Trends in Admissions and Outcomes for Treatment of Aneurysmal Subarachnoid Hemorrhage in the United States

Analysis and comparison of trends in the burden of subarachnoid hemorrhage in china and globally, 1990-2021

BACKGROUND

Subarachnoid hemorrhage (SAH), the rarest form of hemorrhagic stroke, is associated with high mortality and disability rates. Therefore, it is a major public health concern.

METHODS

This study reviewed the epidemiological characteristics of SAH in China and worldwide, focusing on the 2021 Global Burden of Disease (GBD) database. Researchers, using the GBD database, conducted epidemiological studies that included joinpoint regression analyses covering the incidence, mortality, prevalence, and disability-adjusted life years of SAH in the years 1990-2021. This analysis revealed the trends and effects of SAH in China and globally.

RESULTS

From 1990 to 2021, the age-standardized incidence rate (ASIR) in China decreased from 17.96 to 7.81 per 100,000 people. The age-standardized mortality rate (ASMR) decreased from 27.29 to 4.72 per 100,000 people. This resulted in a 51.58 % reduction in mortality. In contrast, both the ASIR and ASMR showed a slower decline at the global level. China has reported that women aged 70 years and older are at a high risk for SAH. Furthermore, middle-aged men have high prevalence and mortality rates.

CONCLUSIONS

The current observations warrant the design of focused interventions for both the elderly and female patients with oblique stroke. They can be useful for addressing the SAH burden globally. This study provides valuable information regarding the effectiveness of existing healthcare interventions. This information can also inform future strategies for the prevention and management of SAH.

High risk and low incidence diseases: Aneurysmal subarachnoid hemorrhage

INTRODUCTION

Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition that carries a high rate of morbidity.

OBJECTIVE

This review highlights the pearls and pitfalls of aSAH, including presentation, diagnosis, and management in the emergency department based on current evidence.

DISCUSSION

aSAH is a type of hemorrhagic stroke, most commonly from rupture of a saccular aneurysm, which results in leakage of blood into the subarachnoid space. It presents acutely and has many mimics, making the diagnosis difficult. Patients who present with either sentinel or acute presentation of a headache that is described as sudden or severe, has associated neck stiffness, cranial nerve deficits, syncope, seizure, and/or coma should raise suspicion for the diagnosis. Non-contrast head computed tomography is the imaging modality of choice for evaluation and diagnosis of the disease in patients who present acutely. Further diagnostic testing with lumbar puncture or advanced neuroimaging may be required in patients who present >6 h after symptom onset. Patients with aSAH require critical, multidisciplinary care, with particular attention to management of airway, breathing, and circulation; expeditious referral for neurosurgical intervention; coagulopathy reversal; and prophylaxis against downstream complications.

CONCLUSION

An understanding of aSAH can assist emergency clinicians in diagnosing and managing this disease.

Meningeal lymphatic drainage: novel insights into central nervous system disease

In recent years, increasing evidence has suggested that meningeal lymphatic drainage plays a significant role in central nervous system (CNS) diseases. Studies have indicated that CNS diseases and conditions associated with meningeal lymphatic drainage dysfunction include neurodegenerative diseases, stroke, infections, traumatic brain injury, tumors, functional cranial disorders, and hydrocephalus. However, the understanding of the regulatory and damage mechanisms of meningeal lymphatics under physiological and pathological conditions is currently limited. Given the importance of a profound understanding of the interplay between meningeal lymphatic drainage and CNS diseases, this review covers seven key aspects: the development and structure of meningeal lymphatic vessels, methods for observing meningeal lymphatics, the function of meningeal lymphatics, the molecular mechanisms of meningeal lymphatic injury, the relationships between meningeal lymphatic vessels and CNS diseases, potential regulatory mechanisms of meningeal lymphatics, and conclusions and outstanding questions. We will explore the relationship between the development, structure, and function of meningeal lymphatics, review current methods for observing meningeal lymphatic vessels in both animal models and humans, and identify unresolved key points in meningeal lymphatic research. The aim of this review is to provide new directions for future research and therapeutic strategies targeting meningeal lymphatics by critically analyzing recent advancements in the field, identifying gaps in current knowledge, and proposing innovative approaches to address these gaps.

