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Zolnourian A, Garland P, Holton P, Arora M, Rhodes J, Uff C, Birch T, Howat D, Franklin S, Galea I, Bulters D. A Randomised Controlled Trial of SFX-01 After Subarachnoid Haemorrhage - The SAS Study. Transl Stroke Res 2024:10.1007/s12975-024-01278-1. [PMID: 39028412 DOI: 10.1007/s12975-024-01278-1] [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: 04/26/2024] [Revised: 07/02/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Abstract
SFX-01 is a novel drug for clinical delivery of sulforaphane (SFN). SFN is a potent nuclear factor erythroid 2-related factor 2 activator that reduces inflammation and oxidation, improving outcomes after subarachnoid haemorrhage (SAH) in animal models. This was a multi-centre, double-blind, placebo-controlled, parallel-group randomised clinical trial to evaluate the safety, pharmacokinetics and efficacy of 28 days of SFX-01 300 mg BD in patients aged 18-80 with spontaneous SAH and high blood load on CT. Primary outcomes were (1) safety, (2) plasma and CSF SFN and metabolite levels and (3) vasospasm on transcranial doppler ultrasound. Secondary outcomes included CSF haptoglobin and malondialdehyde and clinical outcome on the modified Rankin Scale (mRS) and SAH outcome tool (SAHOT). A total of 105 patients were randomised (54 SFX-01, 51 placebo). There were no differences in adverse events other than nausea (9 SFX-01 (16.7%), 1 placebo (2.0%)). SFN, SFN-glutathione and SFN-N-acetyl-cysteine AUClast were 16.2, 277 and 415 h × ng/ml. Plasma SFN was higher in GSTT1 null individuals (t = 2.40, p = 0.023). CSF levels were low with many samples below the lower limit of quantification and predicted by the CSF/serum albumin ratio (R2 = 0.182, p = 0.039). There was no difference in CSF haptoglobin (1.981 95%CI 0.992-3.786, p = 0.052) or malondialdehyde (1.12 95%CI 0.7477-1.687, p = 0.572) or middle cerebral artery flow velocity (1.04 95%CI 0.903-1.211, p = 0.545) or functional outcome (mRS 1.647 95%CI 0.721-3.821, p = 0.237, SAHOT 1.082 95%CI 0.464-2.525, p = 0.855). SFX-01 is safe and effective for the delivery of SFN in acutely unwell patients. SFN penetrated CSF less than expected and did not reduce large vessel vasospasm or improve outcome. Trial registration: NCT02614742 clinicaltrials.gov.
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Affiliation(s)
| | - Patrick Garland
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Patrick Holton
- Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Mukul Arora
- Neurosurgery, University Hospital Southampton, Southampton, UK
| | - Jonathan Rhodes
- Neuro Intensive Care, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Tony Birch
- Medical Physics, University Hospital Southampton, Southampton, UK
| | | | | | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
- Neurology, University Hospital Southampton, Southampton, UK
| | - Diederik Bulters
- Neurosurgery, University Hospital Southampton, Southampton, UK.
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
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Berli S, Barbagallo M, Keller E, Esposito G, Pagnamenta A, Brandi G. Sex-Related Differences in Mortality, Delayed Cerebral Ischemia, and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. J Clin Med 2024; 13:2781. [PMID: 38792323 PMCID: PMC11122382 DOI: 10.3390/jcm13102781] [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: 04/16/2024] [Revised: 04/30/2024] [Accepted: 05/06/2024] [Indexed: 05/26/2024] Open
Abstract
Background/Objective: Sex-related differences among patients with aneurysmal subarachnoid hemorrhage (aSAH) and their potential clinical implications have been insufficiently investigated. To address this knowledge gap, we conduct a comprehensive systematic review and meta-analysis. Methods: Sex-specific differences in patients with aSAH, including mortality, delayed cerebral ischemia (DCI), and functional outcomes were assessed. The functional outcome was dichotomized into favorable or unfavorable based on the modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Glasgow Outcome Scale Extended (GOSE). Results: Overall, 2823 studies were identified in EMBASE, MEDLINE, PubMed, and by manual search on 14 February 2024. After an initial assessment, 74 studies were included in the meta-analysis. In the analysis of mortality, including 18,534 aSAH patients, no statistically significant differences could be detected (risk ratio (RR) 0.99; 95% CI, 0.90-1.09; p = 0.91). In contrast, the risk analysis for DCI, including 23,864 aSAH patients, showed an 11% relative risk reduction in DCI in males versus females (RR, 0.89; 95% CI, 0.81-0.97; p = 0.01). The functional outcome analysis (favorable vs. unfavorable), including 7739 aSAH patients, showed a tendency towards better functional outcomes in men than women; however, this did not reach statistical significance (RR, 1.02; 95% CI, 0.98-1.07; p = 0.34). Conclusions: In conclusion, the available data suggest that sex/gender may play a significant role in the risk of DCI in patients with aSAH, emphasizing the need for sex-specific management strategies.
