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Dai Z, Zhang L, Liu X, Kou M, An L, Wang W, Xu J, Su Y. Predictive Value of Quantitative Electroencephalogram Combined with Transcranial Doppler Ultrasound in Delayed Cerebral Ischemia after Subarachnoid Hemorrhage. World Neurosurg 2024; 186:e48-e53. [PMID: 38310949 DOI: 10.1016/j.wneu.2024.01.150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 01/24/2024] [Accepted: 01/25/2024] [Indexed: 02/06/2024]
Abstract
OBJECTIVE To explore the predictive value of transcranial Doppler ultrasound (TCD) combined with quantitative electroencephalogram (QEEG) in delayed cerebral ischemia (DCI) caused by aneurysmal subarachnoid hemorrhage (aSAH). METHODS The participants were 105 patients with aSAH treated from June 2020 to December 2022. Patients were divided into DCI group (n = 34) and non-DCI group (n = 71) according to the presence of DCI 14 days after onset. Further comparison was conducted on the baseline data as well as the parameters of QEEG and TCD within 24 hours after admission. Multivariate logistic analysis was performed to investigate risk factors related to DCI within 14 days of admission in aSAH patients. RESULTS There were significant differences in the comparison of the proportion of Hunt-Hess grading, relative δ power (RDP), relative α power (RAP), relative α/β power ratio (ADR), as well as peak systolic velocity (Vs), mean blood flow velocity (MBFV) and pulsatility index (PI) of middle cerebral artery between the two groups (P < 0.05). Furthermore, Logistic regression analysis revealed that ADR (odds ratio 1.668, 95% CI 1.369-4.345) and MBFV of middle cerebral artery (odds ratio 3.279, 95% CI 2.332-6.720) were risk factors for the occurrence of DCI in aSAH patients (P < 0.05). In addition, evaluation of the predictive value revealed that combined use of the 2 indicators showed the highest predictive value (area under the curve 0.959, 95% CI 0.896-0.993). CONCLUSIONS Patients with aSAH complicated by DCI have relatively higher MBFV of middle cerebral artery and ADR. Combined use of the 2 indicators can provide reference for early prediction of DCI in aSAH patients.
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Affiliation(s)
- Zhicheng Dai
- Department of Neurosurgery, The First People's Hospital of Baiyin City, Baiyin, China.
| | - Lina Zhang
- Department of Electrophysiology, The First People's Hospital of Baiyin City, Baiyin, China
| | - Xuewu Liu
- Department of Neurosurgery, The First People's Hospital of Baiyin City, Baiyin, China
| | - Minqian Kou
- Department of Electrophysiology, The First People's Hospital of Baiyin City, Baiyin, China
| | - Longfei An
- Department of Neurosurgery, The First People's Hospital of Baiyin City, Baiyin, China
| | - Wenxuan Wang
- Department of Electrophysiology, The First People's Hospital of Baiyin City, Baiyin, China
| | - Jingyuan Xu
- Department of Electrophysiology, The First People's Hospital of Baiyin City, Baiyin, China
| | - Yan Su
- Department of Electrophysiology, The First People's Hospital of Baiyin City, Baiyin, China
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Su Y, Cao Y, Zang H, Gao W, Liu X, Li F, An Q, Dai Z. Combined Transcranial Doppler and Melatonin Levels to Predict Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Neurologist 2024:00127893-990000000-00131. [PMID: 38602912 DOI: 10.1097/nrl.0000000000000565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024]
Abstract
OBJECTIVE To investigate the early prediction value of transcranial Doppler ultrasound (TCD) combined with serum melatonin level for delayed cerebral ischemia (DCI) caused by subarachnoid hemorrhage (SAH). METHODS This paper is a prospective study. A total of 120 patients with SAH treated were included. The patients were divided into the DCI group (40 cases) and non-DCI group (80 cases) according to whether DCI occurred 14 days after SAH (DCI usually occurs 4 to 14 d after bleeding). Baseline data, serum melatonin level, and TCD test results within 24 hours after admission were compared between the 2 groups. Multivariate logistic analysis was used to analyze the factors affecting the occurrence of DCI after SAH. The value of serum melatonin level, middle cerebral artery mean blood flow velocity (MBFV) and their combination in predicting DCI in SAH patients was evaluated. RESULTS Univariate analysis showed that there were statistically significant differences in the proportion of Fisher grade, Hunt-Hess grade, serum melatonin level, middle cerebral artery systolic blood flow velocity (Vs), MBFV and pulse index (PI) between the 2 groups (P<0.05). Serum melatonin levels, middle cerebral artery Vs, MBFV, and PI in the DCI group were higher than those in non-DCI group. Logistic regression (LR) analysis showed that serum melatonin level (OR=1.796, 95% CI: 1.575-4.123) and middle cerebral artery MBFV (OR=3.279, 95% CI: 2.112-4.720] were the influencing factors for DCI in SAH patients (P<0.05). CONCLUSION Middle cerebral artery MBFV and serum melatonin levels were higher in patients with SAH complicated with DCI, and the combination of the 2 could provide a reference for early clinical prediction of DCI in patients with aneurysmal subarachnoid hemorrhage (aSAH).
