Identification of specific age groups with a high risk for developing cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Association Between High Preoperative White Blood Cell-to-Hemoglobin Ratio and Postoperative Symptomatic Cerebral Vasospasm in Patients With Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Cerebral vasospasm after aneurysmal subarachnoid hemorrhage (ASAH) is a serious complication and has a strong relationship with systemic inflammatory responses. Given previously reported relationships between leukocytosis and anemia with ASAH-related cerebral vasospasm, this study examined the association between the preoperative white blood cell-to-hemoglobin ratio (WHR) and postoperative symptomatic cerebral vasospasm (SCV) in patients with ASAH.

METHODS

Demographic, preoperative (comorbidities, ASAH characteristics, laboratory findings), intraoperative (operation and anesthesia), and postoperative (SCV, other neurological complications, clinical course) data were retrospectively analyzed in patients with ASAH who underwent surgical or endovascular treatment of the culprit aneurysm. Patients were divided into high-WHR (n=286) and low-WHR (n=257) groups based on the optimal cutoff value of preoperative WHR (0.74), and stabilized inverse probability weighting was performed between the 2 groups. The predictive power of the WHR and other preoperative systemic inflammatory indices (neutrophil-to-albumin, neutrophil-to-lymphocyte, platelet-to-lymphocyte, platelet-to-neutrophil, platelet-to-white blood cell ratios, and systemic immune-inflammation index) for postoperative SCV was evaluated.

RESULTS

Postoperative SCV was more frequent in the high-WHR group than in the low-WHR group before (33.2% vs. 12.8%; P <0.001) and after (29.4% vs. 19.1%; P =0.005) inverse probability weighting. Before weighting, the predictive power for postoperative SCV was the highest for the WHR among the preoperative systematic inflammatory indices investigated (area under receiver operating characteristics curve 0.66, P <0.001). After weighting, preoperative WHR ≥0.74 was independently associated with postoperative SCV (odds ratio 1.76; P =0.006).

CONCLUSIONS

High preoperative WHR was an independent predictor of postoperative SCV in patients with ASAH.

Cerebral Vasospasm as a Critical Yet Overlooked Complication Following Tumor Craniotomy: A Systematic Review of Case Reports and Case Series

Background: Cerebral vasospasm after craniotomy tumor (CVACT) is a rare complication that can occur following tumor craniotomy and significantly affects the outcome of patients. Unfortunately, it is not well understood, leading to delayed and ineffective management. This study aims to investigate CVACT by examining the factors contributing to its occurrence, its underlying mechanisms, diagnostic approaches, management strategies, and outcomes. The goal is to identify the characteristics and risk factors associated with CVACT, its clinical symptoms, diagnostic methods, management options, and potential outcomes. Methods: A systematic search used relevant keywords to identify cases of "cerebral vasospasm" after tumor resection in PubMed and Science Direct databases. Relevant cross-references were added by manually searching the references of all retrieved articles. Result: We included 60 inclusion patients from 14 case reports and 13 case series with 33 (55%) females and 27 (45%) males with a mean age of 44.05 ± 16.8 years. The most common tumors were pituitary adenomas, which were found in 22 (36.66%), the most common tumor location was the middle cranial fossa (75%), and the most common surgery technique used was transsphenoidal surgery (50%). Most of those who experience vasospasm have a craniotomy with the TSS technique (50%) with complications of intraoperative bleeding. The range of onset of VS symptoms postoperatively was 0-30 days (mean 6.59 d). The symptoms included asymptomatic, headache, loss of vision, hemiparesis, diplopia, etc. The vascular involvement was mainly anterior circulation (78.33%). The diagnostic tools most commonly used were angiography and transcranial doppler (TCD). The most common management of VS from the included studies was pharmacology. The survival rate was 61.66%. We found the tumor location and vascular-affected vasospasm were significantly correlated with mortality rates: p = 0.015 and p = 0.02. Conclusions: Cerebral vasospasm after craniotomy tumor removal (CVACT) frequently arises in tumors situated in the medial cranial fossa, predominantly pituitary adenomas and meningiomas. The minimally invasive surgical approach of TSS may contribute to the mechanism of CVACT incidence. The existence of preoperative vascular pathology, as encasement or narrowing, appears to be a predictor alongside the incidence of intra- or postoperative hemorrhage. The vascular structures most susceptible to vasospasm are located in the anterior circulation of the Willis circle, which appears to correlate with the vascular problems that typically undergo preoperative encasement of the internal carotid artery (ICA). The most reliable and real time diagnostic instrument employed is TCD, while imaging continues to be the gold standard. Nimodipine treatment continues to be a viable therapeutic option that can enhance patient outcomes.

