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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [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: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Petkar S, Chakole V, Nisal R, Priya V. Cerebral Perfusion Unveiled: A Comprehensive Review of Blood Pressure Management in Neurosurgical and Endovascular Aneurysm Interventions. Cureus 2024; 16:e53635. [PMID: 38449959 PMCID: PMC10917124 DOI: 10.7759/cureus.53635] [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: 12/28/2023] [Accepted: 02/05/2024] [Indexed: 03/08/2024] Open
Abstract
This comprehensive review delves into the intricate dynamics of cerebral perfusion and blood pressure management within the context of neurosurgical and endovascular aneurysm interventions. The review highlights the critical role of maintaining a delicate hemodynamic balance, given the brain's susceptibility to fluctuations in blood pressure. Emphasizing the regulatory mechanisms of cerebral perfusion, particularly autoregulation, the study advocates for a nuanced and personalized approach to blood pressure control. Key findings underscore the significance of adhering to tailored blood pressure targets to mitigate the risks of ischemic and hemorrhagic complications in both neurosurgical and endovascular procedures. The implications for clinical practice are profound, calling for heightened awareness and precision in hemodynamic management. The review concludes with recommendations for future research, urging exploration into optimal blood pressure targets, advancements in monitoring technologies, investigations into long-term outcomes, and the development of personalized approaches. By consolidating current knowledge and charting a path for future investigations, this review aims to contribute to the continual enhancement of patient outcomes in the dynamic field of neurovascular interventions.
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Affiliation(s)
- Shubham Petkar
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vivek Chakole
- Anaesthesiology, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Roshan Nisal
- Anaesthesiology, awaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Vishnu Priya
- Anaesthesiology, awaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Miszczenkow H, Krzych Ł. Insights into Hemodynamic Features of Survivors and the Deceased with Acute Brain Injury: A Step Forward Tailored Treatment. J Clin Med 2023; 12:4021. [PMID: 37373714 DOI: 10.3390/jcm12124021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 05/24/2023] [Accepted: 06/08/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Pulmonary artery catheters are widely used for hemodynamical monitoring in critically ill patients. Acute brain injury is among the severe conditions treated in an intensive care unit. The advanced monitoring of hemodynamical parameters, fluid balance and adequate administered treatment based on those values are components of goal-directed therapy. METHODS A prospective observational study included adult patients who were hospitalized in the ICU due to acute bran injury, excluding brain oedema after cardiac arrest. Each patient had PAC inserted and hemodynamic data were collected during the first 3 days of the ICU stay every 6 h. Patients were divided into two groups based on the endpoint: the survivors and the deceased. RESULTS Length of stay in hospital differed between patiens. All patients, regardless of their outcome, had noradrenaline administered. The initial values of PAP differed between the groups (p = 0.05). There were positive correlations noticed between noradrenaline dose, CVP and fluid balance when compared to PCWP in a group of survivors and a positive correlation in the fluid balance when compared to PAP and PVRI. Lactate serum concentrations presented a correlation with the dose of noradrenaline in both groups. CONCLUSIONS Upon acute brain injury, values of PVRI and PAP increase. This is corelated with fluid load and worsened by an excessive fluid treatment in the case of an inconsiderate approach for stabilizing the patient hemodynamically. PAC may present limited advantages in terms of PAP and PVRI control during the treatment.