TMEM119-positive microglial cells in cerebrospinal fluid, a potential new marker for neuroinflammatory response after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a debilitating condition with significant morbidity and mortality rates. Despite advancements in treatment, understanding the underlying pathophysiology, particularly the inflammatory response, remains crucial for improving patient outcomes. In this study, we investigated the presence of transmembrane protein 119 (TMEM119) of microglial cells in cerebrospinal fluid (CSF) as a potential marker for neuroinflammation following aSAH. CSF samples were collected from aSAH patients, pathological and healthy controls, processed, and analyzed using immunocytochemistry. TMEM119-positive microglial cells were consistently identified in the CSF of aSAH patients, exhibiting amoeboid morphology and intense staining. Importantly, microglial cells were detected as early as the first day post-bleeding, persisting throughout the acute phase in some cases. Analysis of consecutive samples revealed varying trends in microglial cell numbers, with a peak during the initial phase followed by a gradual decline. Our findings suggest that microglia may migrate into the CSF following aSAH, potentially serving as an early predictor of inflammatory-related CNS damage. This study underscores the importance of understanding neuroinflammatory processes in aSAH and opens avenues for further research on the role of microglia in CNS disorders by liquid biopsy.

National trends in surgical treatment and clinical outcomes among patients with aneurysmal subarachnoid hemorrhage in the Republic of Korea

OBJECTIVE

In this study, changes in treatment methods and patient prognosis were analyzed using a Korean nationwide medical insurance information database.

METHODS

Patients with subarachnoid hemorrhage who received surgical treatment for cerebral aneurysm from 2005 to 2020 were included. The specific surgery type was classified using the surgical code and according to whether stents were used. Yearly trends in mortality rates and poor prognosis, using tracheostomy as proxy, were analyzed by a simple regression analysis. A multistep logistic regression analysis was performed to evaluate the risk factors of mortality and poor prognosis.

RESULTS

Overall, 83,587 patients were included. Females were predominant (64.5%). Microsurgical clip usage rate decreased by approximately two-thirds from 78.8% in 2005 to 24.4% in 2020. Contrarily, endovascular treatment proportion gradually increased, and stent-assisted coil embolization rate surpassed microsurgical clip usage rate in 2020 (24.6% vs. 24.4%). In the multivariate analysis, endovascular treatment correlated positively with 3-month mortality (hazard ratio [HR]: 1.13, 95% confidence interval [CI]: 1.07-1.19, P<0.0001), although correlated negatively with poor prognosis (tracheostomy) (HR: 0.93, 95% CI: 0.89-0.98, P=0.0050).

CONCLUSIONS

According to the treatment trend analysis, during the 16 years studied, for patients with subarachnoid hemorrhage due to ruptured cerebral aneurysm, the endovascular treatment rate increased rapidly and stent-assisted coil embolization rate surpassed that of microsurgical clip ligation. Diversification of treatment methods has led to a decrease in mortality and improved prognosis.

Long-term functional outcomes among patients surviving aneurysmal subarachnoid hemorrhage: The KOSCO study

BACKGROUND AND OBJECTIVES

Aneurysmal subarachnoid hemorrhage (aSAH) remains a significant global health concern, and therefore, understanding their functional outcomes is essential. The aim of this study was to investigate the 1-year functional outcomes of patients with aSAH.