Impact of intracranial atherosclerosis burden on vasospasm risk and outcomes in aneurysmal subarachnoid hemorrhage

BACKGROUND

Cerebral vasospasm is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH) and occurs more commonly in younger patients. We hypothesized that intracranial atherosclerosis, which is seen predominantly in older patients, affects vasospasm risk. We sought to determine association between intracranial atherosclerosis burden with vasospasm and outcomes in aSAH.

METHODS

We retrospectively reviewed a cohort of consecutive patients with aSAH admitted to a Comprehensive Stroke Center between 2016 and 2023. Intracranial atherosclerosis burden was quantified by using modified Woodcock (MW) score on CT angiograms. Vasospasm was defined based on transcranial Doppler (TCD) criteria. Poor outcome was defined as 3-month modified Rankin Scale 3-6.

RESULTS

We reviewed 392 patients and included 302 (mean age 56.8 years [SD 13.3], 65 % female and 70 % white) in the final analysis. MW scores were measured with excellent intra-rater and inter-rater reliability (Cohen's kappa coefficient 0.9 and 0.83 respectively) ranging from 0 to 3 (mean 0.59, SD 0.83) with higher scores in older patients (beta coefficient 0.019, 95 % CI 0.009-0.028; p < 0.001). Higher MW calcification score was associated with lower risk of vasospasm (OR 0.52 per point increase, 95 % CI 0.36-0.78; p = 0.001). There was an inverse correlation between MW scores and severity of vasospasm (beta coefficient -0.29, 95 % CI -0.48, -0.1; p = 0.003). However, MW score was not independently associated with poor functional outcome (p = 0.62).

CONCLUSIONS

Intracranial atherosclerosis is a potential mechanism for lower TCD-based vasospasm in older patients with aSAH; however, it may not impact functional outcomes. Larger prospective studies are needed to confirm our findings.

Risk Factors for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review of Observational Studies

Cerebral vasospasm (CV) following subarachnoid hemorrhage (SAH) remains one of the leading causes of high mortality and poor outcomes. Understanding the risk factors associated with CV is pivotal to improving patients' outcomes. We conducted an extensive search for analytical observational studies that analyzed the correlation between various variables and the likelihood of CV development among adult patients with SAH (age ≥ 18 years). Five scholar databases were used, namely, PubMed, EBSCO, Web of Science, Science Direct, and Google Scholar. Relevant studies published between January 1st, 2016, and August 9th, 2023, were included. The Newcastle-Ottawa Scale was adopted to assess the risk of bias among included observational studies. A total of 33 studies met the inclusion criteria. Of the 24,958 patients with SAH who were identified, 6,761 patients had a subsequent CV (27.1%). Several statistically significant risk factors were reported across the literature. Younger age, female sex, smoking, alcohol intake, modified Fisher grade 3-4, higher Hunt and Hess grading, and the presence of multiple comorbidities (diabetes, hypertension, congestive heart failure, and history of stroke) were among the well-established risk factors for CV. Additionally, leukocytosis was consistently reported to be a significant predictor in multiple studies, providing compelling evidence for its association with CV. Even though single studies reported an association between CV and certain variables, further research is necessary to investigate the implications of these findings. These include arterial tortuosity, hypokalemia, potassium to glucose gradient, hypoalbuminemia, anemia, von Willebrand factor and vascular endothelial growth factor, use of desflurane, and hemodynamic stability. Overall, this systemic review provides a comprehensive summary of the current data that evaluates the potential risk factors for the development of CV after SAH. However, because of data heterogeneity, certain factors require further validation in their correlation with CV development. Larger-scale observational and clinical trials are mandatory to extensively investigate the significant predictors of CV to lay the scientific foundation for improving outcomes in susceptible patients with SAH.

