Subarachnoid Hemorrhage

Cerebrospinal fluid soluble growth stimulation expressed gene 2: A potential predictor of outcome for prognosis after aneurysmal subarachnoid hemorrhage

Background

Serum concentration of soluble growth stimulation expressed gene 2 (sST2) appears to have prognostic value in patients with aneurysmal subarachnoid hemorrhage (aSAH) by now. This study aimed to investigate the relationship between cerebrospinal fluid (CSF) sST2 concentration and outcome in patients with aSAH.

Methods

A total of 65 aSAH patients who met the inclusion criteria in the Neurosurgery Department of Jining No.1 People's Hospital from March 2021 to August 2022 were selected as the research objects. 35 patients with the third month Modified-Rankin-Scale (mRS) score of 0-2 were divided into good prognosis group, and 30 patients with the third month mRS score of 3-5 were divided into poor prognosis group. CSF was collected by lumbar puncture for the first 5 days after aneurysm surgery. CSF sST2 concentration was determined using an enzyme-linked immunosorbent assay.

Results

In all patients, CSF sST2 concentrations initially increased, peaked on day 2, and then decreased. Compared with the good prognosis group, the sST2 concentration was significantly increased in the poor prognosis group at 1, 2, 3, 4 and 5 days after aSAH surgery. CSF sST2 concentration exhibited good diagnostic performance for predicting outcome (area under the receiver operating characteristic curve = 0.988). Additionally, CSF sST2 concentration has good performance for predicting cerebral edema, but only in the poor prognosis group (area under the curve = 0.93).

Conclusions

Elevated CSF sST2 concentration is associated with poor outcome in aSAH patients. CSF sST2 may have a role as a predictive biomarker in these patients.

Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage

OBJECTIVE

Patient safety indicators (PSI) are a set of potentially preventable events related to patient safety and opportunities for improvement. Eight pertinent PSI have been identified in patients with aneurysmal subarachnoid haemorrhage (ASAH), such as decubitus ulcer, and central line-related bacteraemia. Our aim was to evaluate the efficacy of a health care quality protocol to prevent the appearance of PSI in ASAH patients.

METHODS

Adult patients treated for ASAH were included in a retrospective control group of 35 patients and a prospective experimental group of 35 patients when the prevention program was implemented. We evaluated the occurrence of PSI, and its relation to age, sex, Hunt and Hess scale grade, type of aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale scores.

RESULTS

Both groups had similar characteristics except for a longer hospital stay in the control group. The overall PSI prevalence decreased significantly in the experimental group compared to the control group. The experimental group had a decreased risk for having at least one PSI: OR = 0.21 (0.08-0.57, CI 95%). The absolute risk reduction is 37.1% (58.9%-15.4%), the preventable fraction for the population is 28.3% (10.6%-40.0%), and the number needed to treat is 2.69.

CONCLUSIONS

The health care quality protocol is effective to prevent ISP in ASAH patients. Implementing this prevention program has no effect on the neurological state of the patient at the hospital discharge. Still, it is successful in decreasing the PSI prevalence and the days of hospital stay.

Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms

OBJECTIVE

To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA).

METHODS

IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation.

RESULTS

Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND.

CONCLUSIONS

Significant IONM changes during EVT for rIA are associated with an increased risk of PPND.

SIGNIFICANCE

IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.

Interaction between Neurogenic Pulmonary Edema and Thoracic 3 DRG Degeneration Following Spinal Subarachnoid Hemorrhage: First Experimental Study

BACKGROUND

 Neurogenic pulmonary edema (NPE) following subarachnoid hemorrhage (SAH) is still one of the most catastrophic complications with high morbidity and mortality rates. Systemic sympathetic hyperactivity has been considered in the pathogenesis, but it has not been clarified. In this study, we investigate the relationship between the degeneration of the T3 dorsal root ganglion (DRG) and the development of NPE following spinal SAH.

METHODS

 The study was conducted on 23 rabbits. Five rabbits were used as the control group, 5 as the sham group (n = 5), and 13 as the study group. The correlation between the degenerated neuronal densities of the T3 nerve axons and neurons in the DRG and NPE scores was analyzed statistically.

RESULTS

 A correlation between the neuronal degeneration of the T3 nerve, its DRG, and high NPE scores was found in the study group and the sham group. Massive NPE was detected in the study group along with neural degeneration of T3 axons and ganglia.

CONCLUSION

 The present study indicates that NPE and pulmonary artery vasospasm can be prevented by reducing T3 DRG degeneration.

Taurine ameliorates sensorimotor function by inhibiting apoptosis and activating A2 astrocytes in mice after subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is a form of severe acute stroke with very high mortality and disability rates. Early brain injury (EBI) and delayed cerebral ischemia (DCI) contribute to the poor prognosis of patients with SAH. Currently, some researchers have started to focus on changes in amino acid metabolism that occur in brain tissues after SAH. Taurine is a sulfur-containing amino acid that is semi-essential in animals, and it plays important roles in various processes, such as neurodevelopment, osmotic pressure regulation, and membrane stabilization. In acute stroke, such as cerebral hemorrhage, taurine plays a neuroprotective role. However, the role of taurine after subarachnoid hemorrhage has rarely been reported. In the present study, we established a mouse model of SAH. We found that taurine administration effectively improved the sensorimotor function of these mice. In addition, taurine treatment alleviated sensorimotor neuron damage and reduced the proportion of apoptotic cells. Furthermore, taurine treatment enhanced the polarization of astrocytes toward the neuroprotective phenotype while inhibiting their polarization toward the neurotoxic phenotype. This study is the first to reveal the relationship between taurine and astrocyte polarization and may provide a new strategy for SAH research and clinical treatment.

Investigation of the protective effects of piceatannol on experimental subarachnoid hemorrhage in rats

BACKGROUND

Subarachnoid hemorrhage (SAH) is one of the most prevalent brain injuries in humans which has poor prognosis and high mortality rates. Due to several medical or surgical treatment methods, a gold standard method doesn't exist for SAH treatment. Piceatannol (PCN), a natural analog of resveratrol, was reported to reduce inflammation and apoptosis promising a wide range of therapeutic alternatives. In this study, we aimed to investigate the effects of PCN in an experimental SAH model. The alleviating effects of PCN in the hippocampus in an experimental SAH model were investigated for the first time.

METHODS AND RESULTS

In this study, 27 Wistar Albino male rats (200-300 g; 7-8 week) were used. Animals were divided into three groups; SHAM, SAH, and SAH + PCN. SAH model was created with 120 µl of autologous arterial tail blood to prechiasmatic cisterna. 30 mg/kg PCN was administered intraperitoneally at 1st h after SAH. Neurological evaluation was performed with Garcia's score. RT-PCR was performed for gene expression levels in the hippocampus. Pyknosis, edema, and apoptosis were evaluated by H&E and TUNEL staining. Our results indicated that PCN administration reduced apoptosis (P < 0.01), cellular edema, and pyknosis (P < 0.05) in the hippocampus after SAH. Moreover, PCN treatment significantly decreased the expression levels of TNF-α (P < 0.01), IL-6 (P < 0.05), NF-κB (P < 0.05), and Bax (P < 0.05) in the hippocampus.

CONCLUSIONS

Our results demonstrated that PCN might be a potential therapeutic adjuvant agent for the treatment of early brain injury (EBI) following SAH. Further studies are required to clarify the underlying mechanisms and treatment options of SAH.

Ferroptosis in early brain injury after subarachnoid hemorrhage: review of literature

Spontaneous subarachnoid hemorrhage (SAH), mainly caused by ruptured intracranial aneurysms, is a serious acute cerebrovascular disease. Early brain injury (EBI) is all brain injury occurring within 72 h after SAH, mainly including increased intracranial pressure, decreased cerebral blood flow, disruption of the blood-brain barrier, brain edema, oxidative stress, and neuroinflammation. It activates cell death pathways, leading to neuronal and glial cell death, and is significantly associated with poor prognosis. Ferroptosis is characterized by iron-dependent accumulation of lipid peroxides and is involved in the process of neuron and glial cell death in early brain injury. This paper reviews the research progress of ferroptosis in early brain injury after subarachnoid hemorrhage and provides new ideas for future research.