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Affiliation(s)
- Yan Su
- Departments of Electrophysiology
| | - Yonggui Cao
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
| | - Haoran Zang
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
| | - Wuzhou Gao
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
| | - Xuewu Liu
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
| | - Fuqing Li
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
| | | | - Zhicheng Dai
- Neurosurgery, The First People's Hospital of Baiyin, Baiyin, China
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Narayan V, Kumar M, Mahajan S, Ganesh V, Luthra A, Gupta T, Rawat A, Singh A, Vyas S, Narayanan V, Depuru A, Kaur K, Panda N, Bhagat H. The Role of Serum Matrix Metalloproteinase-9 as a Predictor of Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. J Mol Neurosci 2024; 74:18. [PMID: 38315311 DOI: 10.1007/s12031-024-02194-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/26/2024] [Indexed: 02/07/2024]
Abstract
Delayed cerebral ischemia (DCI) is one of the major causes of a poor neurological outcome following aneurysmal subarachnoid hemorrhage (aSAH). Several biomarkers, including matrix metalloproteinase-9 (MMP-9), have been evaluated to predict the development of DCI for timely management. This prospective cohort study was done on 98 patients with aSAH presenting within 72 h of the ictus. Serum samples were collected preoperatively, 7 days after ictus, 10 days after ictus, or when the patient developed DCI, whichever was earlier. The primary objective was to correlate the serum MMP-9 levels with the development of DCI. The secondary objectives were to correlate the serum MMP-9 levels with sonographic vasospasm and the neurological outcome. There was no correlation between the serum MMP-9 levels and the development of DCI (p = 0.37). Similarly, there was no correlation between the serum MMP-9 levels and the sonographic vasospasm (0.05) nor with the modified Rankin Scale (mRS) at discharge (p = 0.27), mRS at 3 months (p = 0.22), and Glasgow Outcome Scale Extended (GOSE) at 3 months (p = 0.15). Serum MMP-9 levels do not predict the development of DCI following aSAH.
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Affiliation(s)
- Vinitha Narayan
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Munish Kumar
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Shalvi Mahajan
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Venkata Ganesh
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Ankur Luthra
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Tulika Gupta
- Department of Anatomy, PGIMER, Chandigarh, India
| | - Amit Rawat
- Department of Pediatric Immunology, PGIMER, Chandigarh, India
| | | | - Sameer Vyas
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | - Vidhya Narayanan
- Department of Anesthesia, Sree Balaji Medical College and Hospital, Chennai, Tamil Nadu, India
| | | | - Kirandeep Kaur
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Nidhi Panda
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India
| | - Hemant Bhagat
- Department of Anesthesia and Intensive Care 4th Floor, Nehru Hospital PGIMER, Sector 12, Chandigarh, 160012, India.