METHODS

We retrospectively analyzed data of patients with aSAH from the Korean Stroke Cohort for Functioning and Rehabilitation study, up to 1 year post-onset. The cohort data were collected twice. The first data was collected from August 2012 through May 2015, and the second data was collected from January to December in 2020, from nine different hospitals. Assessments were performed from 7 days to 1 year. Disability, measured by modified Rankin Scale (mRS), was analyzed in terms of good outcome (mRS 0 or 1) and mortality. In addition, functional level was further assessed using Functional Independence Measure (FIM) in aSAH survivors at 1 year post-onset. A subgroup analysis was conducted, with participants further classified into two groups: one with mild-to-moderate disability (mRS 0-3) and another with severe disability (mRS 4 or 5), as reported 7 days after onset. Multiple imputation method was used to handle missing data. In addition, mixed-effects model was used to analyze the trajectory of FIM.

RESULTS

A total of 517 patients with aSAH were included. Of these, 246 (47.6%) showed mild-to-moderate disability and 271 (52.4%) showed severe disability at 7 days. At 1 year after onset, the mortality rate was 6.0% and the good outcome was reported in 76.2% of patients. In aSAH survivors at 1 year, FIM showed a significant improvement over time, with a significant difference demonstrated between the subgroups. Age, initial clinical severity, and cognitive function at 7 days were also identified as significant covariates.

CONCLUSIONS

The majority of patients reporting mild-to-moderate disability at 7 days exhibited good functional outcome, and even among those with severe disability, there was a favorable outcome with continuous improvement in their functional levels. Therefore, proper assessments and effective management should be employed to achieve favorable functional outcomes among aSAH survivors.

Evidence-Based Approach to Cerebral Vasospasm and Delayed Cerebral Ischemia: Milrinone as a Therapeutic Option-A Narrative Literature Review and Algorithm Treatment Proposition

Aneurysmal subarachnoid hemorrhage (aSAH) is a severe neurocritical condition often complicated by cerebral vasospasm (CVS), leading to delayed cerebral ischemia (DCI) and significant morbidity and mortality. Despite advancements in management, therapeutic options with robust evidence remain limited. Milrinone, a phosphodiesterase type 3 (PDE3) inhibitor, has emerged as a potential therapeutic option. Intravenous milrinone demonstrated clinical and angiographic improvement in 67% of patients, reducing the need for mechanical angioplasty and the risk of functional disability at 6 months (mRS ≤ 2). Side effects, including hypotension, tachycardia, and electrolyte disturbances, were observed in 33% of patients, occasionally leading to early drug discontinuation. Based on the evidence, we propose a treatment algorithm for using milrinone to optimize outcomes and standardize its application in neurocritical care settings.

Temporal trends and practice variation in early repair of the ruptured aneurysm among patients with aneurysmal subarachnoid hemorrhage in the United States, 2012-2019

BACKGROUND

Early repair of the ruptured cerebral aneurysm (RRCA), preferably within 24 h of onset, is endorsed by clinical guideline as the preferred management strategy for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, a comprehensive picture of this guideline-recommended usage in contemporary clinical practice is not available.

AIMS

This study aimed to characterize trends over time and practice variation in the implementation of an early RRCA strategy among patients with aSAH in a large, national representative data.

METHODS

Using data from the 2012-2019 National Inpatient Sample, we measured trends in the proportion of early RRCA, defined as within day 1 of admission, overall, and by demographic and geographical subgroups. In addition, we created multilevel regression models to quantify hospital-level variation in the early RRCA rates.

RESULTS

We identified 82,615 aSAH hospitalizations (mean age = 56.1 years; 68.9% women) undergoing RRCA and, among these, 84.0% (95% confidence interval (CI) = 83.4-84.7%) receiving early RRCA. The proportion of early RRCA increased steadily from 82.5% in 2012 to 85.8% in 2019 (p for trend <0.001). The proportion of patients receiving early RRCA across geographic regions ranged from 78.7% to 87.9%, with a median (interquartile range (IQR)) of 84.2% (83.0-86.1%). In contrast, the delivery of early RRCA varied widely among hospitals, with a median (IQR) rate of 86.1% (75.0-100.0%) and a range from 0% to 100.0%. The median odds ratio for the early use of RRCA treatment was 1.24 (95% CI = 1.21-1.27) in 2019, indicating 24% increased odds of implementing early RRCA if moving from a lower-use to a higher-use hospital.