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.

The role of previous medical history and secondary complications for the outcome of aneurysmal subarachnoid hemorrhage in elderly patients

BACKGROUND

Aneurysmal subarachnoid hemorrhage (SAH) presents a devastating diagnosis for elderly individuals, resulting in high morbidity and mortality rates. The aim of the study was to analyze the impact of medical history and complications during SAH on the outcome of elderly patients.

METHODS

Consecutive SAH cases aged ≥ 65 years old treated in our hospital between 01/2003 and 06/2016 were included (n = 218). Data on comorbidities, previous medication, initial severity, secondary complications, and the outcome were collected. Study endpoints were occurrence of cerebral infarcts, in-hospital mortality, and unfavorable outcome at 6 months after SAH.

RESULTS

Cerebral infarcts were documented in 111 (51.2 % ) individuals. Multivariate analysis showed that angiographic vasospasm caused an increase (adjusted odds ratio [aOR] = 3.11, p = 0.022) in the risk of infarction, whereas aspirin treatment decreased (aOR = 0.25, p = 0.001) the risk of infarction. In turn, increasing age (aOR = 1.11, p = 0.002), intracranial hypertension (>20 mmHg, aOR = 3.32, p = 0.006) and acute kidney failure (aOR = 6.65, p = 0.035) during SAH were independently related to the risk of in-hospital mortality (n = 50; 22.9 % ). Finally, patients' age (aOR = 1.09, p = 0.022), high initial SAH burden (WFNS ≥ 4: aOR = 7.5, p < 0.0001; intraventricular hemorrhage: aOR = 4.38, p = 0.007), aneurysm clipping (aOR = 4.07, p = 0.018), and intracranial hypertension during SAH (aOR = 4.08, p = 0.006) were independent predictors of unfavorable outcome (n = 106/192; 55.5 % ). Previous medical history showed no negative impact on the severity, course and outcome of SAH.

CONCLUSION

About half of elderly SAH patients face poor outcomes after aneurysm securing. The initial severity of and complications during SAH are the major contributors to poor treatment results. Our findings might help to optimize the treatment strategies.

Preoperative Rehearsal Sketch for Cerebral Aneurysm Clipping Improves the Accuracy and the Safety of the Surgical Procedure

OBJECTIVE

With advances in endovascular therapy, the number of cerebral aneurysm clippings has been decreasing. However, some patients are indicated for clipping surgeries. In such circumstances, preoperative simulation is important for the safety and educational aspects of the operation. Herein, we introduce a simulation method using the preoperative rehearsal sketch and report its applicability.

METHODS

We compared the preoperative rehearsal sketch with the surgical view for all patients who underwent cerebral aneurysm clipping by neurosurgeons below the seventh grade between April 2019 and September 2022 in our facility. The aneurysm, running of parent and branched arteries, perforators, veins, and clip working were evaluated by senior doctors and scored as follows: correct, 2; partially correct, 1; incorrect, 0; and total score, 12. We retrospectively evaluated the relationship between these scores and postoperative perforator infarctions and, in addition, compared that between simulated and not simulated cases.

RESULTS

In the simulated cases, the total scores did not correlate with perforator infarctions, but assessments of the aneurysm, perforators, and clip working affected the total score (P = 0.039, 0.014, and 0.049, respectively). Moreover, perforator infarctions were significantly less in the simulated cases (6.3% vs. 38.5%; P = 0.03).

CONCLUSIONS

Precise interpretations of preoperative images and considerations of three-dimensional images are imperative to perform safe and accurate surgeries using preoperative simulation. Although perforators are not always detected preoperatively, it is possible to presume in the surgical view using anatomic knowledge. Therefore, drawing the preoperative rehearsal sketch improves the safety of surgical procedure.

Different Risk Factors Between Cerebral Infarction and Symptomatic Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

Cerebral infarction due to cerebral vasospasm (IVS) after aneurysmal subarachnoid hemorrhage is associated with poor outcomes and symptomatic cerebral vasospasm (SVS). However, the difference of risk factors between SVS and IVS was unclear to date. In this study, we aimed to elucidate the risk factors for SVS and IVS based on the registry study.

