraoperative data were meticulously documented for analysis.

RESULTS

Fifteen patients were included in the study, with a mean age of 52 years. The mean Hunt-Hess score at admission was 2.2, encompassing 2 unruptured and 13 ruptured aneurysms. Intraoperative anatomical visualization perfectly matched the preoperative 3D model in 13 cases, with discrepancies in two. Neuronavigation demonstrated a mean accuracy of 1.76 mm, remaining consistent in 14 patients, and accurately tracking the planned trajectory. Postoperative complications occurred in 26.5 % of patients, including two fatalities, with no navigation-related complications. Incomplete aneurysm occlusion was observed in one case. The mean mRS score at 6 months was 2.46.

CONCLUSIONS

The employment of 3D CTA for preoperative simulation and intraoperative neuronavigation holds significant potential in enhancing the surgical management of DACA aneurysms. Despite some discrepancies and technical limitations, the overall precision of preoperative simulations and the strategic value of intraoperative neuronavigation highlight their utility in improving surgical outcomes.

Patients with aneurysmal subarachnoid haemorrhage treated in Swedish intensive care: A registry study

BACKGROUND

Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening disease with high mortality and morbidity. Patients with aSAH in Sweden are cared for at one of six neuro intensive care units (NICU) or at a general intensive care unit (ICU).This study aimed to describe the incidence, length of stay, time in ventilator and mortality for these patients.

METHODS

This is a retrospective, descriptive study of patients with aSAH, registered in the Swedish Intensive care Registry between 2017 and 2019. The cohort was divided in sub-cohorts (NICU and general ICU) and regions. Mortality was analysed with logistic regression.

RESULTS

A total of 1520 patients with aSAH from five regions were included in the study. Mean age of the patients were 60.6 years and 58% were female. Mortality within 180 days of admission was 30% (n = 456) of which 17% (n = 258) died during intensive care. A majority of the patients were treated at one hospital and in one ICU (70%, n = 1062). More than half of the patients (59%, n = 897) had their first intensive care admission at a hospital with a NICU. Patients in the North region had the lowest median GCS (10) and the highest SAPS3 score (60) when admitted to NICU. Treatment with invasive mechanical ventilation differed significantly between regions; 91% (n = 80) in the region with highest proportion versus 56% (n = 94) in the region with the lowest proportion, as did mortality; 16% (n = 44) versus 8% (n = 23). No differences between regions were found regarding age, sex and length of stay.

CONCLUSIONS

Patients with aSAH treated in a NICU or in an ICU in Sweden differs in characteristics. The study further showed some differences between regions which might be reduced if there were national consensus and treatment guidelines implemented.

Nanoarchitectonic Engineering of Thermal-Responsive Magnetic Nanorobot Collectives for Intracranial Aneurysm Therapy

Stent-assisted coiling is a main treatment modality for intracranial aneurysms (IAs) in clinics, but critical challenges remain to be overcome, such as exogenous implant-induced stenosis and reliance on antiplatelet agents. Herein, an endovascular approach is reported for IA therapy without stent grafting or microcatheter shaping, enabled by active delivery of thrombin (Th) to target aneurysms using innovative phase-change material (PCM)-coated magnetite-thrombin (Fe3O4-Th@PCM) FTP nanorobots. The nanorobots are controlled by an integrated actuation system of dynamic torque-force hybrid magnetic fields. With robust intravascular navigation guided by real-time ultrasound imaging, nanorobotic collectives can effectively accumulate and retain in model aneurysms constructed in vivo, followed by controlled release of the encapsulated Th for rapid occlusion of the aneurysm upon melting the protective PCM (thermally responsive in a tunable manner) through focused magnetic hyperthermia. Complete and stable aneurysm embolization is confirmed by postoperative examination and 2-week postembolization follow-up using digital subtraction angiography (DSA), contrast-enhanced ultrasound (CEUS), and histological analysis. The safety of the embolization therapy is assessed through biocompatibility evaluation and histopathology assays. This strategy, seamlessly integrating secure drug packaging, agile magnetic actuation, and clinical interventional imaging, avoids possible exogenous implant rejection, circumvents cumbersome microcatheter shaping, and offers a promising option for IA therapy.

Correlation between early intracranial pressure and cerebral perfusion pressure with 28-day intensive care unit mortality in patients with hemorrhagic stroke

INTRODUCTION

Hemorrhagic stroke may cause changes in intracranial pressure (ICP) and cerebral perfusion pressure (CPP), which may influence the prognosis of patients. The aim of this study was to investigate the relationship between early ICP, CPP, and 28-day mortality in the intensive care unit (ICU) of patients with hemorrhagic stroke.