Feasibility and Reliability of Transcranial POCUS Color-Coded Duplex Sonography Performed by Physicians of Varied Ultrasound Experience in Diagnosing Vasospasm in Aneurysmal Subarachnoid Hemorrhage

PURPOSE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality, which is largely attributable to secondary complications such as vasospasm and subsequent delayed cerebral ischemia. Transcranial Doppler (TCD) is recommended for the screening of vasospasm; however, technicians are not always available. We aimed to see how feasible and reliable bedside transcranial point-of-care ultrasound (POCUS) color-coded duplex sonography was compared with formal non-imaging TCD in measuring velocities and in diagnosing vasospasm.

METHODS

This was a prospective observational study that took place in the neuroscience intensive care unit at a single academic medical center. Patients with aSAH who were undergoing formal TCDs were scanned on days 2-10 of their admission by physicians of ranging ultrasound experience. Absolute velocities were compared as well as the diagnosis of vasospasm via POCUS and formal TCDs.

RESULTS

A total of 226 bedside ultrasound exams were performed and compared with 126 formal TCD studies. Sonographic windows were obtained in 89.4% of patients. Scans took 6.6 minutes to complete on average by the advanced group versus 14.5 minutes in the beginner. Correlation ranged from .52 in the beginner group to .65 in the advanced. When good quality of images obtained at a depth of 4-5 cm were reviewed, correlation of mean velocities increased to .96. Overall sensitivity for diagnosing vasospasm was 75%, with a specificity of 99% and negative predictive value of 99%.

CONCLUSION

Overall, POCUS TCD cannot replace a formal study performed by expert sonographers. An abbreviated POCUS scan can be performed quickly, however, particularly with more experienced operators. POCUS TCD can also feasibly detect vasospasm, and accurate velocities can be obtained by those with all levels of ultrasound experience. Care must be taken on image interpretation that velocities are obtained at an appropriate depth to ensure appropriate insonation of the MCA as well as in optimal alignment with the vessel to obtain the most accurate velocities.

Brain Plasticity Modulator p75 Neurotrophin Receptor in Human Urine after Different Acute Brain Injuries-A Prospective Cohort Study

Acute brain injuries (ABIs) pose a substantial global burden, demanding effective prognostic indicators for outcomes. This study explores the potential of urinary p75 neurotrophin receptor (p75NTR) concentration as a prognostic biomarker, particularly in relation to unfavorable outcomes. The study involved 46 ABI patients, comprising sub-cohorts of aneurysmal subarachnoid hemorrhage, ischemic stroke, and traumatic brain injury. Furthermore, we had four healthy controls. Samples were systematically collected from patients treated at the University Hospital of Turku between 2017 and 2019, at early (1.50 ± 0.70 days) and late (9.17 ± 3.40 days) post-admission time points. Urinary p75NTR levels, measured by ELISA and normalized to creatinine, were compared against patients' outcomes using the modified Rankin Scale (mRS). Early urine samples showed no significant p75NTR concentration difference between favorable and unfavorable mRS groups. In contrast, late samples exhibited a statistically significant increase in p75NTR concentrations in the unfavorable group (p = 0.033), demonstrating good prognostic accuracy (AUC = 70.9%, 95% CI = 53-89%, p = 0.03). Assessment of p75NTR concentration changes over time revealed no significant variation in the favorable group (p = 0.992) but a significant increase in the unfavorable group (p = 0.009). Moreover, p75NTR concentration was significantly higher in ABI patients (mean ± SD 40.49 ± 28.83-65.85 ± 35.04 ng/mg) compared to healthy controls (mean ± SD 0.54 ± 0.44 ng/mg), irrespective of sampling time or outcome (p < 0.0001). In conclusion, late urinary p75NTR concentrations emerged as a potential prognostic biomarker for ABIs, showing increased levels associated with unfavorable outcomes regardless of the specific type of brain injury. While early samples exhibited no significant differences, the observed late increases emphasize the time-dependent nature of this potential biomarker. Further validation in larger patient cohorts is crucial, highlighting the need for additional research to establish p75NTR as a reliable prognostic biomarker across various ABIs. Additionally, its potential role as a diagnostic biomarker warrants exploration.

Hyperoxia in neurocritical care: Current perspectives

In recent years, a lot of controversies have emerged regarding conservative versus liberal oxygen therapy in critically ill patients. While neurologically injured patients might have higher oxygen demand due to high cerebral metabolism, recent studies have clearly shown that hyperoxia may not be beneficial in improving the neurological outcome in traumatic brain injury, subarachnoid hemorrhage, and acute ischemic stroke. Rather, hyperoxia might worsen neurological outcome in such conditions by various mechanisms like direct cerebral vasoconstriction or by increased excitotoxicity, which in turn leads to lipid peroxidation and generation of harmful reactive oxygen species. This article brings into insight the current evidence on the effect of hyperoxia on these three acute neurological insults.

Frailty in aneurysmal subarachnoid hemorrhage: the risk analysis index

BACKGROUND

Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research.

METHODS

Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2.

RESULTS

42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001).

CONCLUSION

The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.

Modern Imaging of Aneurysmal Subarachnoid Hemorrhage

In this review, we discuss the imaging of aneurysmal subarachnoid hemorrhage (SAH). We discuss emergency brain imaging, aneurysm detection techniques, and the management of CTA-negative SAH. We also review the concepts of cerebral vasospasm and delayed cerebral ischemia that occurs after aneurysm rupture and their impact on patient outcomes. These pathologies are distinct, and the use of multimodal imaging modalities is essential for prompt diagnosis and management to minimize morbidity from these conditions. Lastly, new advances in artificial intelligence and advanced imaging modalities such as PET and MR imaging scans have been shown to improve the detection of aneurysms and potentially predict outcomes early in the course of SAH.

Not Your Typical Thunderclap Headache

We present the case of a young adult female who presented to the emergency department with headache and vomiting. After treatment with intravenous fluids, diphenhydramine and metoclopramide the headache completely resolved. Because of the patient's persistent symptoms and past medical history of systemic lupus erythematosus, a noncontrast head CT scan was done. In this case, the patient had a subarachnoid hemorrhage with edema and mass effect, detected on a noncontrast head CT scan. The patient required a nicardipine drip for blood pressure control. The patient recovered well and was discharged at her normal state of health. This case demonstrates the importance of maintaining high clinical suspicion for life-threatening emergencies even in patients with unremarkable physical exams who experience symptomatic improvement after treatment.

Non-Aneurysmal Perimesencephalic Subarachnoid Hemorrhage: A Literature Review

Spontaneous non-aneurysmal subarachnoid haemorrhage (NAPMSAH) (addressing point 1) is a relatively rare occurrence in clinical settings as it is rarely misdiagnosed and usually involves a significantly better prognosis than the classical aneurysmal pattern. We hereby focused on a comprehensive analysis of this distinct pathological entity with the purpose of analysing possible pathophysiological entities, outcomes and treatment options involving this diagnosis with a focus on demographical, epidemiological and clinical data. The clinical setting includes focal neurological signs related to the anatomical structures, while computer tomography followed by tomographic angiography are the most common diagnosis tools, with a typical hyperdense lesion involving the midbrain, fourth ventricle and subthalamic areas without an angiographic correspondent, such as an aneurysmal pathology. Further investigations can also be used to highlight this diagnosis, such as interventional angiography or magnetic resonance imaging. Given the rarity of this condition and its relatively better prognosis, treatment options usually remain conservative. In the present review, the main characteristics of NAPMSAH are discussed.