CONCLUSIONS

Most patients in the United States with aSAH received early RRCA treatment and exhibited an upward trend over the recent 8-year period. However, substantial variation in access to early RRCA was observed across population subgroups, particularly at the hospital level. Future efforts are necessary to identify further sources of this variation and to develop initiatives that could represent an opportunity to optimize guideline-based quality of care in aSAH management.

DATA ACCESS STATEMENT

The data are available from the corresponding author upon reasonable request following completion of onboarding and verification procedures as specified by the HCUP.

Trajectory clustering of immune cells and its association with clinical outcomes after aneurysmal subarachnoid hemorrhage

Background and purpose

The immune response following aneurysmal subarachnoid hemorrhage (aSAH) can exacerbate secondary brain injury and impact clinical outcomes. As the immune response after aSAH is a dynamic process, we aim to track and characterize immune cell trajectories over time to identify patterns associated with various clinical outcomes.

Methods

In this retrospective single-center study of patients with aSAH, we analyzed immune cell count trajectories, including neutrophil, monocyte, and lymphocyte counts, collected from day 1 to day 14. These trajectories were classified into four distinct clusters utilizing the k-means longitudinal clustering method. A comprehensive multivariable analysis was performed to explore the associations of these immune cell clusters with various clinical outcomes. These outcomes included a Modified Rankin Scale score (mRS) of 3 to 6, indicative of poor functional outcomes, along with complications including shunt dependency, vasospasm, and secondary cerebral infarction.

Results

In this study, 304 patients with aSAH were analyzed. The trajectories of immune cell counts, including neutrophils, monocytes, and lymphocytes, were successfully categorized into four distinct clusters for each immune cell type. Within neutrophil clusters, both persistent neutrophilia and progressive neutrophilia were associated with poor functional outcomes, shunt dependency, and vasospasm, with resolving neutrophilia showing a lesser degree of these associations. Within monocyte clusters, early monocytosis was associated with vasospasm, whereas delayed monocytosis was associated with shunt dependency. Within lymphocyte clusters, both early transient lymphopenia and early prolonged lymphopenia were associated with poor functional outcomes.

Conclusion

Our study demonstrates that distinct immune cell trajectories post-aSAH, identified through unsupervised clustering, are significantly associated with specific clinical outcomes. Understanding these dynamic immune responses may provide key insights with potential for future therapeutic strategies.

Effect of astragalus membranaceus on neurological function in acute aneurysmal subarachnoid hemorrhage patients with high inflammation: A preliminary randomized, double-blind, placebo-controlled clinical trial

Background and aim

Astragalus membranaceus (AM) is a traditional Chinese herb. Our previous study revealed that AM can enhance neurological function in patients with acute intracerebral hemorrhage. The aim of this study was to investigated the effects of AM on patients with acute aneurysmal subarachnoid hemorrhage (aSAH).

Experimental procedure

Eighty-eight patients experiencing acute aSAH were randomly allocated to either the treatment group (TG) comprising 44 patients, who received 3 g of AM orally thrice daily for 14 days, or the control group (CG) with 44 patients, who received 3 g of a placebo.

Results

Eighty-three patients (41 in CG and 42 in TG) completed the trial. Stratified analyses revealed serum interleukin-6 (IL-6) median ≥7.28 pg/mL at baseline. The percentage of good GOS scores (GOS 4 or 5) at two weeks (W2) and four weeks (W4) was significantly higher in TG than in CG (W2: 35.3 % vs. 7.7 %, p = 0.042; W4: 62.5 % vs. 30.8 %, p = 0.044). Moreover, a higher percentage of Barthel index scores (>60) was observed in TG than in CG at W2 (35.3 % vs. 7.7 %, p = 0.042) after AM or placebo administration.