METHODS

The modified World Federation of Neurosurgical Societies scale study comprises 1863 cases. Patients with aneurysmal subarachnoid hemorrhage who underwent radical treatment within 72 hours with a premorbid modified Rankin Scale score 0-2 as the inclusion criteria were retrospectively examined. The risk factors for SVS and IVS were analyzed using multivariable logistic regression analysis.

RESULTS

Among them, 1090 patients who met the inclusion criteria were divided into 2 groups according to SVS and IVS; 273 (25%) patients with SVS and 92 (8.4%) with IVS. Age was not a risk factor for SVS, but for IVS, and Fisher scale was a risk factor for SVS, but not for IVS.

CONCLUSIONS

The prevalence of IVS was not associated with the Fisher scale but with older age, suggesting possible factors other than SVS. Different associated factors between SVS and IVS were confirmed in this study.

Association of pre-admission antihypertensive agents and outcomes in aneurysmal subarachnoid hemorrhage

BACKGROUND

Delayed cerebral ischemia (DCI) and poor functional outcome are common complications in patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). It has been proposed that pre-admission beta-blocker therapy may lower cerebral vasospasm (cVSP) risk after aSAH; however, this association with other antihypertensives is unknown. We sought to determine the association between antihypertensives and clinical outcomes in aSAH patients.

METHODS

We performed a retrospective study on a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2021. Association between pre-admission use of antihypertensives and patient outcomes was determined. Primary outcomes included DCI and poor functional outcome at 3 months after discharge defined as modified Rankin scale [mRS] 4-6. The secondary outcome was cVSP identified using transcranial Doppler (TCD).

RESULTS

The cohort consisted of 306 aSAH patients with mean age 57.1 (SD 13.6) years with 187 females (61 %). Although pre-admission use of beta-blockers (OR 0.40, 95 % CI 0.21-80, p = 0.02), calcium channel blockers (OR 0.43, 95 % CI 0.19-0.93, p = 0.035), and thiazide (OR 0.31, 95 % CI 0.11-0.86, p = 0.025) were associated with lower risk of cVSP in univariate analysis, we did not find any association in a multivariate model after adjusting for age. There was no association between any class of antihypertensives and DCI or functional outcome.

CONCLUSION

Pre-admission use of antihypertensive agents may affect TCD findings, however, none of them appear to be independently associated with DCI or functional outcome. Larger prospective studies are needed to establish any potential association.

Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Objectives

We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler.

Methods

A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries.

Results

Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05).

Conclusion

Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.

Role of serum biomarkers and transcranial Doppler in predicting cerebral vasospasm after aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) can have serious consequences related to vasospasm and delayed cerebral ischemia (DCI). Serum biomarkers have emerged as a promising assessment tool to facilitate earlier diagnosis of cerebral vasospasm (CV) and to identify pre-clinical vessel narrowing.

Objectives

Our aim was to detect the predictive value of serum biomarkers such as von Willebrand factor (vWF), vascular endothelial growth factor (VEGF) and matrix metalloproteinase9 (MMP-9) in CV after aSAH.

Subjects and methods

Thirty five patients with recent aSAH were included. Patients were divided into two groups; 19 patients (CV group) and 16 patients (non-CV group). The CV group was further subdivided into 9 symptomatic (DCI) and 10 asymptomatic patients. All patients underwent transcranial Doppler (TCD) evaluations three times a week for 2 weeks measuring the mean flow velocities. Serum level of vWF, MMP-9, and VEGF were assessed twice (at onset and within 2 weeks).

Results

A statistically significant increase in serum biomarker levels was found in the CV group. Cutoff value for vWF, MMP-9, and VEGF were > 4985 ng/ml, > 495 ng/ml, and > 184 pg/ml, respectively. Statistically significant positive correlations were found between serum levels of biomarkers and degree of vasospasm. No difference was found in the biomarkers between symptomatic CV and asymptomatic CV.

Conclusion

Serum biomarkers are a reliable tool to predict CV following aSAH, their levels reflect the severity of vascular vasospasm, yet, they cannot predict DCI. TCD has a strong role in early detection, monitoring of post subarachnoid vasospasm and successfully capturing asymptomatic DCI.