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Kim Y, Mehta A, Nair R, Felbaum DR, Mai JC, Armonda RA, Chang JJ. The TCD hyperemia index to detect vasospasm and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage. J Neuroimaging 2023; 33:725-730. [PMID: 37291461 DOI: 10.1111/jon.13132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 05/19/2023] [Accepted: 05/31/2023] [Indexed: 06/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Elevated mean flow velocity (MFV) on transcranial Doppler (TCD) is used to predict vasospasm after aneurysmal subarachnoid hemorrhage (SAH). Hyperemia should be considered when observing elevated MFV. Lindegaard ratio (LR) is commonly used but does not enhance predictive values. We introduce a new marker, the hyperemia index (HI), calculated as bilateral extracranial internal carotid artery MFV divided by initial flow velocity. METHODS We evaluated SAH patients hospitalized ≥7 days between December 1, 2016 and June 30, 2022. We excluded patients with nonaneurysmal SAH, inadequate TCD windows, and baseline TCD obtained after 96 hours from onset. Logistic regression was conducted to assess the significant associations of HI, LR, and maximal MFV with vasospasm and delayed cerebral ischemia (DCI). Receiver operating characteristic analyses were employed to find the optimal cutoff value for HI. RESULTS Lower HI (odds ratio [OR] 0.10, 95% confidence interval [CI] 0.01-0.68), higher MFV (OR 1.03, 95% CI 1.01-1.05), and LR (OR 2.02, 95% CI 1.44-2.85) were associated with vasospasm and DCI. Area under the curve (AUC) for predicting vasospasm was 0.70 (95% CI 0.58-0.82) for HI, 0.87 (95% CI 0.81-0.94) for maximal MFV, and 0.87 (95% CI 0.79-0.94) for LR. The optimal cutoff value for HI was 1.2. Combining HI <1.2 with MFV improved positive predictive value without altering the AUC value. CONCLUSIONS Lower HI was associated with a higher likelihood of vasospasm and DCI. HI <1.2 may serve as a useful TCD parameter to indicate vasospasm and DCI when elevated MFV is observed, or when transtemporal windows are inadequate.
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Affiliation(s)
- Yongwoo Kim
- Comprehensive Stroke Center, MedStar Washington Hospital Center, Washington, DC, USA
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amit Mehta
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
| | - Reshmi Nair
- Center for Biostatistics, Informatics and Data Science, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University School of Medicine and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jason J Chang
- Department of Neurology, Georgetown University School of Medicine and MedStar Georgetown University Hospital, Washington, DC, USA
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
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Hoh BL, Ko NU, Amin-Hanjani S, Chou SHY, Cruz-Flores S, Dangayach NS, Derdeyn CP, Du R, Hänggi D, Hetts SW, Ifejika NL, Johnson R, Keigher KM, Leslie-Mazwi TM, Lucke-Wold B, Rabinstein AA, Robicsek SA, Stapleton CJ, Suarez JI, Tjoumakaris SI, Welch BG. 2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association. Stroke 2023; 54:e314-e370. [PMID: 37212182 DOI: 10.1161/str.0000000000000436] [Citation(s) in RCA: 65] [Impact Index Per Article: 65.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
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.
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Chang JJ, Kepplinger D, Metter EJ, Felbaum DR, Mai JC, Armonda RA, Aulisi EF. Pressure reactivity index for early neuroprognostication in poor-grade subarachnoid hemorrhage. J Neurol Sci 2023; 450:120691. [PMID: 37267816 DOI: 10.1016/j.jns.2023.120691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Pressure reactivity index (PRx) utilizes moving correlation coefficients from intracranial pressure (ICP) and mean arterial pressures to evaluate cerebral autoregulation. We evaluated patients with poor-grade subarachnoid hemorrhage (SAH), identified their PRx trajectories over time, and identified threshold time points where PRx could be used for neuroprognostication. METHODS Patients with poor-grade SAH were identified and received continuous bolt ICP measurements. Dichotomized outcomes were based on ninety-day modified Rankin scores and disposition. Smoothed PRx trajectories for each patient were created to generate "candidate features" that looked at daily average PRx, cumulative first-order changes in PRx, and cumulative second-order changes in PRx. "Candidate features" were then used to perform penalized logistic regression analysis using poor outcome as the dependent variable. Penalized logistic regression models that maximized specificity for poor outcome were generated over several time periods and evaluated how sensitivities changed over time. RESULTS 16 patients with poor-grade SAH were evaluated. Average PRx trajectories for the good (PRx < 0.25) and poor outcome groups (PRx > 0.5) started diverging at post-ictus day 8. When targeting specificities ≥88% for poor outcome, sensitivities for poor outcome consistently increased to >70% starting at post-ictus days 12-14 with a maximum sensitivity of 75% occurring at day 18. CONCLUSIONS Our results suggest that by using PRx trends, early neuroprognostication in patients with SAH and poor clinical exams may start becoming apparent at post-ictus day 8 and reach adequate sensitivities by post-ictus days 12-14. Further study is required to validate this in larger poor-grade SAH populations.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA; Department of Neurology, Georgetown University Medical Center, Washington, DC, USA.