Conclusion

Administering AM for 14 days has shown potential in enhancing neurological function four weeks post-aSAH onset, especially in patients with a serum IL-6 level median ≥7.28 pg/mL. Therefore, further research is warranted to explore the anti-inflammatory role of AM. However, this study's limitations include a small sample size and the single-center design, signifying its status as a preliminary investigation.

Trends in Hospitalization and Mortality Rates Associated with Subarachnoid Hemorrhage and Unruptured Cerebral Aneurysms in Brazil

BACKGROUND

Epidemiology of spontaneous subarachnoid hemorrhage (SAH) and unruptured intracranial aneurysm (UIA) is valuable for determining neurosurgical and general health care effectiveness. There is an information gap regarding these conditions in middle- and low-income countries. Therefore, we aimed to investigate hospitalization and mortality rates for SAH and UIA in Brazil from 2011 to 2019.

METHODS

This observational, population-based study used hospital admission and mortality data and included all SAH- and UIA-related public hospitalizations and deaths occurring from 2011 to 2019. Data were obtained from the Ministry of Health National Hospitalisation and Mortality Information Systems. Population data were obtained from the Brazilian Institute of Geography and Statistics. Simple linear regression models with normal responses were adjusted to explain the temporal evolution of variables. Joinpoint regression models were adjusted to detect moments of significant change in variable behavior. Graduated choropleth maps were generated using georeferencing and geospatial analyses.

RESULTS

Annual SAH hospitalization and mortality coefficients were 4.81/100,000 and 2.49/100,000 persons, respectively. UIA hospitalization and mortality coefficients were 1.21/100,000 and 0.24/100,000 persons, respectively. In addition to regional differences, we found a stable SAH hospitalization trend and an increasing mortality rate of 0.062 cases/100,000 inhabitants annually. The UIA hospitalization rate increased by 0.074 cases/100,000 inhabitants annually, and mortality decreased by 0.07 deaths/100,000 inhabitants annually.

CONCLUSIONS

In Brazil, the SAH hospitalization trend is stable, although there is a worrisome increasing SAH-related mortality trend. A better scenario was observed for UIA, with an increase in hospitalizations and decrease in mortality.

CT perfusion imaging in aneurysmal subarachnoid hemorrhage. State of the art

CT perfusion (CTP) images can be easily and rapidly obtained on all modern CT scanners and have become part of the routine imaging protocol of patients with aneurysmal subarachnoid haemorrhage (aSAH). There is a growing body of evidence supporting the use of CTP imaging in these patients, however, there are significant differences in the software packages and methods of analysing CTP. In. addition, no quantitative threshold values for tissue at risk (TAR) have been validated in this patients' population. Here we discuss the contribution of the technique in the identification of patients at risk of aSAH-related delayed cerebral ischemia (DCI) and in the assessment of the response to endovascular rescue therapy (ERT). We also address the limitations and pitfalls of automated CTP postprocessing that are specific to aSAH patients as compared to acute ischemic stroke (AIS).

Race, Ethnicity, and Gender Disparities in the Management and Outcomes of Critically Ill Adults with Acute Stroke

Racial, ethnicity and sex disparities are pervasive in the evaluation and acute care of ischemic stroke patients. Administration of intravenous thrombolysis and mechanical thrombectomy are the most critical steps in ischemic stroke treatment but compared to White patients, ischemic stroke patients from minority racial and ethnic groups are less likely to receive these potentially life-saving interventions. Sex and racial disparities in intracerebral hemorrhage or subarachnoid hemorrhage treatment have not been well studied.