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Affiliation(s)
- Hanna Miszczenkow
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Medyków 14, 40-752 Katowice, Poland
| | - Łukasz Krzych
- Department of Anesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, Medyków 14, 40-752 Katowice, Poland
- Department of Cardiac Anesthesia and Intensive Care, Silesian Centre for Heart Diseases, Marii Skłodowskiej-Curie 9, 41-800 Zabrze, Poland
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Said M, Gümüs M, Rodemerk J, Chihi M, Rauschenbach L, Dinger TF, Darkwah Oppong M, Dammann P, Wrede KH, Sure U, Jabbarli R. The value of ventricular measurements in the prediction of shunt dependency after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:1545-1555. [PMID: 37127799 DOI: 10.1007/s00701-023-05595-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Chronic hydrocephalus requiring shunt placement is a common complication of aneurysmal subarachnoid hemorrhage (SAH). Different risk factors and prediction scores for post-SAH shunt dependency have been evaluated so far. We analyzed the value of ventricle measurements for prediction of the need for shunt placement in SAH patients. METHODS Eligible SAH cases treated between 01/2003 and 06/2016 were included. Initial computed tomography scans were reviewed to measure ventricle indices (bifrontal, bicaudate, Evans', ventricular, Huckman's, and third ventricle ratio). Previously introduced CHESS and SDASH scores for shunt dependency were calculated. Receiver operating characteristic analyses were performed for diagnostic accuracy of the ventricle indices and to identify the clinically relevant cut-offs. RESULTS Shunt placement followed in 221 (36.5%) of 606 patients. In univariate analyses, all ventricular indices were associated with shunting (all: p<0.0001). The area under the curve (AUC) ranged between 0.622 and 0.662. In multivariate analyses, only Huckman's index was associated with shunt dependency (cut-off at ≥6.0cm, p<0.0001) independent of the CHESS score as baseline prediction model. A combined score (0-10 points) containing the CHESS score components (0-8 points) and Huckman's index (+2 points) showed better diagnostic accuracy (AUC=0.751) than the CHESS (AUC=0.713) and SDASH (AUC=0.693) scores and the highest overall model quality (0.71 vs. 0.65 and 0.67), respectively. CONCLUSIONS Ventricle measurements are feasible for early prediction of shunt placement after SAH. The combined prediction model containing the CHESS score and Huckman's index showed remarkable diagnostic accuracy regarding identification of SAH individuals requiring shunt placement. External validation of the presented combined CHESS-Huckman score is mandatory.
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Affiliation(s)
- Maryam Said
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany.
- Department of Neurosurgery and Spine Surgery, Evangelisches Krankenhaus Oldenburg, Oldenburg, Germany.
| | - Meltem Gümüs
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Jan Rodemerk
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Mehdi Chihi
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Laurèl Rauschenbach
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Thiemo F Dinger
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Marvin Darkwah Oppong
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Karsten H Wrede
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Ulrich Sure
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital of Essen, Essen, Germany
- Center for Translational Neuro- & Behavioral Sciences (C-TNBS), University Duisburg-Essen, Essen, Germany
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Rhim JK, Park JJ, Kim H, Jeon JP. Early and Prolonged Mild Hypothermia in Patients with Poor-Grade Subarachnoid Hemorrhage: A Pilot Study. Ther Hypothermia Temp Manag 2022; 12:229-234. [PMID: 36130134 DOI: 10.1089/ther.2022.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We assessed the feasibility of therapeutic early and prolonged mild hypothermia (MH) in patients with poor-grade subarachnoid hemorrhage (SAH). A retrospective pilot study was conducted for poor-grade SAH patients at two university hospitals from March 2015 to December 2018 who had received MH immediately after coil embolization and maintained a target temperature of 34-35°C for 5 days. A matched controlled design at a 1:2 ratio was used to compare MH therapy outcomes. The primary goal was to assess the two groups' severe functional outcomes at discharge defined as a modified Rankin Scale score of 4-6. The secondary aim was to assess mortality and severe vasospasm depending upon MH. A binary logistic regression analysis was performed to identify relevant risk factors for the outcomes. A total of 54 patients (18 with MH treatment and 36 without MH treatment) were included. Severe functional outcome was significantly decreased in poor-grade SAH patients with MH (n = 7, 38.9%) than those without MH (n = 25, 69.4%; p = 0.031). In patients treated with MH, mortality and severe vasospasm tended to be less common, although the difference was not statistically significant. A binary logistic regression analysis revealed that early and prolonged MH (odds ratio [OR] = 0.156, 95% confidence intervals [CI]: 0.037-0.644) and severe vasospasm (OR = 5.593, 95% CI: 1.372-22.812) were risk factors for severe functional outcomes. This study shows potential therapeutic effect of early and prolonged MH treatment in poor-grade SAH patients. A randomized controlled study with a large number of patients is warranted in the future.
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Affiliation(s)
- Jong-Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Heungcheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
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