PATIENTS AND METHODS

A retrospective study was performed using the Medical Information Mart for Intensive Care (MIMIC-IV) and the eICU Collaborative Research Database (eICU-CRD), including hemorrhagic stroke patients in the ICU with recorded ICP monitoring. The median values of ICP and CPP were collected for the first 24 h of the patient's monitoring. The primary outcome was 28-day ICU mortality. Multivariable Cox proportional hazards models were used to analyze the relationship between ICP, CPP, and 28-day ICU mortality. Restricted cubic regression splines were used to analyze nonlinear relationships.

RESULTS

The study included 837 patients with a 28-day ICU mortality rate of 19.4%. Multivariable analysis revealed a significant correlation between early ICP and 28-day ICU mortality (HR 1.08, 95% CI 1.04-1.12, p < 0.01), whereas early CPP showed no correlation with 28-day ICU mortality (HR 1.00, 95% CI 0.98-1.01, p = 0.57), with a correlation only evident when CPP < 60 mmHg (HR 1.99, 95% CI 1.14-3.48, p = 0.01). The study also identified an early ICP threshold of 16.5 mmHg.

DISCUSSION AND CONCLUSION

Early ICP shows a correlation with 28-day mortality in hemorrhagic stroke patients, with a potential intervention threshold of 16.5 mmHg. In contrast, early CPP showed no correlation with patient prognosis.

White matter abnormalities in aneurysmal and angiographically negative subarachnoid hemorrhage: A diffusion kurtosis imaging study

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) and angiographically negative subarachnoid hemorrhage (anSAH) cause an abrupt rise in intracranial pressure, resulting in shearing forces, causing damage to the white matter tracts. This study aims to investigate whole-brain white matter abnormalities with diffusion kurtosis imaging (DKI) after both aSAH and anSAH and explores whether these abnormalities are associated with impaired cognitive functioning.

METHODS

Five months post-ictus, 34 patients with aSAH, 24 patients with anSAH and 17 healthy controls (HC) underwent DKI MRI scanning and neuropsychological assessment (measuring verbal memory, psychomotor speed, executive control, and social cognition). Differences in DKI measures (fractional anisotropy, mean diffusivity, axial diffusivity [AD], radial diffusivity, and mean kurtosis) were examined using tract-based spatial statistics. Significant voxel masks were then correlated with neuropsychological scores.

RESULTS

All DKI measures differed significantly between patients with aSAH and HC, but no significant differences were found between patients with anSAH and HC. Although the two SAH groups did not differ significantly on all DKI parameters, effect sizes indicated that the anSAH group might be more similar to HC. Cognitive impairments were found for both SAH groups relative to HC. No significant associations were found between these impairments and white matter abnormalities in the aSAH group, but lower psychomotor speed scores were associated with higher AD values (r = -0.41, p = 0.04) in patients with anSAH.

CONCLUSIONS

Patients with aSAH showed significant white matter diffusion abnormalities, while the anSAH group, despite cognitive deficits, did not. However, there were no significant differences between the SAH groups, and no correlations between DKI metrics and cognitive measures, except for one test on psychomotor speed in the anSAH group. Overall, this study suggests that while anSAH may not be as severe as aSAH, it is still not a benign condition. Further research with larger anSAH cohorts is necessary to gain a more precise understanding of white matter injuries, particularly regarding their prevalence.

The Potential Therapeutic Effects of Tadalafil on the Endothelium in a Subarachnoid Hemorrhage Animal Model: Insights from Immunohistochemical Staining

This study investigated the potential of phosphodiesterase type 5 (PDE-5) inhibitors, specifically tadalafil, in preventing the delayed cerebral ischemia (DCI) post-rupture of cerebral aneurysms. A total of 19 rabbits were used in this study, divided into different treatment groups, including nimodipine alone, tadalafil alone, and a combination of nimodipine and tadalafil. Both nimodipine and tadalafil showed some impact on reducing endothelial apoptosis in the basilar arteries, although the effects were not statistically significant. Notably, the nimodipine group exhibited significantly lower levels of Bax in the small arterioles compared to the SAH group. These findings suggest that while tadalafil may not directly prevent endothelial cell death like nimodipine, its neuroprotective properties hint at its potential utility in DCI treatment. Further research involving a broader range of apoptosis-related proteins is recommended to enhance our understanding in this area.