Clustering of serum biomarkers involved in post-aneurysmal subarachnoid hemorrhage (aSAH) complications

Post-aSAH sequela is characterized by the onset of life-threatening complications along with the upregulated underlying inflammation. Cerebral vasospasm (CVS) is one of the most frequent complication after aSAH, which contributes majorly to delayed cerebral ischemia and poor clinical outcome. The objective of this study was to identify the clusters of serum biomarkers that are associated with cerebral vasospasm (CVS) after suffering from aneurysmal subarachnoid hemorrhage (aSAH). In this single-center study, serum concentrations of 10 potential biomarkers, together with clinical and demographic parameters, for 66 aSAH patients were recorded within 24 h after aSAH. The dataset was split into a training set (43 patients) and a validation set. Correlation heatmaps for both datasets were computed. Variables with inconsistent correlations on the two subsets were excluded. Clusters of relevant biomarkers were identified on the complete set, separately for patients who developed post-aSAH CVS and those who did not. Two clusters were found to be specific for patients who suffered from CVS: mitochondrial gene fragments (cytochrome B (Cyt-B), cytochrome C oxidase subunit-1 (Cox-1), displacement loop (D-loop), and IL-23, and the other one, containing IL-6, IL-10, age, and Hunt and Hess score. Clusters of serum biomarkers, analyzed within 24 h of the onset of aSAH, days before the CVS development, are expressed differently in patients suffering from post-aSAH CVS, compared to patients without CVS. This suggests that these biomarkers may be involved in the pathophysiological processes leading to CVS and may be used as its early predictors. These interesting findings are potentially highly relevant for the management of CVS and call for validation on a larger sample of patients.

Higher Hospital Frailty Risk Score is associated with increased complications and healthcare resource utilization after endovascular treatment of ruptured intracranial aneurysms

AIM

To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs).

METHODS

A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge.

RESULTS

Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001).

CONCLUSIONS

Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.

Characteristics of subarachnoid hemorrhage associated with COVID-19 infection: A systematic review and descriptive analysis

OBJECTIVE

Subarachnoid hemorrhage (SAH) has been reported as a neurological manifestation in 0.1% of COVID-19 patients. This systematic review investigated the outcomes and predictive factors of SAH in patients with COVID-19.

MATERIALS AND METHODS

An electronic literature search was conducted on PubMed, Embase, and Scopus from inception to 10^th September 2021. Studies reporting SAH in COVID-19 patients were included. Demographic characteristics, risk factors for disease, severity of COVID-19, and mortality of SAH in COVID-19 patients were analyzed. Subgroup analyses stratified by COVID-19 severity and mortality were conducted.

RESULTS

17 case reports, 11 case series, and 2 retrospective cohort studies, with a total of 345 cases of SAH in COVID-19 patients, were included for analysis. Most published cases were reported in the US. Mean age was 55±18.4 years, and 162 patients (48.5%) were female. 242 patients (73.8%) had severe-to-critical COVID-19, 56.7% had aneurysmal SAH, 71.4% were on anticoagulation, and 10.8% underwent surgical treatment. 136 out of 333 patients (40.8%) died. Among patients with severe-to-critical COVID-19, 11 out of 18 (61.1%) died, and 8 out of 8 (100.0%) were non-aneurysmal SAH.

CONCLUSIONS

SAH is a rare but morbid occurrence in COVID-19. The mortality rate of COVID-SAH patients was 40.8%, with a higher prevalence of severe-to-critical COVID-19 (100% versus 53.8%) and non-aneurysmal SAH (85.7% versus 44.6%) among COVID-SAH deaths. Given the changing landscape of COVID-19 variants, further studies investigating the association between COVID-19 and SAH may be warranted to identify the long-term effects of COVID-19.

Downregulation of miR-26b attenuates early brain injury induced by subarachnoid hemorrhage via mediating the KLF4/STAT3/HMGB1 axis

BACKGROUND

Early brain injury (EBI) refers to early-onset secondary complications that occur after subarachnoid hemorrhage (SAH), and associated with high rate of disability and mortality. Recent investigations have indicated microRNA-26b (miR-26b) as a biomarker in the progression of SAH. Accordingly, the present study was designed to elucidate the role of miR-26b in influencing EBI following SAH and the downstream mechanisms.

METHODS

Firstly, SAH rat models and neuron injury models were developed to assess the effect of miR-26b on EBI-like symptoms and subsequent inflammation. Dual-luciferase reporter gene assay was further implemented to evaluate the binding of miR-26b to its putative target gene STAT3. Loss-of-function and rescue experiments were performed to assess the functionality of miR-26b-mediated STAT3 in both models.

RESULTS

miR-26b was found to target KLF4 and negative-modulate its expression, whereby aggravating EBI and inflammatory response in SAH rat models and stimulating hemoglobin-induced apoptosis in astrocytes. On the other hand, silencing of miR-26b reversed these changes in SAH rat models and hemoglobin (Hb)-induced astrocytes. miR-26b could further activate STAT3 via down-regulation of KLF4. Furthermore, KLF4 knockdown up-regulated HMGB1 to aggravate EBI following SAH.

CONCLUSIONS

Collectively, our findings highlighted the ameliorative effect of miR-26b inhibition on EBI in SAH and the possible mechanism associated with the KLF4/STAT3/HMGB1 axis.

SS31 Confers Cerebral Protection by Reversing Mitochondrial Dysfunction in Early Brain Injury Following Subarachnoid Hemorrhage, via the Nrf2- and PGC-1α-Dependent Pathways

In early brain injury (EBI), oxidative stress occurs following subarachnoid hemorrhage (SAH), and mitochondria are intricately linked to this process. SS31, a mitochondria-targeting antioxidative peptide, has been demonstrated to be beneficial for multiple diseases because of its powerful antioxidant and neuroprotective properties. Although our previous study revealed that SS31 was involved in the powerful antioxidant effect following SAH, the underlying molecular mechanisms remained unclear. Thus, our study aimed to investigate the neuroprotective effects of SS31 by reversing mitochondrial dysfunction in EBI following SAH, via activating the Nrf2 signaling and PGC-1α pathways. Our findings confirmed that SS31 ameliorated SAH-triggered oxidative insult. SS31 administration decreased redundant reactive oxygen species, alleviated lipid peroxidation, and elevated the activities of antioxidant enzymes. Concomitant with the inhibited oxidative insult, SS31 dramatically attenuated neurological deficits, cerebral edema, neural apoptosis, and blood-brain barrier disruption following SAH. Moreover, SS31 remarkably promoted nuclear factor-erythroid 2 related factor 2 (Nrf2) nuclear shuttle and upregulated the expression levels of heme oxygenase-1 and NADPH: quinine oxidoreductase1. Additionally, SS31 enhanced the expression levels of PGC-1α and its target genes, and increased the mtDNA copy number, promoting mitochondrial function. However, PGC-1α-specific inhibitor SR-18292 pretreatment dramatically suppressed SS31-induced Nrf2 expression and PGC-1α activation. Furthermore, pretreatment with SR-18292 reversed the neuroprotective and antioxidant roles of SS31. These significant beneficial effects were associated with the activation of the Nrf2 signaling and PGC-1α pathways and were antagonized by SR-18292 administration. Our findings reveal that SS31 exhibits its neuroprotective activity by reversing mitochondrial dysfunction via activating the Nrf2 signaling pathway, which could be mediated through PGC-1α activation.