Potential role of endothelial progenitor cells in the pathogenesis and treatment of cerebral aneurysm

Cerebral aneurysm (CA) is a significant health concern that results from pathological dilations of blood vessels in the brain and can lead to severe and potentially life-threatening conditions. While the pathogenesis of CA is complex, emerging studies suggest that endothelial progenitor cells (EPCs) play a crucial role. In this paper, we conducted a comprehensive literature review to investigate the potential role of EPCs in the pathogenesis and treatment of CA. Current research indicates that a decreased count and dysfunction of EPCs disrupt the balance between endothelial dysfunction and repair, thus increasing the risk of CA formation. Reversing these EPCs abnormalities may reduce the progression of vascular degeneration after aneurysm induction, indicating EPCs as a promising target for developing new therapeutic strategies to facilitate CA repair. This has motivated researchers to develop novel treatment options, including drug applications, endovascular-combined and tissue engineering therapies. Although preclinical studies have shown promising results, there is still a considerable way to go before clinical translation and eventual benefits for patients. Nonetheless, these findings offer hope for improving the treatment and management of this condition.

CT perfusion-guided administration of IV milrinone is associated with a reduction in delayed cerebral infarction after subarachnoid hemorrhage

Delayed cerebral ischemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a singular pathological entity necessitating early diagnostic approaches and both prophylactic and curative interventions. This retrospective before-after study investigates the effects of a management strategy integrating perfusion computed tomography (CTP), vigilant clinical monitoring and standardized systemic administration of milrinone on the occurrence of delayed cerebral infarction (DCIn). The "before" period included 277 patients, and the "after" one 453. There was a higher prevalence of Modified Fisher score III/IV and more frequent diagnosis of vasospasm in the "after" period. Conversely, the occurrence of DCIn was reduced with the "after" management strategy (adjusted OR 0.48, 95% CI [0.26; 0.84]). Notably, delayed ischemic neurologic deficits were less prevalent at the time of vasospasm diagnosis (24 vs 11%, p = 0.001 ), suggesting that CTP facilitated early detection. In patients diagnosed with vasospasm, intravenous milrinone was more frequently administered (80 vs 54%, p < 0.001 ) and associated with superior hemodynamics. The present study from a large cohort of aSAH patients suggests, for one part, the interest of CTP in early diagnosis of vasospasm and DCI, and for the other the efficacy of CT perfusion-guided systemic administration of milrinone in both preventing and treating DCIn.

Trends in Demographic and Geographic Disparities in Stroke Mortality Among Older Adults in the United States

BACKGROUND

Stroke is a leading cause of morbidity and mortality in the United States among older adults. However, the impact of demographic and geographic risk factors remains ambiguous. A clear understanding of these associations and updated trends in stroke mortality can influence health policies and interventions.

METHODS

This study characterizes stroke mortality among older adults (age ≥55) in the US from January 1999 to December 2020, sourcing data from the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research. Segmented regression was used to analyze trends in crude mortality rate and age-adjusted mortality rate (AAMR) per 100,000 individuals stratified by stroke subcategory, sex, ethnicity, urbanization, and state.

RESULTS

A total of 3,691,305 stroke deaths occurred in older adults in the US between 1999 and 2020 (AAMR = 233.3), with an overall decrease in AAMR during these years. The highest mortality rates were seen in nonspecified stroke (AAMR = 173.5), those 85 or older (crude mortality rate1276.7), men (AAMR = 239.2), non-Hispanic African American adults (AAMR = 319.0), and noncore populations (AAMR = 276.1). Stroke mortality decreased in all states from 1999 to 2019 with the greatest and least decreases seen in California (-61.9%) and Mississippi (-35.0%), respectively. The coronavirus pandemic pandemic saw increased stroke deaths in most groups.

CONCLUSIONS

While there's a decline in stroke-related deaths among US older adults, outcome disparities remain across demographic and geographic sectors. The surge in stroke deaths during coronavirus pandemic reaffirms the need for policies that address these disparities.