Innovative prognostication: a novel nomogram for post-interventional aneurysmal subarachnoid hemorrhage patients

Background and purpose

Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) is a common acute cerebrovascular disease characterized by severe illness, high mortality, and potential cognitive and motor impairments. We carried out a retrospective study at Fujian Provincial Hospital to establish and validate a model for forecasting functional outcomes at 6 months in aSAH patients who underwent interventional embolization.

Methods

386 aSAH patients who underwent interventional embolization between May 2012 and April 2022 were included in the study. We established a logistic regression model based on independent risk factors associated with 6-month adverse outcomes (modified Rankin Scale Score ≥ 3, mRS). We evaluated the model's performance based on its discrimination, calibration, clinical applicability, and generalization ability. Finally, the study-derived prediction model was also compared with other aSAH prognostic scales and the model's itself constituent variables to assess their respective predictive efficacy.

Results

The predictors considered in our study were age, the World Federation of Neurosurgical Societies (WFNS) grade of IV-V, mFisher score of 3-4, secondary cerebral infarction, and first leukocyte counts on admission. Our model demonstrated excellent discrimination in both the modeling and validation cohorts, with an area under the curve of 0.914 (p < 0.001, 95%CI = 0.873-0.956) and 0.947 (p < 0.001, 95%CI = 0.907-0.987), respectively. Additionally, the model also exhibited good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 9.176, p = 0.328). The clinical decision curve analysis and clinical impact curve showed favorable clinical applicability. In comparison to other prediction models and variables, our model displayed superior predictive performance.

Conclusion

The new prediction nomogram has the capability to forecast the unfavorable outcomes at 6 months after intervention in patients with aSAH.

Knowledge domain and emerging trends in the rupture risk of intracranial aneurysms research from 2004 to 2023

BACKGROUND

Intracranial aneurysms (IAs) pose significant health risks, attributable to their potential for sudden rupture, which can result in severe outcomes such as stroke and death. Despite extensive research, the variability of aneurysm behavior, with some remaining stable for years while others rupture unexpectedly, remains poorly understood.

AIM

To employ bibliometric analysis to map the research landscape concerning risk factors associated with IAs rupture.

METHODS

A systematic literature review of publications from 2004 to 2023 was conducted, analyzing 3804 documents from the Web of Science Core Collection database, with a focus on full-text articles and reviews in English. The analysis encompassed citation and co-citation networks, keyword bursts, and temporal trends to delineate the evolution of research themes and collaboration patterns. Advanced software tools, CiteSpace and VOSviewer, were utilized for comprehensive data visualization and trend analysis.

RESULTS

Analysis uncovered a total of 3804 publications on IA rupture risk factors between 2006 and 2023. Research interest surged after 2013, peaking in 2023. The United States led with 28.97% of publications, garnering 37706 citations. Notable United States-China collaborations were observed. Capital Medical University produced 184 publications, while Utrecht University boasted a citation average of 69.62 per publication. "World Neurosurgery" published the most papers, contrasting with "Stroke", the most cited journal. The PHASES score from "Lancet Neurology" emerged as a vital rupture risk prediction tool. Early research favored endovascular therapy, transitioning to magnetic resonance imaging and flow diverters. "Subarachnoid hemorrhage" stood out as a recurrent keyword.

CONCLUSION

This study assesses global IA research trends and highlights crucial gaps, guiding future investigations to improve preventive and therapeutic approaches.

Geo-demographic trends in nontraumatic subarachnoid hemorrhage-related mortality among older adults in the United States, 1999-2020

Introduction

Nontraumatic subarachnoid hemorrhage (ntSAH) often results from a ruptured aneurysm and correlates with significant morbidity and mortality, particularly among the older population. Despite its impact, limited comprehensive studies evaluate the longitudinal trends in ntSAH-related mortality in older adults in the United States (US).

Methods

The authors conducted a retrospective analysis using the CDC WONDER database from 1999 to 2020, analyzing Multiple Cause-of-Death Public Use death certificates to identify ntSAH as a contributing factor in the death of adults aged 65 years and older. We calculated age-adjusted mortality rates (AAMR) and annual percent change (APC) to examine trends across demographic variables such as sex, race/ethnicity, urbanization, and states/census region.