Clinical Comparison of FD-CT and MS-CT in Aneurysmal Subarachnoid Haemorrhage: A Single Center Experience

Single-center comparison of postinterventional multislice computed tomography (MS-CT) and flat-detector computed tomography (FD-CT) in patients with subarachnoid haemorrhage (SAH) and endovascularly treated cerebral aneurysms with a focus on detection of posttherapeutical complications. Patients with endovascularly treated aneurysmal SAH undergoing both MS-CT and FD-CT within 24 h after intervention were included. Datasets were compared regarding image quality (IQ) as well as qualitative (detection of SAH, intracerebral haemorrhage [ICH], intraventricular haemorrhage [IVH], external ventricular drain [EVD] position, acute obstructive hydrocephalus [AOH]) and quantitative (cella media distance [CMD], modified Graeb score [GS]) parameters. 410 patients with endovascularly treated aneurysmal SAH were included. IQ was equal between MS-CT and FD-CT. FD-CT allowed equal detection of SAH and ICH in comparison to MS-CT. FD-CT allowed excellent detection of IVH and delineation of EVD position with strong agreement to MS-CT findings. FD-CT allowed equal detection of AOH in comparison to MS-CT. There was no significant difference of CMD and GS between FD-CT and MS-CT. Postinterventional FD-CT yields equivalent diagnostic value in patients with endovascular treated SAH as MS-CT. Enabling reliable detection of SAH-associated complications within the angiosuite, FD-CT might be an efficient and safe imaging modality in these clinical emergencies.

Preventing Poor Outcomes for Neurosurgical Patients

Ensuring that patients with neurosurgical conditions have the best possible outcome requires early diagnosis, monitoring, and interventions to prevent complications and optimize care. Here, we review several neurosurgical conditions and the measures taken to prevent complications and optimize outcomes. We hope that the practical tips provided herein prove helpful in caring for neurosurgical patients.

Exosomes in subarachnoid hemorrhage: A scoping review

INTRODUCTION

Vasospasm is a common complication following subarachnoid hemorrhage (SAH), causing increased ischemia and tissue injury, and is implicated as a major risk factor for poor outcomes. The success of current treatments for vasospasm is limited, with limited efficacy and unclear clinical benefits. Exosomes, vesicles that carry small molecules such as miRNA, have been theorized as a potential vasospasm treatment. In this study, we aim to survey the current literature discussing the role of exosomes in the setting of SAH.

METHODS

Following PRISMA guidelines, we performed a scoping review evaluating the role of exosomes in the treatment of SAH. The search was conducted using PubMed and Scopus, and all original research papers studying exosomal profiles of SAH research subjects or SAH therapy were eligible for inclusion.

RESULTS

After screening and full text review, seven papers were selected for final inclusion. Of these, two studies analyzed the expression profile of endogenous exosomes after SAH. Four papers identified and characterized miRNA-based exosomal therapies to attenuate early brain injury (EBI) after SAH. One paper discussed the role of protein overexpression in exosome delivery of miRNA for EBI after SAH. Interestingly, all identified papers studying exosomal therapy demonstrated anti-apoptotic or anti-inflammatory effects of miRNA exosomes acting via the BDNF/TrkB/CREB or HDAC3/NF-κB pathways.

CONCLUSION

Identified studies demonstrate potential neuroprotective benefits of miRNA-based exosomal treatment of EBI and SAH. Findings warrant further research investigating the anti-inflammatory and anti-apoptotic role of exosomal miRNA delivery in SAH models, specifically targeting the common pathway identified by the authors.

Vitamin D level is associated with rupture of intracranial aneurysm in patients with subarachnoid hemorrhage

Background

Increasing evidence supports the relationship between vitamin D levels and stroke. However, there are few studies on the association between vitamin D levels and subarachnoid hemorrhage (SAH), especially in patients with aneurysmal SAH. The present study investigated the association between vitamin D level and rupture of intracranial aneurysm in a cohort of patients with SAH.

Methods

The data of patients diagnosed with SAH at our hospital between September 2019 and December 2020 were retrospectively reviewed. Patients' information was collected, and serum vitamin D levels were measured. Computed tomography was performed to confirm SAH diagnosis, and digital subtraction angiography was performed to determine whether SAH was caused by rupture of an intracranial aneurysm. Multivariate logistic regression analyses were performed to investigate the association between vitamin D level and aneurysmal SAH.

Results

Overall, 193 patients with SAH were evaluated; 160 with aneurysmal SAH (age 55.86 ± 12.30 years, 63.15% female) and 33 with non-aneurysmal SAH (age 56.21 ± 9.92 years, 45.45% female). Univariate analysis showed that the vitamin D level in aneurysmal SAH was lower than that in non-aneurysmal SAH (16.95 ± 8.69 vs. 22.74 ± 9.12 ng/ml, p = 0.001). In addition, there were more patients with hypertension in aneurysmal SAH group than in non-aneurysmal SAH group (53.75 vs. 24.24%, p = 0.002). Notably, there was still a strong correlation between vitamin D level and aneurysmal SAH after adjusting for confounders in the multivariate model [OR (odds ratio), 0.935; 95% CI (confidence interval), 0.890–0.983; p = 0.008].

Conclusion

Vitamin D level is associated with rupture of intracranial aneurysm in patients with SAH. Patients with aneurysmal SAH have lower vitamin D levels than those with non-aneurysmal SAH.

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.

Dexmedetomidine Inhibits Gasdermin D-Induced Pyroptosis via the PI3K/AKT/GSK3β Pathway to Attenuate Neuroinflammation in Early Brain Injury After Subarachnoid Hemorrhage in Rats

Subarachnoid hemorrhage (SAH) is one kind of life-threatening stroke, which leads to severe brain damage. Pyroptosis plays a critical role in early brain injury (EBI) after SAH. Previous reports suggest that SAH-induced brain edema, cell apoptosis, and neuronal injury could be suppressed by dexmedetomidine (Dex). In this study, we used a rat model of SAH to investigate the effect of Dex on pyroptosis in EBI after SAH and to determine the mechanisms involved. Pyroptosis was found in microglia in EBI after SAH. Dex significantly alleviated microglia pyroptosis via reducing pyroptosis executioner GSDMD and inhibited the release of proinflammatory cytokines induced by SAH. Furthermore, the reduction of GSDMD by Dex was abolished by the PI3K inhibitor LY294002. In conclusion, our data demonstrated that Dex reduces microglia pyroptosis in EBI after SAH via the activation of the PI3K/AKT/GSK3β pathway.

Extracellular vesicles derived from bone marrow mesenchymal stem cells alleviate neurological deficit and endothelial cell dysfunction after subarachnoid hemorrhage via the KLF3-AS1/miR-83-5p/TCF7L2 axis

BACKGROUND

New data are accumulating on the effects of mesenchymal stem cell-derived extracellular vesicles (MSC-EVs) in cerebrovascular diseases. We explored the potential role of KLF3-AS1-containing bone marrow MSC-EVs (BMSC-EVs) in a rat model of subarachnoid hemorrhage (SAH).

METHODS

A rat model of SAH was established by endovascular perforation method, into which KLF3-AS1-containing EVs from BMSCs or miR-183-5p mimic were injected. Further, brain microvascular endothelial cells (BMECs) were induced by oxyhemoglobin (OxyHb) to simulate in vitro setting, which were co-cultured with KLF3-AS1-containing EVs from BMSCs. Effects of KLF3-AS1 on neurological deficits in vivo and endothelial cell dysfunction in vitro were investigated. We also performed bioinformatics analysis to predict downstream factors miR-183-5p and TCF7L2, which were verified by RIP, RNA pull-down and luciferase activity assays.

RESULTS

BMSC-EVs was demonstrated to alleviate neurological deficits in SAH rats and endothelial cell dysfunction in OxyHb-induced BMECs. In addition, BMSC-EVs were shown to deliver KLF3-AS1 to BMECs, where KLF3-AS1 bound to miR-183-5p and miR-183-5p targeted TCF7L2. In vivo results confirmed that BMSC-EVs regulated the KLF3-AS1/miR-183-5p/TCF7L2 signaling axis to attenuate neurological deficit and endothelial dysfunction after SAH.

CONCLUSION

Overall, KLF3-AS1 delivered by BMSC-EVs upregulate TCF7L2 expression by binding to miR-138-5p, thus attenuating neurological deficits and endothelial dysfunction after SAH.