| | - David Kepplinger
- Department of Statistics, George Mason University, Fairfax, VA, USA
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
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Chang JJ, Fazlalizadeh H, Dowlati E, Triano M, Withington C, Felbaum DR, Mai JC, Armonda RA, Kumar P, Kenigsberg B, Medvedofsky D. Cardiac patterns for differentiation of neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage versus acute ischemic stroke. Echocardiography 2023; 40:343-349. [PMID: 36880639 DOI: 10.1111/echo.15552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 12/02/2022] [Accepted: 02/20/2023] [Indexed: 03/08/2023] Open
Abstract
AIMS Neurogenic stunned myocardium (NSM) has heterogeneous presentations for acute ischemic stroke (AIS) and aneurysmal subarachnoid hemorrhage (SAH). We sought to better define NSM and differences between AIS and SAH by evaluating individual left ventricular (LV) functional patterns by speckle tracking echocardiography (STE). METHODS We evaluated consecutive patients with SAH and AIS. Via STE, LV longitudinal strain (LS) values of basal, mid, and apical segments were averaged and compared. Different multivariable logistic regression models were created by defining stroke subtype (SAH or AIS) and functional outcome as dependent variables. RESULTS One hundred thirty-four patients with SAH and AIS were identified. Univariable analyses using the chi-squared test and independent samples t-test identified demographic variables and global and regional LS segments with significant differences. In multivariable logistic regression analysis, when comparing AIS to SAH, AIS was associated with older age (OR 1.07, 95% CI 1.02-1.13, p = 0.01), poor clinical condition on admission (OR 7.74, 95% CI 2.33-25.71, p < 0.001), decreased likelihood of elevated admission serum troponin (OR .09, 95% CI .02-.35, p < 0.001), and worse LS basal segments (OR 1.18, 95% CI 1.02-1.37, p = 0.03). CONCLUSION In patients with neurogenic stunned myocardium, significantly impaired LV contraction by LS basal segments was found in patients with AIS but not with SAH. Individual LV segments in our combined SAH and AIS population were also not associated with clinical outcomes. Our findings suggest that strain echocardiography may identify subtle forms of NSM and help differentiate the NSM pathophysiology in SAH and AIS.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Neurology, Georgetown University Medical Center, Washington, DC, USA
| | - Hooman Fazlalizadeh
- Department of Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center., Washington, DC, USA
| | - Matthew Triano
- Georgetown University School of Medicine, Washington, DC, USA
| | | | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center., Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center., Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center., Washington, DC, USA
| | - Preetham Kumar
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin Kenigsberg
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA.,Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Diego Medvedofsky
- Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA
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Rehman S, Phan HT, Chandra RV, Gall S. Is sex a predictor for delayed cerebral ischaemia (DCI) and hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH)? A systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:199-210. [PMID: 36333624 PMCID: PMC9840585 DOI: 10.1007/s00701-022-05399-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis. METHODS A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies. RESULTS There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11-1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27-2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78-1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99-1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57-1.33). CONCLUSIONS Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Hoang T Phan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Monash Health, Melbourne, VIC, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
- Monash University, Melbourne, VIC, Australia.
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Khawaja AM, McNulty J, Thakur UV, Chawla S, Devi S, Liew A, Mirshahi S, Du R, Mekary RA, Gormley W. Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 46:3. [PMID: 36471088 DOI: 10.1007/s10143-022-01913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, Wayne State University, Detroit, MI, 48201, USA
| | - Jack McNulty
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
| | | | - Shreya Chawla
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shervin Mirshahi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA.
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - William Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
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10
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Biomarker Associations in Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2022; 23:ijms23158789. [PMID: 35955921 PMCID: PMC9369444 DOI: 10.3390/ijms23158789] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Revised: 08/01/2022] [Accepted: 08/04/2022] [Indexed: 11/24/2022] Open
Abstract
The prognosis for patients with aneurysmal subarachnoid hemorrhage (aSAH) is heavily influenced by the development of delayed cerebral ischemia (DCI), but the adequate and effective therapy of DCI to this day has not been resolved. Multiplex serum biomarker studies may help to understand the pathophysiological processes underlying DCI. Samples were collected from patients with aSAH at two time points: (1) 24 h (Day 1) and (2) 5−7 days after ictus. Serum concentrations of eotaxin, FGF-2, FLT-3L, CX3CL1, Il-1b, IL-4, IP-10, MCP3, and MIP-1b were determined using a customized MILLIPLEX Human Cytokine/Chemokine/Growth Factor Panel A multiplex assay. The functional outcome was defined by the modified Rankin scale (favorable: 0−2, unfavorable: 3−6) measured on the 30th day after aSAH. One-hundred and twelve patients with aSAH were included in this study. The median level of CX3CL1 and MCP-3 measured on Days 5−7 were significantly higher in patients with DCI compared with those without DCI (CX3CL1: with DCI: 110.5 pg/mL, IQR: 82−201 vs. without DCI: 82.6, 58−119, p = 0.036; and MCP-3: with DCI: 22 pg/mL (0−32) vs. without DCI: 0 (0−11), p < 0.001). IP-10, MCP-3, and MIP-1b also showed significant associations with the functional outcome after aSAH. MCP-3 and CX3CL1 may play a role in the pathophysiology of DCI.
