Systemic metabolism and energy consumption after microsurgical clipping and endovascular coiling for aneurysmal subarachnoid hemorrhage

Altered levels of transthyretin in human cerebral microdialysate after subarachnoid haemorrhage using proteomics; a descriptive pilot study

BACKGROUND

Subarachnoid haemorrhage (SAH) is one of the most severe forms of stroke in which delayed cerebral ischemia is one of the major complications. Neurointensive care aims at preventing and treating such complications and identification of biomarkers of early signs of ischemia might therefore be helpful.

METHODS

We aimed at describing proteome profile in cerebral microdialysate in four patients with aneurysmal SAH using two dimensional gel electrophoresis in combination with mass spectrometry in search for new biomarkers for delayed cerebral ischemia and to investigate if there were temporal fluctuations in those biomarkers over time after aneurysmal bleed.

RESULTS

The results showed transthyretin in nine different proteoforms (1001, 1102, 2101, 3101, 4101, 4102, 5001, 5101, 6101) in cerebral microdialysate samples from four patients having sustained SAH. Several proteoforms show highly differing levels and pooled analysis of all samples showed varying optical density related to time from aneurysmal bleed, indicating a temporal evolution.

CONCLUSIONS

Transthyretin proteoforms have not earlier been shown in cerebral microdialysate after SAH and we describe differing levels based on proteoform as well as time from subarachnoid bleed. Transthyretin is well known to be synthetized in choroid plexus, whilst intraparenchymal synthesis remains controversial. The results need to be confirmed in larger studies in order to further describe transthyretin.

Impact of Nutritional Status on Outcomes of Stroke Survivors: A Post Hoc Analysis of the NHANES

Stroke, a neurological emergency, is a leading cause of death and disability in adults worldwide. In acute or rehabilitative stages, stroke survivors sustain variable neurological recovery with long-term disabilities. The influence of post-stroke nutritional status on long-term survival has not been confirmed. Using the United States National Health and Nutrition Examination Survey data (2001−2010), we conducted a matched-cohort analysis (929 and 1858 participants in stroke and non-stroke groups, respectively) to investigate the influence of nutritional elements on post-stroke survival. With significantly lower nutrient consumption, the mortality risk was 2.2 times higher in stroke patients compared to non-stroke patients (Kaplan−Meier method with Cox proportional hazards model: adjusted hazard ratio, 2.208; 95% confidence interval: 1.887−2.583; p < 0.001). For several nutritional elements, the lower consumption group had significantly shorter survival than the higher consumption stroke subgroup; moreover, stroke patients with the highest 25% nutritional intake for each nutritional element, except moisture and total fat, had significantly shorter survival than non-stroke patients with the lowest 25% nutrition. Malnutrition is highly prevalent in stroke patients and is associated with high mortality rates. The dynamic change in energy requirements throughout the disease course necessitates dietary adjustment to ensure adequate nutritional intake.

Early Enteral Nutrition with High-Protein Whey Peptide Digestive Nutrients May Improve Prognosis in Subarachnoid Hemorrhage Patients