Correlation between clinical severity and extent of autonomic cardiovascular impairment in the acute phase of subarachnoid hemorrhage

Background and aim

To assess associations between clinical severity and possible dysfunction of autonomic cardiovascular modulation within the acute phase after spontaneous subarachnoid hemorrhage (SAH).

Methods

In this prospective observational study, in 51 patients with spontaneous SAH, Hunt-and-Hess scores (H&H) were assessed and cardiovascular autonomic modulation was monitored within 24 h after SAH-onset. From 5 min time-series of R–R-intervals (RRI) and blood-pressure (BP) recordings, we calculated autonomic parameters including time-domain [RRI-coefficient-of-variation (RRI-CV) and square-root-of-the-mean-squared-differences-of-successive-RRIs (RMSSD)] and frequency-domain parameters [low- and high-frequency-powers of RRI- and BP-modulation (RRI-LF-, RRI-HF-, SBP-LF-powers) and RRI-total-powers]. Data were compared to those of 20 healthy volunteers.

Results

RRI- and BP-values did not differ between groups. Yet, parameters of sympathetic (RRI-LF-powers 141.0 (18.9–402.4) ms² vs 442.3 (246.8–921.2) ms², p = 0.001) and total autonomic modulation (RRI-CV 2.4 (1.2–3.7) ms² vs 3.7 (3.1–5.3) ms², p = 0.001) were significantly lower in patients than in controls. Subgroup analyses (patients with H&H < 3 vs H&H ≥ 3) and Spearman-rank-correlations revealed increasing loss of sympathetic (RRI-LF-powers 338.6 (179.7–710.4) ms² vs 72.1 (10.1–175.9) ms², p = 0.001, rho = − 0.524) and total autonomic modulation (RRI-CV 3.5 (2.3–5.4) ms² vs 1.6 (1.0–2.8) ms², p < 0.001, rho = − 0.519) with higher H&H-scores. Multiple-logistic-regression underlined the significant influence of H&H-scores on sympathetic (RRI-LF-powers, p = 0.033) and total autonomic modulation (RRI-CV, p = 0.040) compared to possible confounders (e.g., age, intubation).

Conclusion

Within the acute phase, spontaneous SAH induces a decrease in sympathetic and total autonomic cardiovascular modulation. Higher H&H-scores were associated with increasing autonomic dysfunction and may therefore augment the risk of cardiovascular complications and poor clinical outcome.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-022-11220-w.

Suberoylanilide hydroxamic acid suppresses axonal damage and neurological dysfunction after subarachnoid hemorrhage via the HDAC1/HSP70/TDP-43 axis

Increased focus has been placed on the role of histone deacetylase inhibitors as crucial players in subarachnoid hemorrhage (SAH) progression. Therefore, this study was designed to expand the understanding of SAH by exploring the downstream mechanism of the histone deacetylase inhibitor suberoylanilide hydroxamic acid (SAHA) in SAH. The expression of TDP-43 in patients with SAH and rat models of SAH was measured. Then, western blot analysis, immunofluorescence staining, and transmission electron microscope were used to investigate the in vitro effect of TDP-43 on a neuronal cell model of SAH established by oxyhemoglobin treatment. Immunofluorescence staining and coimmunoprecipitation assays were conducted to explore the relationship among histone deacetylase 1 (HDAC1), heat shock protein 70 (HSP70), and TDP-43. Furthermore, the in vivo effect of HDAC1 on SAH was investigated in rat models of SAH established by endovascular perforation. High expression of TDP-43 in the cerebrospinal fluid of patients with SAH and brain tissues of rat models of SAH was observed, and TDP-43 accumulation in the cytoplasm and the formation of inclusion bodies were responsible for axonal damage, abnormal nuclear membrane morphology, and apoptosis in neurons. TDP-43 degradation was promoted by the HDAC1 inhibitor SAHA via the acetylation of HSP70, alleviating SAH, and this effect was verified in vivo in rat models. In conclusion, SAHA relieved axonal damage and neurological dysfunction after SAH via the HSP70 acetylation-induced degradation of TDP-43, highlighting a novel therapeutic target for SAH.

Detection of subarachnoid haemorrhage with spectrophotometry of cerebrospinal fluid - a comparison of two methods

OBJECTIVES

Spectrophotometric absorption curve analysis of cerebrospinal fluid (CSF) for oxyhaemoglobin and bilirubin is necessary to accurately diagnose subarachnoid haemorrhage (SAH) in patients with typical symptoms but with negative findings on X-ray examinations. In this study, we evaluated the performance of two methods for interpreting absorption curves; one method from the United Kingdom National External Quality Assessment Service (UK-NEQAS) and the other from the national quality assurance programme in Sweden (Equalis).

METHODS

Consecutive absorbance curves (n=336) were interpreted with two different methods, and their performance was compared to the diagnosis as stated in the patient records.

RESULTS

The UK-NEQAS method displayed equal sensitivity to the Equalis method, but the specificity of the UK-NEQAS method was significantly higher than the Equalis method resulting in fewer false positive results. For UK-NEQAS, a positive predictive value (PPV) of 84.6% and a negative predictive value (NPV) of 99.7% were observed, whereas the Equalis method had a PPV of 27.5% and an NPV of 99.7%.

CONCLUSIONS

The semi-automated method based on the guidelines from UK-NEQAS provides an efficient and correct interpretation of absorbance curves with short turn-around times. We propose using this method for the routine interpretation of CSF spectrophotometric curves.

Enhancing S-nitrosoglutathione reductase decreases S-nitrosylation of Drp1 and reduces neuronal apoptosis in experimental subarachnoid hemorrhage both in vivo and in vitro

Subarachnoid hemorrhage (SAH) is a hemorrhagic stroke with a high mortality and disability rate. Nitric oxide (NO) can promote blood supply through vasodilation, leading to protein S-nitrosylation. However, the function of S-nitrosylation in neurons after SAH remains unclear. Excessive NO in the pathological state is converted into S-nitrosoglutathione (GSNO) and stored in cells, which leads to high S-nitrosylation of intracellular proteins and causes nitrosative stress. S-nitrosoglutathione reductase (GSNOR) promotes GSNO degradation and protects cells from excessive S-nitrosylation. We conducted an in vivo rat carotid puncture model and an in vitro neuron hemoglobin intervention. The results showed that SAH induction increased NO, GSNO, neuron protein S-nitrosylation, and neuronal apoptosis, while decreasing the level and activity of GSNOR. GSNOR overexpression by lentivirus decreased GSNO but had little effect on NO. GSNOR overexpression also improved short- and long-term neurobehavioral outcomes in rats and alleviated nitrosative stress. Furthermore, GSNOR reduced neuronal apoptosis and played a neuroprotective role by alleviating Drp1 S-nitrosylation, reducing mitochondrial division. Thus, the regulation of GSNOR in early brain injury and neuronal denitrosylation may play an important role in neuroprotection.

Endocrine dysregulation in aneurysmal subarachnoid haemorrhage

INTRODUCTION

Aneurysmal Subarachnoid haemorrhage (aSAH) is one of the most common causes of neurocritical care admission. Consistent evidence has been suggestive of endocrine dysregulation in aSAH. This review aims to provide an up-to-date presentation of the available evidence regarding endocrine dysregulation in aneurysmal subarachnoid haemorrhage.

METHODS

A comprehensive literature search was performed using PubMed database. All available evidence related to endocrine dysregulation in hypothalamic-pituitary hormones, adrenal hormones and natriuretic peptides after aSAH, published since 2010, were reviewed.