Nomogram for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage in the Chinese population

BACKGROUND

Delayed cerebral ischemia is a serious complication of aneurysmal subarachnoid hemorrhage with debilitating and fatal consequences. Lack of well-established risk factors impedes early identification of high-risk patients with delayed cerebral ischemia. A nomogram provides personalized, evidence-based, and accurate risk estimation. To offset the lack of a predictive tool, we developed a nomogram to predict delayed cerebral ischemia before performing surgical interventions for aneurysmal subarachnoid hemorrhage to aid surgical decision-making.

METHODS

We retrospectively collected data from 887 consecutive eligible Chinese patients who underwent surgical clipping or endovascular coiling for aneurysmal subarachnoid hemorrhage. Patients who previously underwent surgery formed the training cohort (n = 621) for nomogram development; those who underwent surgery later formed the validation cohort (n = 266) to confirm the performance of the model. A multivariate logistic regression analysis identified the independent risk factors associated with delayed cerebral ischemia, which were then incorporated into the nomogram.

RESULTS

Delayed cerebral ischemia was identified in 158/621 patients (25.4%) in the training cohort and in 66/266 patients (24.8%) in the validation cohort. Preoperative factors associated with delayed cerebral ischemia were age > 65 years, modified Fisher grade of 3-4, ruptured aneurysm in the anterior circulation, Hunt-Hess grade of 4-5, high blood pressure on admission, and plasma homocysteine level ≥ 10 μmol/L. Incorporating these six factors in the nomogram achieved efficient concordance indices of 0.73 (95% confidence interval, 0.68-0.77) and 0.65 (95% confidence interval, 0.57-0.72) in predicting delayed cerebral ischemia in the training and validation cohorts, respectively.

CONCLUSIONS

Our model can help determine an individual's risk of developing delayed cerebral ischemia in the Chinese population, and thereby, facilitate reasonable treatment-related decision-making.

Radiological scales predicting delayed cerebral ischemia in subarachnoid hemorrhage: systematic review and meta-analysis

PURPOSE

Delayed cerebral ischemia (DCI) is a severe complication of aneurysmal subarachnoid hemorrhage (aSAH). The extent of subarachnoid blood is a strong predictor of DCI and is frequently estimated with the Fisher scale, modified Fisher scale, or Hijdra sum score. It is unclear which scale has the strongest association with clinical DCI. To evaluate this, we performed a systematic review of the literature.

METHODS

We performed a MEDLINE and EMBASE search from 1980 to 20th of June 2017. Radiological grade and occurrence of clinical DCI were extracted along with odds ratios (ORs) for DCI. When possible, pooled ORs with 95% confidence intervals were calculated per grade increase on the radiological scale.

RESULTS

Fifty-three studies were included. The Fisher scale was significantly associated with DCI in 62% of the studies compared to 88-100% for the other scales. In studies using the Fisher scale, Fisher 3 had the strongest association with DCI (pooled OR 3.21 (1.87-5.49)). In studies using the modified Fisher score, DCI occurred most frequently (42%) in modified Fisher 4. No pooled OR could be calculated for the other scales.

CONCLUSION

The Fisher scale, modified Fisher scale, and Hijdra sum score are all associated with clinical DCI. The risk of DCI, however, does not increase with increasing Fisher grade as opposed to the modified Fisher scale. Furthermore, the modified Fisher scale was more commonly significantly associated with DCI than the Fisher scale, which may advocate using the modified Fisher in future SAH-related studies.

Vasospasm following aneurysmal subarachnoid hemorrhage: prediction, detection, and intervention

Background

Vasospasm of the cerebral blood vessels is a common complication of aneurysmal subarachnoid hemorrhage (aSAH) which results in delayed cerebral ischemia (DCI) and worsening of the outcome.

Methods

This study was performed on 41 aSAH patients diagnosed by non-contrast brain CT, CT angiography, and digital subtraction angiography followed by interventional aneurysmal embolization. Patients were followed up for 20 days by clinical assessment, EEG monitoring, and transcranial duplex studies (TCD) for early detection of vasospasm and DCI.