Results

A total of 78,260 ntSAH-related deaths (AAMR 8.50 per 100,000 individuals) occurred among older adults in the US from 1999 to 2020. The overall AAMR for ntSAH decreased from 9.98 in 1999 to 8.67 in 2020 with an APC of -0.7% [95% CI (-1.0, -0.3)]. However, the authors observed a noticeable rise from 2013 to 2020 with an APC of 1.7% [95% CI (0.8, 2.6)]. Sex, racial, and regional disparities were evident with higher mortality rates for ages 85 or greater (crude mortality rate 16.6), women (AAMR 9.55), non-Hispanic Asian or Pacific Islander (AAMR 12.5), and micropolitan areas (AAMR 8.99), and Western US (AAMR 8.65).

Conclusion

Mortality from ntSAH increases with age, affects women disproportionately, and occurs more often in an inpatient setting. These findings necessitate targeted, multi-dimensional health policies and clinical interventions. Specialties beyond neurosurgery can utilize this data for improved risk stratification and early treatment. Policymakers should focus on equitable resource allocation and community-level interventions to mitigate these trends effectively.

A nomogram model for predicting postoperative prognosis in patients with aneurysmal subarachnoid hemorrhage using preoperative biochemical indices

OBJECTIVE

The nutritional status and inflammatory responses of patients with aneurysmal subarachnoid hemorrhage (aSAH) play a vital prognostic role. We investigated the relationship between preoperative prognostic nutritional index (PNI)、neutrophil/albumin ratio (NAR)、platelet/albumin ratio (PAR) and other factors and the clinical prognosis of patients who underwent clipping for aSAH and its predictive model.

METHODS

The clinical data of 212 patients with aSAH who underwent neurosurgery at Nanyang Central Hospital between 2018 and 2023 were retrospectively analyzed. Based on the Glasgow Outcome Scale (GOS) score at 6 months postoperatively, the patients were categorized into two groups: poor (GOSI-III) and good (GOSIV-V) prognosis groups. Multivariate logistic regression analysis was performed to determine the predictive value of preoperative PNI、NAR、PAR、hyperlipidemia and Glasgow Coma Scale (GCS) for prognosis. Furthermore, nomograms and prognostic prediction models were constructed. Receiver operating characteristic curves and area under the curve (AUC) were utilized to determine the predictive values.

RESULTS

Multivariate logistic regression analysis revealed that PNI (OR = 1.250, 95%CI 1.060 ~ 1.475, P = 0.008), NAR (OR = 0.000, 95%CI 0.000 ~ 0.004, P = 0.000), PAR(OR = 0.515, 95%CI 0.283 ~ 0.937, P = 0.030), hyperlipidemia (OR = 4.627, 95%CI 1.166 ~ 18.367, P = 0.029), and GCS(OR = 1.446, 95%CI 1.041 ~ 2.008, P = 0.028) are independent risk factors for poor postoperative prognosis. The total score of the nomogram was 200, and the AUC value was 0.972.

CONCLUSIONS

PNI and NAR can reflect the nutritional status and inflammatory responses of patients.They are significantly associated with the postoperative prognosis of patients with aSAH. Comprehensively analyzing PNI and NAR combined with other clinical indicators can more effectively guide treatment and help predict prognosis.

Early and delayed blood-brain barrier permeability predicts delayed cerebral ischemia and outcomes following aneurysmal subarachnoid hemorrhage

OBJECTIVES

This study aimed to monitor blood-brain barrier permeability within 24 h and during the delayed cerebral ischemia (DCI) time window (DCITW) spanning 4-14 days after aneurysmal subarachnoid hemorrhage (aSAH) and to investigate its correlation with both DCI occurrence and outcomes at three months.

METHODS

A total of 128 patients were stratified based on the DCI occurrence and three-month modified Rankin scale scores. Comparison of Ktrans at admission (admission Ktrans) and during DCITW (DCITW Ktrans) was conducted between DCI and non-DCI groups, as well as between groups with good and poor outcomes. Changes in Ktrans were also analyzed. Multivariate logistic regression analysis was performed to identify independent predictors of DCI and poor outcomes.

RESULTS

Admission Ktrans (0.58 ± 0.18 vs 0.47 ± 0.12, p = 0.002) and DCITW Ktrans (0.54 ± 0.19 vs 0.41 ± 0.14, p < 0.001) were significantly higher in the DCI group compared with the non-DCI group. Although both were higher in the poor outcome group than the good outcome group, the difference was not statistically significant at admission (0.53 ± 0.18 vs 0.49 ± 0.14, p = 0.198). Ktrans in the non-DCI group (0.47 ± 0.12 vs 0.41 ± 0.14, p = 0.004) and good outcome group (0.49 ± 0.14 vs 0.41 ± 0.14, p < 0.001) decreased significantly from the admission to DCITW. Multivariate analysis identified DCITW Ktrans and admission Ktrans as independent predictors of poor outcomes (OR = 1.73, 95%CI: 1.24-2.43, p = 0.001) and DCI (OR = 1.75, 95%CI: 1.25-2.44, p = 0.001), respectively.