RESULTS

There have been reports of varying prevalence of dysregulation in hypothalamic-pituitary and adrenal hormones in aSAH. The cause of this dysregulation and its pattern remain unclear. Hypothalamic-pituitary and adrenal dysregulation have been associated with higher incidence of poor neurological outcome and increased mortality. Whilst there is evidence that long-term dysregulation of these axes may also develop, it appears to be less frequent than the acute-phase dysregulation and transient in pattern. Increased levels of catecholamines have been reported in the hyper-acute phase of aSAH with reported inconsistent correlation with the outcomes and the complications of the disease. There is growing evidence that of a causal link between the endocrine dysregulation and the development of hyponatraemia and delayed cerebral ischaemia, in the acute phase of aSAH. However, the pathophysiological mechanism and pattern of endocrine dysregulation which could be causally associated with these complications still remain debatable.

CONCLUSION

The evidence, mainly from small observational and heterogeneous in methodology studies, is suggestive of adverse effects of the endocrine dysregulation on the outcome and the incidence of complications of the disease. However, the cause of this dysregulation and a pathophysiological mechanism that could link its presence with the development of acute complications and the outcome of the aSAH remain unclear. Further research is warranted to elucidate the clinical significance of endocrine dysregulation in subarachnoid haemorrhage.

Cerebral Vasospasm-Left Heart Failure-Cerebral Infarction May Be a Potential Pathophysiological Mechanism of Malignant Cerebral Vasospasm

ABSTRACT

Cerebral vasospasm (CV) and delayed cerebral ischemia are serious complications after ruptured aneurysm with high mortality and disability rate. However, there are few reports of cardiogenic CV, the mechanism is unclear, and the treatment recommended by the guidelines is not detailed. This article describes in detail a 47-year-old woman with intracranial aneurysm rupture and hemorrhage. After interventional operation, left heart failure worsened CV and cerebral infarction. This article summarizes the diagnosis and treatment process of patients in detail, summarizes the treatment strategies of cardiogenic CV, and elaborates the pathological mechanism of CV-left heart failure-CV and cerebral infarction. Increase new understanding of the clinical diagnosis and treatment strategies of cardiogenic CV.

Spinal subarachnoid haemorrhage secondary to spinal rheumatoid vasculitis: a case report

Introduction

Spinal subarachnoid haemorrhage is extremely rare in cases of subarachnoid haemorrhage and possesses servere characteristics. Additionally, spinal rheumatoid vasculitis is rare for spinal subarachnoid haemorrhage. The pathogenesis is unknown.

Case presentation

A 52-year-old woman with a 10-year history of seropositive rheumatoid arthritis was managed with leflunomide and celecoxib, and stable low disease activity was achieved. The patient had also been diagnosed with spinal subarachnoid haemorrhage secondary to isolated spinal rheumatoid vasculitis and obtained good therapeutic effects.

Conclusion

This is the first case to describe spinal subarachnoid haemorrhage secondary to isolated spinal vasculitis in a patient with rheumatoid arthritis, which provides more proof of anomalous neovascularization in the central nervous system in rheumatoid arthritis.

Neurogenic pulmonary edema in subarachnoid hemorrhage: relevant clinical concepts

BACKGROUND

Subarachnoid hemorrhage (SAH) continues to be a condition that carries high rates of morbidity, mortality, and disability around the world. One of its complications is neurogenic pulmonary edema (NPE), which is mainly caused by sympathetic hyperactivity. Due to the complexity of the pathophysiological process and the unspecificity of the clinical presentation, it is little known by general practitioners, medical students and other health care workers not directly related to the neurological part, making the management of this chaotic condition difficult. This review aims to present recent evidence on clinical concepts relevant to the identification and management of NPE secondary to SAH.

MAIN BODY OF THE ABSTRACT

NPE is defined as a syndrome of acute onset following significant central nervous system (CNS) injury. Its etiology has been proposed to stem from the release of catecholamines that produce cardiopulmonary dysfunction, with this syndrome being associated with spinal cord injury, cerebrovascular disorders, traumatic brain injury, status epilepticus, and meningitis. NPE has long been considered a rare event; but it may occur more frequently, mainly in patients with SAH. There are two clinical presentations of NPE: the early form develops in the first hours/minutes after injury, while the late form presents 12-24 h after neurological injury. Clinical manifestations consist of non-specific signs of respiratory distress: dyspnea, tachypnea, hypoxia, pink expectoration, crackles on auscultation, which usually resolve within 24-48 h in 50% of patients. Unfortunately, there are no tools to make the specific diagnosis, so the diagnosis is by exclusion. The therapeutic approach consists of two interventions: treatment of the underlying neurological injury to reduce intracranial pressure and control sympathetic hyperactivity related to the lung injury, and supportive treatment for pulmonary edema.

SHORT CONCLUSION

SAH is a severe condition that represents a risk to the life of the affected patient due to the possible complications that may develop. NPE is one of these complications, which due to the common manifestation of a respiratory syndrome, does not allow early and accurate diagnosis, being a diagnosis of exclusion. Therefore, in any case of CNS lesion with pulmonary involvement, NPE should be suspected immediately.

A Controlled Study of Continuous Lumbar Drainage of Fluid and Lumbar Puncture Drainage for Aneurysmal SAH after Intracranial Aneurysm Clipping

Objective

To analyze the different effects of Continuous Lumbar Drainage of fluid and lumbar puncture drainage for aneurysmal subarachnoid hemorrhage (SAH) after intracranial aneurysm clipping.

Method

Seventy-five patients with aneurysmal SAH who underwent aneurysm clipping were retrospectively analyzed and were divided into two groups according to the different postoperative drainage methods. The lumbar spine group received lumbar puncture drainage, and the lumbar cistern group received lumbar pool continuous drainage to compare the efficacy.

Result

The time to normalize intracranial pressure and headache relief after drainage treatment in the lumbar cistern group was shorter than that in the lumbar spine group. The GOS score was higher than that in the lumbar spine group, and the cerebral artery flow velocity and NIHSS score were significantly lower than those in the lumbar spine group (P < 0.05). The total effective rate of drainage treatment was 76.32% in the lumbar cistern group, which was higher than that in the lumbar spine group (54.05%) (P < 0.05). The total complication rate was 18.42% in the lumbar cistern group, which was lower than that in the lumbar spine group (40.54%) (P < 0.05).

Conclusion

Continuous Lumbar Drainage of fluid after intracranial aneurysm clipping for aneurysmal SAH can control symptoms more rapidly, reduce neurological deficits, and improve prognosis than lumbar puncture. Also, the drainage is safer and more widely used.

Celastrol protects against early brain injury after subarachnoid hemorrhage in rats through alleviating blood-brain barrier disruption and blocking necroptosis

BACKGROUND

Subarachnoid hemorrhage (SAH) is a life-threatening disease worldwide, and effective pharmaceutical treatment is still lacking. Celastrol is a plant-derived triterpene which showed neuroprotective potential in several types of brain insults. This study aimed to investigate the effects of celastrol on early brain injury (EBI) after SAH.

METHODS

A total of sixty-one male Sprague-Dawley rats were used in this study. Rat SAH endovascular perforation model was established to mimic the pathological changes of EBI after SAH. Multiple methods such as 3.0T MRI scanning, immunohistochemistry, western blotting and propidium iodide (PI) labeling were used to explore the therapeutic effects of celastrol on SAH.

RESULTS

Celastrol treatment attenuated SAH-caused brain swelling, reduced T2 lesion volume and ventricular volume in MRI scanning, and improved overall neurological score. Albumin leakage and the degradation of tight junction proteins were also ameliorated after celastrol administration. Celastrol protected blood-brain bairrer integrity through inhibiting MMP-9 expression and anti-neuroinflammatory effects. Additionally, necroptosis-related proteins RIP3 and MLKL were down-regulated and PI-positive cells in the basal cortex were less in the celastrol-treated SAH group than that in untreated SAH group.

CONCLUSIONS

Celastrol exhibits neuroprotective effects on EBI after SAH and deserves to be further investigated as an add-on pharmaceutical therapy.