Results

The most common ruptured aneurysmal sites were middle cerebral, anterior communicating, posterior communicating, terminal internal carotid, and anterior cerebral arteries respectively. The incidence of vasospasm was 36.8% of the included cases; 57% progressed to DCI while 43% passed a spontaneous regressive course. The most common arteries undergoing vasospasm were the MCA followed by the ACA, ICA, and lastly the basilar arteries. The mean time of vasospasm development as detected by EEG monitoring and/or TCD was 8.4 ± 2.8 days which was earlier than clinical signs by 12.5 ± 5.3 h in those progressed to DCI.

Conclusion

Continuous EEG monitoring and TCD are valuable methods for early detection of vasospasm and they allow for early therapeutic intervention before irreversible ischemic neurological deficits take place.

Early Hemodynamic Changes Based on Initial Color-Coding Angiography as a Predictor for Developing Subsequent Symptomatic Vasospasm After Aneurysmal Subarachnoid Hemorrhage

INTRODUCTION

Prediction of vasospasm after aneurysmal subarachnoid hemorrhage (aSAH) remains imperfect and currently relies on clinical and radiographic characteristics. Whether early hemodynamic changes may refine risk stratification for delayed vasospasm (DV) after aSAH was analyzed.

METHODS

Patients with aSAH (n = 53) and a control group with unruptured intracranial aneurysms (UIA) (n = 12) with initial color-coding angiography at admission were included in this study (n = 65). Clinical and radiologic data were collected, and uni- and multivariate analysis was used to correlate the occurrence of DV (manifesting clinically or detected with transcranial Doppler or angiography) with hemodynamic features of the initial angiography including Tmax and mean transit times (MTTs).

RESULTS

In the aSAH patient cohort, 37 of 53 patients with aSAH (70%) developed DV. After we controlled for the effects of age, Hunt and Hess grade, and modified Fisher grade, patients with DV had a shorter mean region of interest peak time (Tmax) of the anterior cerebral artery A2 segment (P = 0.036) and the middle cerebral artery M1 (P = 0.045) and M3 (P = 0.013) segments. Mean MTTs between internal carotid artery to middle cerebral artery M3 segment (P = 0.026) was also significantly shorter in patients with DV when compared with controls.

CONCLUSIONS

Tmax and MTT on angiography within 48 hours of aneurysm rupture before treatment provide an early quantitative assessment in patients with aSAH and in this small study were predictive for the development of subsequent symptomatic DV. Early identification of patients with aSAH at greatest risk of DV may ameliorate clinical outcome through timely, selective implementation of aggressive prophylactic therapy to prevent the effects of DV.

Predictors of Acute Vertebrobasilar Vasospasm following Tumor Resection in the Foramen Magnum Region

Objective

Cerebral vasospasm can occur after skull base tumor removal. Few studies concentrated on the posterior circulation vasospasm after tumor resection in the posterior fossa. We aimed to identify the risk factors associated with postoperative vertebrobasilar vasospasm after tumor resection in the foramen magnum.

Methods

We retrospectively reviewed the data of 62 patients with tumors in the foramen magnum at our institution from January 2010 to January 2015. The demographic data, tumor features, surgical characteristics were collected. Vertebrobasilar vasospasm was evaluated by bedside transcranial Doppler before surgery and on postoperative day 1, 3, 7. Univariate and multivariate analyses were performed to determine the predictors of postoperative vasospasm in the posterior circulation.

Results

Vertebrobasilar vasospasm was detected in 28 (53.8%) of the 62 patients at a mean time of 3.5 days after surgery. There were 5 (8%) patients with severe vasospasm according to the grading criteria. Age, tumor type, tumor size, vertebral artery encasement, and surgical time were significantly related to vasospasm in the univariate analysis. Further multivariate analysis demonstrated that only age and vertebral artery encasement were independent risk factors predicting the occurrence of postoperative vertebrobasilar vasospasm.

Conclusions

The incidence of acute vertebrobasilar vasospasm is not uncommon after foramen magnum tumor resection. Age and vertebral artery encasement are significantly correlated with postoperative vasospasm. Close monitoring of vasospasm should be given to patients with younger age and the presence of vertebral artery encasement on the preoperative imaging to facilitate early diagnosis and intervention.