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Affiliation(s)
- Sarah Berli
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Massimo Barbagallo
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Emanuela Keller
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
| | - Giuseppe Esposito
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, 8091 Zurich, Switzerland
- Department of Neurosurgery, University Hospital Zurich, 8091 Zurich, Switzerland
| | - Alberto Pagnamenta
- Clinical Trial Unit, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Department of Intensive Care, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
- Division of Pneumology, University of Geneva, 1211 Geneva, Switzerland
| | - Giovanna Brandi
- Faculty of Medicine, University of Zurich, 8032 Zurich, Switzerland
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, 8091 Zurich, Switzerland
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Gaastra B, Whyte S, Hankin B, Bulters D, Galea I, Campbell N. An assistive listening device improves hearing following aneurysmal subarachnoid haemorrhage. Eur J Neurol 2024; 31:e16240. [PMID: 38332663 PMCID: PMC11235765 DOI: 10.1111/ene.16240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 01/05/2024] [Accepted: 01/24/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND AND PURPOSE Hearing impairment is common following aneurysmal subarachnoid haemorrhage (aSAH). Previous studies have demonstrated that auditory processing disorder (APD) is the primary underlying pathology. Assistive listening devices (ALDs) can be used to manage APD but have not been explored in aSAH. The aim of this study was to assess the benefit of an ALD for patients reporting hearing difficulty after aSAH. METHODS This was a prospective pilot single-arm intervention study of an ALD for APD following aSAH. Patients who reported subjective hearing difficulty following aSAH were identified from the Wessex Neurological Centre aSAH database. Speech-in-noise was evaluated using the Bamford-Kowal-Bench (BKB) test under 60 and 65 dB noise conditions. BKB performance was compared with and without an ALD. Cognition was assessed using the Addenbrooke's Cognitive Examination-III. RESULTS Fourteen aSAH patients with self-reported hearing loss were included in the analysis. Under both noise conditions the ALD significantly improved BKB performance (60 dB, Z = -3.30, p < 0.001; 65 dB, Z = -3.33, p < 0.001). There was no relationship between cognition and response to the ALD. CONCLUSIONS This study demonstrates the marked benefit of ALDs to manage APD following aSAH, regardless of cognitive status. This finding has implications for the management of this common yet disabling deficit which impacts quality of life and employment. A further trial of ALDs in this patient group is needed to test whether these large, short-term benefits can be practically translated to the community for long-term benefit when used at home.