Spontaneous spinal epidural hemorrhage and sentinel headache-A case report

OBJECTIVES/BACKGROUND

Expand the differential diagnosis of sentinel headache to include spontaneous spinal epidural hematoma (SSEH) and reinforce the need for lumbar puncture in the evaluation of thunderclap headache. SSEH is a rare clinical presentation especially in the absence of bleeding tendencies. Clinicians recognize SSEH with typical presenting signs and symptoms including regional paraspinal muscular contraction and pain along with myelopathy. Although thunderclap headache usually does not connote vascular rupture in the spinal epidural compartment, SSEH may rarely present with sentinel headache and later evolve into a myelopathy.

RESULTS AND CONCLUSION

Sentinel headache may be the sole symptom following spontaneous spinal epidural hemorrhage preceding both myelopathic and meningeal signs and symptoms. SSEH can best be diagnosed by lumbar puncture at this early moment potentially averting spinal cord injury.

Flow Diversion in Acute Sub Arachnoid Haemorrhage: A Single Centre Five Year Experience

OBJECTIVES

The role of flow-diversion in acute sub-arachnoid haemorrhage (SAH) is controversial. Many of the published data warns of high rates of procedure-related complications and aneurysmal rebleed. This study evaluates the safety, efficacy, clinical and angiographic outcomes of acute flow-diversion at our institute.

METHODS

The institutional database from June 2015 to June 2020 was retrospectively reviewed for aneurysmal SAH (aSAH) treated with flow diversion. Clinical presentation, procedural details, complications, anti-platelet usage, rebleeding and aneurysm occlusion rates and outcomes were recorded.

RESULTS

22 (59% females; median age 56 years) consecutive patients were identified. None of them were on regular antiplatelets/anticoagulation in the 15-days preceding the treatment. The mean aneurysm diameter was 5.4 mm and the median delay to flow-diversion was 2 days. Almost 73% (16/22) of patients had adjunctive coiling in the same session. There was no aneurysmal rebleed at a median follow up of 8.5 months and 86.3% (19/22 patients) had good clinical outcomes (3-month MRS 0-2). Adverse events related to the flow diversion procedure were seen in 3 patients; none of them had a medium to long-term clinical consequence. Three patients died from complications of SAH, unrelated to the procedure. Vascular imaging follow-up was available for 20 patients and the complete aneurysm occlusion rate was 95%.

CONCLUSION

Flow-diversion could be a reasonably safe and effective technique for treating ruptured aneurysms in appropriately selected patients when conventional options of surgical clipping and coiling are considered challenging.

Computed Tomography Angiography versus Digital Subtraction Angiography as a Primary Diagnostic Tool in Nontraumatic Subarachnoid Hemorrhage: Cost-Effectiveness Analysis Study

BACKGROUND

Digital subtraction angiography (DSA) and computed tomographic angiography (CTA) are used to identify the cause of nontraumatic subarachnoid hemorrhage (SAH). There is no consensus on which to choose as the first diagnostic tool. We aimed to compare the cost-effectiveness of CTA versus DSA as a primary tool for identifying the cause of nontraumatic SAH.

METHODS

A decision analysis model was built to simulate patients undergoing DSA or CTA as a primary diagnostic tool for the cause of nontraumatic SAH. The input data for the study were extracted from literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the model.

RESULTS

In the base case calculation, it cost $1261.82 less and yielded 0.0001 quality-adjusted life year (QALY) when DSA was used as a primary diagnostic imaging tool for nontraumatic SAH. Choosing DSA as a primary tool was cost-effective in more than 65% of iterations in probabilistic sensitivity analysis. Deterministic sensitivity analyses show when the probability of using endovascular treatment is >47.2%, choosing DSA is more cost-effective; otherwise, CTA is more optimal. CTA is more cost-effective when the cost for DSA >2.6 × CTA + $600.

CONCLUSIONS

Based on current literature and our model DSA as a primary diagnostic tool for the cause of nontraumatic SAH is more cost-effective. However, in clinical practice physicians can choose either DSA or CTA according to the scale of endovascular procedures used in their center, as well as the cost correlation between CTA and DSA, which varies among institutions.

Subarachnoid hemorrhage in the emergency department

BACKGROUND

Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician.

DISCUSSION

The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest.

CONCLUSION

Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.

Pseudosubarachnoid hemorrhage: A systematic review of causes, diagnostic modalities, and outcomes in patients who present with pseudosubarachnoid hemorrhage

Background:

Patients with computed tomography (CT) findings consistent with subarachnoid hemorrhage without evidence of hemorrhage following autopsy or cerebrospinal fluid testing are termed to have pseudosubarachnoid hemorrhage (pSAH).

Methods:

A systematic review of literature was conducted based on the preferred reporting items for systematic reviews and meta-analysis statement. Studies were evaluated for associated cause of pSAH, imaging modality used in assessment, method of confirmatory testing, and clinical outcome.

Results:

Fifty studies were included in qualitative analysis including 197 cases of pSAH. Systematic review revealed 23 studies including 110 patients with pSAH attributed to hypoxic-ischemic brain injury following cardiac arrest. Three studies were included in meta-analysis that quantitatively analyzed differences in CT densities in patients with pSAH and true subarachnoid hemorrhage (true SAH). A random effects model meta-analysis showed a statistically significant decrease in densities in the Sylvian fissure in patients with pSAH compared to true SAH and a statistically significant decrease in densities in adjacent parenchyma in patients with pSAH compared to true SAH. Systematic review further revealed 32 patients with pSAH associated with spontaneous intracranial hypotension, 11 patients with pSAH related to infectious etiologies, 15 patients with pSAH associated with subdural hemorrhage, 20 cases of pSAH related to hyperhemoglobinemia, 2 cases related to valproate toxicity, and individual cases related to hyponatremia, diabetic ketoacidosis, sudden infant death syndrome, cerebellar infarction, and dialysis disequilibrium syndrome.

Conclusion:

This study is the first systematic review of causes, diagnostic modalities, and outcomes in patients who present with pSAH. A diagnosis of pSAH may be considered following assessment of CT densities following cardiac arrest.

Pharmaceutical Management for Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage can have deleterious consequences. Vasospasm, delayed cerebral ischemia, and re-hemorrhage can all cause delayed sequelae. Furthermore, severe headaches are common and require careful modulation of pain medications. Limited treatment options currently exist and are becoming more complex with the rising use of oral anticoagulants needing reversal. In this review, we highlight the current treatment options currently employed and address avenues of future discovery based on emerging preclinical data. Furthermore, we dive into the best treatment approach for managing headaches following subarachnoid hemorrhage. The review is designed to serve as a catalyst for further prospective investigation into this important topic.

The role of immune inflammation in aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating disease, which mainly caused by the rupture of an intracranial aneurysm. Clinical trials have demonstrated that cerebral vasospasm (CVS) is not the sole contributor to delayed cerebral ischemia (DCI) and poor outcomes in patients with aSAH. Currently, accumulating evidence suggests that early brain injury (EBI), which occurs within 72 h after the onset of aSAH, lays the foundation for subsequent pathophysiological changes and poor outcomes of patients. The pathological mechanisms of EBI mainly include increased intracranial pressure, oxidative stress, neuroinflammation, blood-brain barrier (BBB) disruption, cerebral edema and cell death. Among them, the brain immune inflammatory responses involve a variety of immune cells and active substances, which play an important role in EBI after aSAH and may be related to DCI and long-term outcomes. Thus, attention should be paid to strategies targeting cerebral immune inflammatory responses. In this review, we discuss the role of immune inflammatory responses in the occurrence and development of aSAH, as well as some inflammatory biomarkers related to CVS, DCI, and aSAH outcomes. In addition, we also summarize the potential therapeutic drugs that target cerebral immune inflammatory responses for patients with aSAH in current research.