CONCLUSION

Elevated Ktrans at admission is associated with the occurrence of DCI. Continuous monitoring of Ktrans from admission to DCITW can accurately identify reversible and irreversible changes and can predict outcomes at 3 months.

CLINICAL RELEVANCE STATEMENT

Ktrans measured with CT perfusion is a valuable tool for predicting both delayed cerebral ischemia and three-month outcomes following aneurysmal subarachnoid hemorrhage. Monitoring changes in Ktrans from admission to time window of delayed cerebral ischemia can guide treatment and management decisions for aneurysmal subarachnoid hemorrhage patients.

KEY POINTS

• Ktrans measured at admission and during the delayed cerebral ischemia time window (4-14 days) holds distinct clinical significance following aneurysmal subarachnoid hemorrhage. • Admission Ktrans serves as a predictor for delayed cerebral ischemia, while continuous assessment of Ktrans from admission to the delayed cerebral ischemia time window can predict three-month outcomes. • Monitoring Ktrans at different stages improves instrumental in enhancing decision-making and treatment planning for patients with aneurysmal subarachnoid hemorrhage.

Effect of Statin Treatment in Patients with Aneurysmal Subarachnoid Hemorrhage: A Network Meta-Analysis

BACKGROUND

There are knowledge gaps regarding the relative efficacy of statins for aneurysmal subarachnoid hemorrhage (aSAH). This study aims to examine the comparative effectiveness and determine the ranking of different statins with network meta‑analysis in patients with aSAH.

METHODS

MEDLINE, Embase, Pubmed, and Cochrane Central Register of Controlled Trials were searched from database inception until December 15, 2022. Outcomes included delayed cerebral ischemia (DCI), functional recovery, and mortality. Relative risk (RRs) ratios and associated 95% confidence intervals (CIs) were estimated. The values derived from surface under the cumulative ranking curve were obtained to rank the treatment hierarchy in the analysis.

RESULTS

We identified 13 trials involving 1,885 patients. Atorvastatin 20 mg (RR 0.68, 95% CI 0.53-0.86), pravastatin 40 mg (RR 0.51, 95% CI 0.31-0.77), and simvastatin 80 mg (RR 0.54, 95% CI 0.40-0.70) were superior to the placebo in preventing DCI. Additionally, simvastatin 80 mg (RR 0.60, 95% CI 0.42-0.84) and pravastatin 40 mg (RR 0.56, 95% CI 0.32-0.93) were associated with a decreased risk of DCI than simvastatin 40 mg. Comparisons across treatment durations suggested that short-term (RR 0.62, 95% CI 0.50-0.76) statin therapy reduced risk of DCI.

CONCLUSIONS

Simvastatin 80 mg might be the most effective intervention in reducing DCI. Additionally, short-term therapy might provide more benefits. Further research with longer follow-up is warranted to validate the current findings in patients with aSAH who are at high risk of DCI.

Cognitive, Mental Health, Functional, and Quality of Life Outcomes 1 Year After Spontaneous Subarachnoid Hemorrhage: A Prospective Observational Study

BACKGROUND

Patients with spontaneous subarachnoid hemorrhage (SAH) frequently encounter cognitive dysfunction and mental health issues with negative effects on health-related quality of life (HR-QoL). Here, we aimed to describe the prevalence of cognitive deficits, mental health problems, and HR-QoL impairments 1 year after SAH.

METHODS

In this prospective observational study, 177 patients with SAH admitted to our neurointensive care unit over a time span of ten years followed the invitation for an in-person 1-year follow-up, including a standardized neuropsychological test battery. Mental health issues (anxiety and depression) and HR-QoL were evaluated using questionnaires (Hospital Anxiety and Depression Scale; 36-item Short Form questionnaire). Functional outcome was assessed with the modified Rankin Scale (mRS) score.

RESULTS

Patients were 54 years of age (interquartile range 47-62 years) and presented with a median Hunt and Hess score of 2 (interquartile range 1-3) at admission. Most patients (93%) achieved good functional 1-year outcomes (mRS score 0-2). Seventy-one percent of patients had deficits in at least one cognitive domain, with memory deficits being the most prevalent (51%), followed by deficits in executive functions (36%), visuoconstruction (34%), and attention (21%). Even patients with perimesencephalic SAH (18%) or with full functional recovery (mRS score = 0, 46%) had a comparable prevalence of cognitive deficits (61% and 60%, respectively). Symptoms of depression and anxiety were reported by 16% and 33% of patients, respectively. HR-QoL was impaired in 37% (55 of 147). Patients with cognitive deficits (p = 0.001) or mental health issues (p < 0.001) more frequently reported impaired HR-QoL.