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Safety and efficacy of a novel robotic transcranial doppler system in subarachnoid hemorrhage. Sci Rep 2022; 12:2266. [PMID: 35145104 PMCID: PMC8831519 DOI: 10.1038/s41598-021-04751-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 12/23/2021] [Indexed: 12/25/2022] Open
Abstract
Delayed cerebral ischemia (DCI) secondary to vasospasm is a determinate of outcomes following non-traumatic subarachnoid hemorrhage (SAH). SAH patients are monitored using transcranial doppler (TCD) to measure cerebral blood flow velocities (CBFv). However, the accuracy and precision of manually acquired TCD can be operator dependent. The NovaGuide robotic TCD system attempts to standardize acquisition. This investigation evaluated the safety and efficacy of the NovaGuide system in SAH patients in a Neuro ICU. We retrospectively identified 48 NovaGuide scans conducted on SAH patients. Mean and maximum middle cerebral artery (MCA) CBFv were obtained from the NovaGuide and the level of agreement between CBFv and computed tomography angiography (CTA) for vasospasm was determined. Safety of NovaGuide acquisition of CBFv was evaluated based on number of complications with central venous lines (CVL) and external ventricular drains (EVD). There was significant agreement between the NovaGuide and CTA (Cohen’s Kappa = 0.74) when maximum MCA CBFv ≥ 120 cm/s was the threshold for vasospasm. 27/48 scans were carried out with CVLs and EVDs present without negative outcomes. The lack of adverse events associated with EVDs/CVLs and the strong congruence between maximal MCA CBFv and CTA illustrates the diagnostic utility of the NovaGuide.
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Alexopoulos G, Zhang J, Karampelas I, Khan M, Quadri N, Patel M, Patel N, Almajali M, Mattei TA, Kemp J, Coppens J, Mercier P. Applied forecasting for delayed cerebral ischemia prediction post subarachnoid hemorrhage: Methodological fallacies. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2021.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Dowlati E, Mualem W, Carpenter A, Chang JJ, Felbaum DR, Sur S, Liu AH, Mai JC, Armonda RA. Early Fevers and Elevated Neutrophil-to-Lymphocyte Ratio are Associated with Repeat Endovascular Interventions for Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:916-926. [PMID: 34850332 DOI: 10.1007/s12028-021-01399-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/09/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Patients with aneurysmal subarachnoid hemorrhage (aSAH) may develop refractory arterial cerebral vasospasm requiring multiple endovascular interventions. The aim of our study is to evaluate variables associated with need for repeat endovascular treatments in refractory vasospasm and to identify differences in outcomes following one versus multiple treatments. METHODS We retrospectively reviewed patients treated for aSAH between 2017 and 2020 at two tertiary care centers. We included patients who underwent treatment (intraarterial infusion of vasodilatory agents or mechanical angioplasty) for radiographically diagnosed vasospasm in our analysis. Patients were divided into those who underwent single treatment versus those who underwent multiple endovascular treatments for vasospasm. RESULTS Of the total 418 patients with aSAH, 151 (45.9%) underwent endovascular intervention for vasospasm. Of 151 patients, 95 (62.9%) underwent a single treatment and 56 (37.1%) underwent two or more treatments. Patients were more likely to undergo multiple endovascular treatments if they had a Hunt-Hess score > 2 (odds ratio [OR] 5.10 [95% confidence interval (CI) 1.82-15.84]; p = 0.003), a neutrophil-to-lymphocyte ratio > 8.0 (OR 3.19 [95% CI 1.40-7.62]; p = 0.028), and more than two fevers within the first 5 days of admission (OR 7.03 [95% CI 2.68-20.94]; p < 0.001). Patients with multiple treatments had poorer outcomes, including increased length of stay, delayed cerebral ischemia, in-hospital complications, and higher modified Rankin scores at discharge. CONCLUSIONS A Hunt-Hess score > 2, a neutrophil-to-lymphocyte ratio > 8.0, and early fevers may be predictive of need for multiple endovascular interventions in refractory cerebral vasospasm after aSAH. These patients have poorer functional outcomes at discharge and higher rates of in-hospital complications.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, DC, USA.