Understanding Cognitive Deficit After Subarachnoid Hemorrhage: A Memory Focused Approach

Aneurysmal subarachnoid hemorrhage (aSAH) is a prevalent condition affecting a large portion of the population, many of them still in productive ages. Memory impairment is a common factor amongst those patients. Memory exerts a pivotal role in productivity. That is why it is important to understand how it can be affected in post-aSAH patients. There are certain areas most affected in cases of memory disturbances, as well as its functional connections with crucial cerebral regions. Active research on functional magnetic resonance and diffusion tension imaging is used to identify compromised areas within the brain. There are suggested factors regarding poor performance, such as cerebrospinal fluid drainage and new infarction areas, which should be addressed properly to benefit these patients and simultaneously help them return to a productive and functional life.

Pseudo-subarachnoid hemorrhage and gadolinium encephalopathy following lumbar epidural steroid injection

Patients with imaging findings concerning for subarachnoid hemorrhage, however, with no evidence of hemorrhage following autopsy or cerebrospinal fluid testing are diagnosed with having pseudo-subarachnoid hemorrhage. A 73-year-old female presented to the emergency department with altered mental status one day after undergoing a lumbar epidural steroid injection at an outside hospital; a noncontrast computed tomography scan of the head revealed evidence of diffuse hyperdensity within the subarachnoid space concerning for subarachnoid hemorrhage. The patient underwent magnetic resonance imaging which demonstrated diffuse opacification of the cerebrospinal fluid spaces with gadolinium and the diagnoses of pseudo-subarachnoid hemorrhage and gadolinium encephalopathy were made. The combination of the neurologic symptoms related to gadolinium encephalopathy and the radiographic findings of pseudo-subarachnoid hemorrhage can create a clinical presentation nearly identical to ruptured aneurysmal subarachnoid hemorrhage. Patient history, magnetic resonance imaging findings, and temporal changes in computed tomography provide vital tools in establishing a diagnosis of pseudo-subarachnoid hemorrhage, especially after an iatrogenic intrathecal contrast administration.

Development and validation of a predictive model for the prognosis in aneurysmal subarachnoid hemorrhage

Background

This study was to conduct a predictive model for the prognosis of aneurysmal subarachnoid hemorrhage (aSAH) and validate the clinical data.

Methods

A total of 235 aSAH patients were enrolled in this study, dividing into the favorable or poor prognosis groups based on Modified Rankin Scale (mRS) at 3 months postoperatively. Multivariate analysis was assessed using binary Logistic regression and Fisher discriminant analysis. The receiver operating characteristic (ROC) curve was used to determine the cut‐off value.

Results

Our findings showed that the high Glasgow Coma Scale (GCS) score 24‐hour after surgery reduced the risk of poor prognosis, and the surgical clipping and elevated neutrophil‐lymphocyte ratio (NLR) increased the risk of poor prognosis. The discriminant function was V = 0.881 × GCS score − 0.523 × NLR − 0.422 × therapeutic approach, and V = −0.689 served as a cut‐off value. When V ≥ −0.689, the good prognosis was considered among these patients with aSAH. The correctness for predicting the prognostic outcomes by self‐validation was 85.11%.

Conclusion

This predictive model established by a discriminant analysis is a useful tool for predicting the prognostic outcomes of aSAH patients, which may help clinicians identify patients at high risk for poor prognosis and optimize treatment after surgery.

Endogenous calcitonin gene-related peptide in cerebrospinal fluid and early quality of life and mental health after good-grade spontaneous subarachnoid hemorrhage-a feasibility series

The vasodilatory calcitonin gene-related peptide (CGRP) is excessively released after spontaneous subarachnoid hemorrhage (sSAH) and modulates psycho-behavioral function. In this pilot study, we prospectively analyzed the treatment-specific differences in the secretion of endogenous CGRP into cerebrospinal fluid (CSF) during the acute stage after good-grade sSAH and its impact on self-reported health-related quality of life (hrQoL). Twenty-six consecutive patients (f:m = 13:8; mean age 50.6 years) with good-grade sSAH were enrolled (drop out 19% (n = 5)): 35% (n = 9) underwent endovascular aneurysm occlusion, 23% (n = 6) microsurgery, and 23% (n = 6) of the patients with perimesencephalic SAH received standardized intensive medical care. An external ventricular drain was inserted within 72 h after the onset of bleeding. CSF was drawn daily from day 1–10. CGRP levels were determined via competitive enzyme immunoassay and calculated as “area under the curve” (AUC). All patients underwent a hrQoL self-report assessment (36-Item Short Form Health Survey (SF-36), ICD-10-Symptom-Rating questionnaire (ISR)) after the onset of sSAH (t₁: day 11–35) and at the 6-month follow-up (t₂). AUC CGRP (total mean ± SD, 5.7 ± 1.8 ng/ml/24 h) was excessively released into CSF after sSAH. AUC CGRP levels did not differ significantly when dichotomizing the aSAH (5.63 ± 1.77) and pSAH group (5.68 ± 2.08). aSAH patients revealed a higher symptom burden in the ISR supplementary item score (p = 0.021). Multiple logistic regression analyses corroborated increased mean levels of AUC CGRP in CSF at t₁ as an independent prognostic factor for a significantly higher symptom burden in most ISR scores (compulsive-obsessive syndrome (OR 5.741, p = 0.018), anxiety (OR 7.748, p = 0.021), depression (OR 2.740, p = 0.005), the supplementary items (OR 2.392, p = 0.004)) and for a poorer performance in the SF-36 physical component summary score (OR 0.177, p = 0.001). In contrast, at t₂, CSF AUC CGRP concentrations no longer correlated with hrQoL. To the best of our knowledge, this study is the first to correlate the levels of endogenous CSF CGRP with hrQoL outcome in good-grade sSAH patients. Excessive CGRP release into CSF may have a negative short-term impact on hrQoL and emotional health like anxiety and depression. While subacutely after sSAH, higher CSF levels of the vasodilator CGRP are supposed to be protective against vasospasm-associated cerebral ischemia, from a psychopathological point of view, our results suggest an involvement of CSF CGRP in the dysregulation of higher integrated behavior.

Compressive myelopathy secondary to posthemorragic arachnoiditis: Case report and literature review

BACKGROUND

Spinal arachnoiditis is an arachnoid inflammatory process frequently caused by infection or spinal surgery; there are different degrees of severity, including arachnoid thickening and severe adhesive lesions that can lead to the development of arachnoid cysts. Non-traumatic subarachnoid haemorrhage (ntSAH) is a relatively uncommon cause of arachnoiditis; further complication with spinal cord compression (SCC) is even more unusual.

METHOD

we describe a 70-year-old female, with SCC caused by arachnoid cysts. Her medical past history was relevant for an episode of ntSAH after rupture of a posterior communicating artery aneurysm, eight months prior to the onset of symptoms. We also present a literature review of previous published cases.

RESULTS

we selected 23 articles with 24 case reports. A noticeable female predominance (11:1) was observed. It is more common between the fourth and fifth decades. The majority of cases (58 %) were secondary to aneurysmal SAH due to rupture of a posterior circulation aneurysm. The most common location of the cyst is in the cervicothoracic spine. The average time between the initial bleeding and symptom development is 3-6 months. The most frequently described treatment is laminectomy and marsupialization of the cyst, but reports show a high recurrence rate.

CONCLUSIONS

ntSAH is an uncommon aetiology of arachnoiditis and arachnoid cysts. SCC from arachnoid cysts secondary to ntSAH is exceptional. Treatment through laminectomy has a relatively high recurrence rate (33 %). We present different hypotheses to try to explain how the alteration of cerebrospinal fluid (CSF) dynamics after ntSAH can lead to arachnoid cyst development and SCC. Although the small number of cases included in the present series precludes us to draw definite conclusions, ventriculoperitoneal shunt (VPS) placement can be considered as an alternative treatment in the management of known ntSAH patients that present recurrent symptomatic arachnoid cysts.