CONCLUSIONS

Most patients with SAH have cognitive deficits and mental health issues 1 year after SAH. These deficits impair patients' quality of life.

Causal Effect Estimation on Imaging and Clinical Data for Treatment Decision Support of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is a medical emergency of brain that has high mortality and poor prognosis. Causal effect estimation of treatment strategies on patient outcomes is crucial for aneurysmal subarachnoid hemorrhage treatment decision-making. However, most existing studies on treatment decision-making support of this disease are unable to simultaneously compare the potential outcomes of different treatments for a patient. Furthermore, these studies fail to harmoniously integrate the imaging data with non-imaging clinical data, both of which are useful in clinical scenarios. In this paper, we estimate the causal effect of various treatments on patients with aneurysmal subarachnoid hemorrhage by integrating plain CT with non-imaging clinical data, which is represented using structured tabular data. Specifically, we first propose a novel scheme that uses multi-modality confounders distillation architecture to predict the treatment outcome and treatment assignment simultaneously. With these distilled confounder features, we design an imaging and non-imaging interaction representation learning strategy to use the complementary information extracted from different modalities to balance the feature distribution of different treatment groups. We have conducted extensive experiments using a clinical dataset of 656 subarachnoid hemorrhage cases, which was collected from the Hospital Authority Data Collaboration Laboratory in Hong Kong. Our method shows consistent improvements on the evaluation metrics of treatment effect estimation, achieving state-of-the-art results over strong competitors. Code is released at https://github.com/med-air/TOP-aSAH.

Short-term mild hyperventilation on intracranial pressure, cerebral autoregulation, and oxygenation in acute brain injury patients: a prospective observational study

Current guidelines suggest a target of partial pressure of carbon dioxide (PaCO2) of 32-35 mmHg (mild hypocapnia) as tier 2 for the management of intracranial hypertension. However, the effects of mild hyperventilation on cerebrovascular dynamics are not completely elucidated. The aim of this study is to evaluate the changes of intracranial pressure (ICP), cerebral autoregulation (measured through pressure reactivity index, PRx), and regional cerebral oxygenation (rSO2) parameters before and after induction of mild hyperventilation. Single center, observational study including patients with acute brain injury (ABI) admitted to the intensive care unit undergoing multimodal neuromonitoring and requiring titration of PaCO2 values to mild hypocapnia as tier 2 for the management of intracranial hypertension. Twenty-five patients were included in this study (40% female), median age 64.7 years (Interquartile Range, IQR = 45.9-73.2). Median Glasgow Coma Scale was 6 (IQR = 3-11). After mild hyperventilation, PaCO2 values decreased (from 42 (39-44) to 34 (32-34) mmHg, p < 0.0001), ICP and PRx significantly decreased (from 25.4 (24.1-26.4) to 17.5 (16-21.2) mmHg, p < 0.0001, and from 0.32 (0.1-0.52) to 0.12 (-0.03-0.23), p < 0.0001). rSO2 was statistically but not clinically significantly reduced (from 60% (56-64) to 59% (54-61), p < 0.0001), but the arterial component of rSO2 (ΔO2Hbi, changes in concentration of oxygenated hemoglobin of the total rSO2) decreased from 3.83 (3-6.2) μM.cm to 1.6 (0.5-3.1) μM.cm, p = 0.0001. Mild hyperventilation can reduce ICP and improve cerebral autoregulation, with minimal clinical effects on cerebral oxygenation. However, the arterial component of rSO2 was importantly reduced. Multimodal neuromonitoring is essential when titrating PaCO2 values for ICP management.

Outcome of Aneurysmal Subarachnoid Hemorrhage Not Altered With Transatlantic Airplane Transfer: A Bicentric Matched Case-control Study

OBJECTIVE

It is recommended that ruptured cerebral aneurysms are treated in a high-volume center within 72 hours of ictus. We assessed the impact of long-distance aeromedical evacuation in patients presenting aSAH.