| | - William Mualem
- School of Medicine, Georgetown University, Washington, DC, USA
| | - Austin Carpenter
- Department of Neurosurgery, New York Medical College, Valhalla, NY, USA
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Samir Sur
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Ai-Hsi Liu
- Department of Radiology, MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, PHC 7, Washington, DC, USA.,Department of Neurosurgery, MedStar Washington Hospital Center, Washington, DC, USA
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Chang JJ, Dowlati E, Triano M, Kalegha E, Krishnan R, Kasturiarachi BM, Gachechiladze L, Pandhi A, Themistocleous M, Katsanos AH, Felbaum DR, Mai JC, Armonda RA, Aulisi EF, Elijovich L, Arthur AS, Tsivgoulis G, Goyal N. Admission Neutrophil to Lymphocyte Ratio for Predicting Outcome in Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105936. [PMID: 34174515 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 01/02/2023] Open
Abstract
PURPOSE We sought to evaluate the relationship between admission neutrophil-to-lymphocyte ratio (NLR) and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. MATERIAL AND METHODS Consecutive patients with aSAH were treated at two tertiary stroke centers during a five-year period. Functional outcome was defined as discharge modified Rankin score dichotomized at scores 0-2 (good) vs. 3-6 (poor). RESULTS 474 aSAH patients were evaluated with a mean NLR 8.6 (SD 8.3). In multivariable logistic regression analysis, poor functional outcome was independently associated with higher NLR, older age, poorer clinical status on admission, prehospital statin use, and vasospasm. Increasing NLR analyzed as a continuous variable was independently associated with higher odds of poor functional outcome (OR 1.03, 95%CI 1.00-1.07, p=0.05) after adjustment for potential confounders. When dichotomized using ROC curve analysis, a threshold NLR value of greater than 6.48 was independently associated with higher odds of poor functional outcome (OR 1.71, 95%CI 1.07-2.74, p=0.03) after adjustment for potential confounders. CONCLUSIONS Higher admission NLR is an independent predictor for poor functional outcome at discharge in aSAH patients. The evaluation of anti-inflammatory targets in the future may allow for improved functional outcome after aSAH.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine. MedStar Washington Hospital Center. Washington, DC, USA; Department of Neurology. Georgetown University Medical Center. Washington, DC, USA.
| | - Ehsan Dowlati
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Matthew Triano
- Department of Critical Care Medicine. MedStar Washington Hospital Center. Washington, DC, USA.
| | - Enite Kalegha
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA.
| | - Rashi Krishnan
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | | | - Leila Gachechiladze
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | - Marios Themistocleous
- Department of Neurosurgery, Pediatric Hospital of Athens, Agia Sophia. Athens, Greece
| | - Aristeidis H Katsanos
- Department of Neurology, National and Kapodistrian University of Athens. Athens, Greece; Division of Neurology, McMaster University and Population Health Research Institute. Hamilton, ON, Canada
| | - Daniel R Felbaum
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA.
| | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA; Department of Neurology, National and Kapodistrian University of Athens. Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
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Morais Filho ABD, Rego TLDH, Mendonça LDL, Almeida SSD, Nóbrega MLD, Palmieri TDO, Giustina GZD, Melo JP, Pinheiro FI, Guzen FP. The physiopathology of spontaneous hemorrhagic stroke: a systematic review. Rev Neurosci 2021; 32:631-658. [PMID: 33594841 DOI: 10.1515/revneuro-2020-0131] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 01/22/2021] [Indexed: 12/29/2022]
Abstract
Hemorrhagic stroke (HS) is a major cause of death and disability worldwide, despite being less common, it presents more aggressively and leads to more severe sequelae than ischemic stroke. There are two types of HS: Intracerebral Hemorrhage (ICH) and Subarachnoid Hemorrhage (SAH), differing not only in the site of bleeding, but also in the mechanisms responsible for acute and subacute symptoms. This is a systematic review of databases in search of works of the last five years relating to the comprehension of both kinds of HS. Sixty two articles composed the direct findings of the recent literature and were further characterized to construct the pathophysiology in the order of events. The road to the understanding of the spontaneous HS pathophysiology is far from complete. Our findings show specific and individual results relating to the natural history of the disease of ICH and SAH, presenting common and different risk factors, distinct and similar clinical manifestations at onset or later days to weeks, and possible complications for both.
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