Background and Objectives: Nutritional management in patients with subarachnoid hemorrhage (SAH) during the acute phase is important; however, there is no proper evidence or recommendations on the appropriate nutrients for early enteral nutrition. This study compared the influence the two different tube-feeding liquid diets for early enteral nutrition might have on the prognosis of patients with SAH. Materials and Methods: In a seven-year period, this single-center retrospective study included 245 patients with aneurysmal SAH who underwent craniotomy and aneurysm neck clipping and received enteral nutrition. The patients were divided into two groups according to the nutrient received: (1) high-protein whey peptide oligomeric formula diet (oligomeric group, 109 patients); and (2) high eicosapentaenoic acid-containing polymeric formula diet (polymeric group, 136 patients). The modified Rankin Scale (mRS) score at discharge was evaluated as the primary outcome. The presence or absence of diarrhea (watery stool and mushy stool) during the period from initiation of enteral nutrition to discharge from the stroke unit was also evaluated. Results: There were no significant differences in patient characteristics between groups. The time until initiation of enteral feeding in the oligomeric and polymeric groups was 2.8 ± 2.3 and 2.9 ± 2.2 days, respectively. The proportion of patients with mRS scores of 0–1 was significantly higher in the oligomeric group (25.7%) than in the polymeric group (14.7%) (p = 0.036), while the incidence of watery stool was significantly lower in the oligomeric group (15.8% to 34.3% in the polymeric group) (p = 0.003). Multivariate analyses confirmed that the oligomeric diet and the presence or absence of diarrhea significantly affected the mRS scores. Conclusions: The adoption of early enteral nutrition with high-protein whey peptide digestive nutrients might be associated with superior mRS scores at discharge and decreased diarrhea in patients with SA, indicating that the choice of nutrients might affect the outcome and prognosis.

Clipping versus coiling for aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis of prospective studies

Neurosurgical clipping and endovascular coiling are both standard therapies to prevent rebleeding after aneurysmal subarachnoid hemorrhage (aSAH). However, controversy still exists about which is the optimal treatment. This meta-analysis aims to assess the effectiveness and safety of two treatments with high-quality evidence. Web of Science, Cochrane Library, EMBASE, Pubmed, Sinomed, China National Knowledge Infrastructure, and Wanfang Data databases were systematically searched on August 5, 2021. Randomized controlled trials (RCTs) and prospective cohort studies that evaluated the effectiveness and safety of clipping versus coiling in aSAH patients at discharge or within 1-year follow-up period were eligible. No restriction was set on the publication date. Meta-analyses were conducted to calculate the pooled estimates and 95% confidence intervals (CI) of relative risk (RR). Eight RCTs and 20 prospective cohort studies were identified. Compared to coiling, clipping was associated with a lower rebleeding rate at discharge (RR: 0.52, 95% CI: 0.29––0.94) and a higher aneurysmal occlusion rate (RR: 1.33, 95% CI: 1.19–1.48) at 1-year follow-up. In contrast, coiling reduced the vasospasm rate at discharge (RR: 1.45, 95% CI: 1.23–1.71) and 1-year poor outcome rate (RR: 1.27, 95% CI: 1.16–1.39). Subgroup analyses presented that among patients with a poor neurological condition at admission, no statistically significant outcome difference existed between the two treatments. The overall prognosis was better among patients who received coiling, but this advantage was not significant among patients with a poor neurological condition at admission. Therefore, the selection of treatment modality for aSAH patients should be considered comprehensively.

Daily systemic energy expenditure in the acute phase of aneurysmal subarachnoid hemorrhage

Background: Patients with subarachnoid hemorrhage often have impaired consciousness and cannot regulate nutritional intakes themselves. Previous studies have demonstrated elevated energy expenditure in the acute phase, but it is not known whether the energy demand is constant during the first week after onset of the disease. In this study, we performed daily measurements of energy expenditure with indirect calorimetry during the first 7 days after aneurysmal subarachnoid hemorrhage in mechanically ventilated patients.Methods: Metabolic measurements were performed daily with indirect calorimetry in 26 patients with aneurysmal subarachnoid hemorrhage. All patients were intubated and mechanically ventilated. The measured value was compared to the predicted values from the Harris-Benedict equation and the Penn State University 1998 equation. Urinary nitrogen excretion was measured daily.Results: There was a significant increase in energy expenditure during days 2-3 compared to days 5-6. The Harris-Benedict equation underestimated metabolic demand. The Penn State 1998 equation was closer to the measured values, but still underestimated caloric need. Urinary nitrogen excretion increased throughout the first week from initially low values.Conclusions: There is a dynamic course in energy expenditure in patients with aneurysmal subarachnoid hemorrhage, with increasing metabolic demand during the first week of the disease. Indirect calorimetry could be used more often to help provide an adequate amount of energy.