METHODS

This case-control study compared patients with aneurysmal subarachnoid hemorrhage (aSAH) who had a 6750 km air transfer from Guadeloupe (a Caribbean island) to Paris, France, for neurointerventional management in a tertiary center with a matched cohort from Paris region treated in the same center over a 10-year period (2010 to 2019). The 2 populations were matched on age, sex, World Federation of Neurological Surgeons score, and Fisher score. The primary outcome was a 1-year modified Rankin Scale score ≤3. Secondary outcomes included time from diagnosis to securing aneurysm, 1-year mortality, and a cost analysis.

RESULTS

Among 128 consecutive aSAH transferred from Guadeloupe, 93 were matched with 93 patients from the Paris area. The proportion of patients with 1-year modified Rankin Scale ≤3 (75% vs 82%, respectively; P= 0.5) and 1-year mortality (18% vs 14%, respectively; P= 0.2) was similar in the Guadeloupe and Paris groups. The median (interquartile range: Q1, Q3) time from diagnosis to securing the aneurysm was higher in the patients from Guadeloupe than those from Paris (48 [30, 63] h vs 23 [12, 24] h, respectively; P< 0.001). Guadeloupean patients received mechanical ventilation (58% vs 38%; P< 0.001) and external ventricular drainage (55% vs 39%; P= 0.005) more often than those from Paris. The additional cost of treating a Guadeloupe patient in Paris was estimated at 7580 Euros or 17% of the estimated cost in Guadeloupe.

CONCLUSIONS

Long-distance aeromedical evacuation of patients with aSAH from Guadeloupe to Paris resulted in a 25-hour increase in time to aneurysm coiling embolization time but did not impact 1-year functional outcomes or mortality.

Hydrogel-Based Therapies for Ischemic and Hemorrhagic Stroke: A Comprehensive Review

Stroke remains the second leading cause of death and a major cause of disability worldwide, significantly impacting individuals, families, and healthcare systems. This neurological emergency can be triggered by ischemic events, including small vessel arteriolosclerosis, cardioembolism, and large artery atherothromboembolism, as well as hemorrhagic incidents resulting from macrovascular lesions, venous sinus thrombosis, or vascular malformations, leading to significant neuronal damage. The resultant motor impairment, cognitive dysfunction, and emotional disturbances underscore the urgent need for effective therapeutic interventions. Recent advancements in biomaterials, particularly hydrogels, offer promising new avenues for stroke management. Hydrogels, composed of three-dimensional networks of hydrophilic polymers, are notable for their ability to absorb and retain substantial amounts of water. Commonly used polymers in hydrogel formulations include natural polymers like alginate, chitosan, and collagen, as well as synthetic polymers such as polyethylene glycol (PEG), polyvinyl alcohol (PVA), and polyacrylamide. Their customizable characteristics-such as their porosity, swelling behavior, mechanical strength, and degradation rates-make hydrogels ideal for biomedical applications, including drug delivery, cell delivery, tissue engineering, and the controlled release of therapeutic agents. This review comprehensively explores hydrogel-based approaches to both ischemic and hemorrhagic stroke therapy, elucidating the mechanisms by which hydrogels provide neuroprotection. It covers their application in drug delivery systems, their role in reducing inflammation and secondary injury, and their potential to support neurogenesis and angiogenesis. It also discusses current advancements in hydrogel technology and the significant challenges in translating these innovations from research into clinical practice. Additionally, it emphasizes the limited number of clinical trials utilizing hydrogel therapies for stroke and addresses the associated limitations and constraints, underscoring the need for further research in this field.

Predicting postacute phase anaemia after aneurysmal subarachnoid haemorrhage: nomogram development and validation

BACKGROUND

Anaemia is a severe and common complication in patients with aneurysmal subarachnoid haemorrhage (aSAH). Early intervention for at-risk patients before anaemia occurs is indicated as potentially beneficial, but no validated method synthesises patients' complicated clinical features into an instrument. The purpose of the current study was to develop and externally validate a nomogram that predicted postacute phase anaemia after aSAH.

METHODS

We developed a novel nomogram for aSAH patients to predict postacute phase anaemia (3 days after occurrence of aSAH, prior to discharge) on the basis of demographic information, imaging, type of treatment, aneurysm features, blood tests and clinical characteristics. We designed the model from a development cohort and tested the nomogram in external and prospective validation cohorts. We included 456 aSAH patients from The First Affiliated Hospital for the development, 220 from Sanmen People's Hospital for external validation and a prospective validation cohort that included 13 patients from Hangzhou Red Cross Hospital. We assessed the performance of the nomogram via concordance statistics and evaluated the calibration of predicted anaemia outcome with observed anaemia occurrence.