Monitoring of Perioperative Microcirculation Dysfunction by Near-Infrared Spectroscopy for Neurological Deterioration and Prognosis of Aneurysmal Subarachnoid Hemorrhage: An Observational, Longitudinal Cohort Study

INTRODUCTION

No evidence has established a direct causal relationship between early microcirculation disturbance after aneurysmal subarachnoid hemorrhage (aSAH) and neurological function prognosis, which is the key pathophysiological mechanism of early brain injury (EBI) in patients with aSAH.

METHODS

A total of 252 patients with aSAH were enrolled in the Neurosurgical Intensive Care Unit of Southwest Hospital between January 2020 and December 2022 and divided into the no neurological deterioration, early neurological deterioration, and delayed neurological deterioration groups. Indicators of microcirculation disorders in EBI included regional cerebral oxygen saturation (rSO2) measured by near-infrared spectroscopy (NIRS), brain oxygen monitoring, and other clinical parameters for evaluating neurological function and determining the prognosis of patients with aSAH.

RESULTS

Our data suggest that the rSO2 is generally lower in patients who develop neurological deterioration than in those who do not and that there is at least one time point in the population of patients who develop neurological deterioration where left and right cerebral hemisphere differences can be significantly monitored by NIRS. An unordered multiple-classification logistic regression model was constructed, and the results revealed that multiple factors were effective predictors of early neurological deterioration: reoperation, history of brain surgery, World Federation of Neurosurgical Societies (WFNS) grade 4-5, Fisher grade 3-4, SAFIRE grade 3-5, abnormal serum sodium and potassium levels, and reduced rSO2 during the perioperative period. However, for delayed neurological deterioration in patients with aSAH, only a history of brain surgery and perioperative RBC count were predictive indicators.

CONCLUSIONS

The rSO2 concentration in patients with neurological deterioration is generally lower than that in patients without neurological deterioration, and at least one time point in the population with neurological deterioration can be significantly monitored via NIRS. However, further studies are needed to determine the role of microcirculation and other predictive factors in the neurocritical management of EBI after aSAH, as these factors can reduce the incidence of adverse outcomes and mortality during hospitalization.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Myelin sheath injury and repairment after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) can lead to damage to the myelin sheath in white matter. Through classification and analysis of relevant research results, the discussion in this paper provides a deeper understanding of the spatiotemporal change characteristics, pathophysiological mechanisms and treatment strategies of myelin sheath injury after SAH. The research progress for this condition was also systematically reviewed and compared related to myelin sheath in other fields. Serious deficiencies were identified in the research on myelin sheath injury and treatment after SAH. It is necessary to focus on the overall situation and actively explore different treatment methods based on the spatiotemporal changes in the characteristics of the myelin sheath, as well as the initiation, intersection and common action point of the pathophysiological mechanism, to finally achieve accurate treatment. We hope that this article can help researchers in this field to further clarify the challenges and opportunities in the current research on myelin sheath injury and treatment after SAH.

Rethinking the initial changes in subarachnoid haemorrhage: Focusing on real-time metabolism during early brain injury

Over the last two decades, neurological researchers have uncovered many pathophysiological mechanisms associated with subarachnoid haemorrhage (SAH), with early brain injury and delayed cerebral ischaemia both contributing to morbidity and mortality. The current dilemma in SAH management inspired us to rethink the nature of the insult in SAH: sudden bleeding into the subarachnoid space and hypoxia due to disturbed cerebral circulation and increased intracranial pressure, generating exogenous stimuli and subsequent pathophysiological processes. Exogenous stimuli are defined as factors which the brain tissue is not normally exposed to when in the healthy state. Intersections of these initial pathogenic factors lead to secondary brain injury with related metabolic changes after SAH. Herein, we summarized the current understanding of efforts to monitor and analyse SAH-related metabolic changes to identify those precise pathophysiological processes and potential therapeutic strategies; in particular, we highlight the restoration of normal cerebrospinal fluid circulation and the normalization of brain-blood interface physiology to alleviate early brain injury and delayed neurological deterioration after SAH.