RESULTS

Variables included in the nomogram were age, treatment method (open surgery or endovascular therapy), baseline haemoglobin level, fasting blood glucose level, systemic inflammatory response syndrome score on admission, Glasgow Coma Scale score, aneurysm size, prothrombin time and heart rate. In the validation cohort, the model for prediction of postacute phase anaemia had a c-statistic of 0.910, with satisfactory calibration (judged by eye) for the predicted and reported anaemia outcome. Among forward-looking forecasts, our predictive model achieved an 84% success rate, which showed that it has some clinical practicability.

CONCLUSIONS

The developed and validated nomogram can be used to calculate individualised anaemia risk and has the potential to serve as a practical tool for clinicians in devising improved treatment strategies for aSAH.

Predictors of Intrahospital Mortality in Aneurysmal Subarachnoid Hemorrhage after Endovascular Embolization

Background and Objectives: Aneurysmal subarachnoid hemorrhage (ASAH) is defined as bleeding in the subarachnoid space caused by the rupture of a cerebral aneurysm. About 11% of people who develop ASAH die before receiving medical treatment, and 40% of patients die within four weeks of being admitted to hospital. There are limited data on single-center experiences analyzing intrahospital mortality in ASAH patients treated with an endovascular approach. Given that, we wanted to share our experience and explore the risk factors that influence intrahospital mortality in patients with ruptured intracranial aneurysms treated with endovascular coil embolization. Materials and Methods: Our study was designed as a clinical, observational, retrospective cross-sectional study. It was performed at the Department for Radiology, University Clinical Center Kragujevac in Kragujevac, Serbia. The study inclusion criteria were ≥18 years, admitted within 24 h of symptoms onset, acute SAH diagnosed on CT, aneurysm on DSA, and treated by endovascular coil embolization from January 2014 to December 2018 at our institution. Results: A total of 66 patients were included in the study-48 (72.7%) women and 18 (27.3%) men, and 19.7% of the patients died during hospitalization. After adjustment, the following factors were associated with in-hospital mortality: a delayed ischemic neurological deficit, the presence of blood in the fourth cerebral ventricle, and an elevated urea value after endovascular intervention, increasing the chances of mortality by 16.3, 12, and 12.6 times. Conclusions: Delayed cerebral ischemia and intraventricular hemorrhage on initial head CT scan are strong predictors of intrahospital mortality in ASAH patients. Also, it is important to monitor kidney function and urea levels in ASAH patients, considering that elevated urea values after endovascular aneurysm embolization have been shown to be a significant risk factor for intrahospital mortality.

Prompt closure versus gradual weaning of external ventricular drain for hydrocephalus following aneurysmal subarachnoid haemorrhage: a statistical analysis plan for the DRAIN randomised clinical trial

BACKGROUND

Insertion of an external ventricular drain (EVD) is a first-line treatment of acute hydrocephalus caused by aneurysmal subarachnoid haemorrhage (aSAH). Once the patient is clinically stable, the EVD is either removed or replaced by a permanent internal shunt. The optimal strategy for cessation of the EVD is unknown. Prompt closure carries a risk of acute hydrocephalus or redundant shunt implantations, whereas gradual weaning may increase the risk of EVD-related infections.

METHODS

DRAIN (Danish RAndomised Trial of External Ventricular Drainage Cessation IN Aneurysmal Subarachnoid Haemorrhage) is an international multicentre randomised clinical trial comparing prompt closure versus gradual weaning of the EVD after aSAH. The primary outcome is a composite of VP-shunt implantation, all-cause mortality, or EVD-related infection. Secondary outcomes are serious adverse events excluding mortality and health-related quality of life (EQ-5D-5L). Exploratory outcomes are modified Rankin Scale, Fatigue Severity Scale, Glasgow Outcome Scale Extended, and length of stay in the neurointensive care unit and hospital. Outcome assessment will be performed 6 months after ictus. Based on the sample size calculation (event proportion 80% in the gradual weaning group, relative risk reduction 20%, alpha 5%, power 80%), 122 participants are required in each intervention group. Outcome assessment for the primary outcome, statistical analyses, and conclusion drawing will be blinded. Two independent statistical analyses and reports will be tracked using a version control system, and both will be published. Based on the final statistical report, the blinded steering group will formulate two abstracts.

CONCLUSION

We present a pre-defined statistical analysis plan for the randomised DRAIN trial, which limits bias, p-hacking, and data-driven interpretations. This statistical analysis plan is accompanied by tables with simulated data, which increases transparency and reproducibility.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03948256. Registered on May 13, 2019.