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Affiliation(s)
- Ben Gaastra
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
- Department of Neurosurgery, Wessex Neurological CentreUniversity Hospital SouthamptonSouthamptonUK
| | - Stuart Whyte
- Faculty of Engineering and Physical Sciences, Auditory Implant ServiceUniversity of SouthamptonSouthamptonUK
| | - Bethan Hankin
- Faculty of Engineering and Physical SciencesUniversity of SouthamptonSouthamptonUK
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological CentreUniversity Hospital SouthamptonSouthamptonUK
| | - Ian Galea
- Faculty of MedicineUniversity of SouthamptonSouthamptonUK
| | - Nicole Campbell
- Faculty of Engineering and Physical Sciences, Auditory Implant ServiceUniversity of SouthamptonSouthamptonUK
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Kessner M, Mehrholz J, Mørkve SH, Taule T. Occupational performance one to five years after aneurysmal subarachnoid haemorrhage: a cohort study. J Rehabil Med 2024; 56:jrm24187. [PMID: 38506427 PMCID: PMC10985495 DOI: 10.2340/jrm.v56.24187] [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: 10/23/2023] [Accepted: 03/07/2024] [Indexed: 03/21/2024] Open
Abstract
OBJECTIVE To report on the self-perceived occupational performance of patients with aneurysmal subarachnoid haemorrhage and examine the associations between aneurysmal subarachnoid haemorrhage characteristics, socio-demographic factors and self-perceived problems. DESIGN A single-centre cohort study design was combined with a cross-sectional analysis. SUBJECTS/PATIENTS All patients with aneurysmal subarachnoid haemorrhage who were capable of performing activities of daily living before discharge from hospital were included. METHODS The assessment of the patient's occupational performance followed a patient-reported outcome measure 1 to 5 years after the subarachnoid haemorrhage. Secondary outcomes comprised scores from the Glasgow Outcome Scale, modified Rankin Scale, Fisher Scale, World Federation of Neurological Societies grading system, vasospasm, and hydrocephalus. RESULTS Of the 62 patients included in the study (66% female, mean age 55 years), 79% reported experiencing issues with occupational performance, most frequently with regard to leisure and productivity. The problems reported were significantly associated with vasospasm (p = 0.021) and the Glasgow Outcome Scale score (p = 0.045). CONCLUSION Even patients who have had aneurysmal subarachnoid haemorrhage with a favourable outcome may encounter occupational performance difficulties for several years. It is vital to use patient-reported outcome measures to identify these issues. This research enhances our comprehension of aneurysmal subarachnoid haemorrhage patients' self-perceived occupational performance and the factors that affect their performance.
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Affiliation(s)
- Marcus Kessner
- Department of Occupational Therapy, Haukeland University Hospital, Bergen, Norway
| | - Jan Mehrholz
- Department of Public Health, Dresden Medical School, Technical University Dresden, Dresden, Germany.
| | | | - Tina Taule
- Department of Occupational Therapy, Haukeland University Hospital, Bergen, Norway; Bachelor in Occupational Therapy, Faculty of Health and Function, Western Norway University of Applied Sciences, Bergen, Norway
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Kaldas A, Zolnourian A, Ewbank F, Digpal R, Narata A, Ditchfield A, Macdonald J, Bulters D. Basilar artery perforator aneurysms: a comparison with non-perforator saccular aneurysms. Acta Neurochir (Wien) 2024; 166:141. [PMID: 38499881 DOI: 10.1007/s00701-024-06026-w] [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: 01/01/2024] [Accepted: 03/05/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Basilar artery perforator aneurysms (BAPAs) are rare. There is no systematic description of their presentation, imaging, natural history and outcomes and how these compare to conventional non-perforator aneurysms. Thus, the authors in this study aimed to compare BAPAs to non-perforator aneurysms. METHODS Cases were identified from a prospective neurovascular database, notes and imaging retrospectively reviewed and compared to a consecutive series of patients with non-perforator aneurysms. Blood volume on CT and vessel wall imaging (VWI) were compared to controls. RESULTS 9/739 patients with aneurysmal subarachnoid haemorrhage (aSAH) harboured BAPAs. Compared to 103 with aSAH from posterior circulation aneurysms, they were more likely to be male (6/9, p = 0.008), but of equal severity (4/9 poor grade, p = 0.736) and need of CSF drainage (5/9, p = 0.154). Blood volume was similar to controls (30.2 ml vs 26.7 ml, p = 0.716). 6/9 BAPAs were initially missed on CTA. VWI showed thick (2.9 mm ± 2.7) bright enhancement (stalk ratio 1.05 ± 0.12), similar to controls with ruptured aneurysms (0.95 ± 0.23, p = 0.551), and greater than unruptured aneurysms (0.43 ± 0.11, p < 0.001). All were initially managed conservatively. Six thrombosed spontaneously. Three grew and had difficult access with few good endovascular options and were treated through a subtemporal craniotomy without complication. None rebled. At 3 months, all presenting in poor grade were mRS 3-4 and those in good grade mRS 1-2. CONCLUSIONS Despite their small size, BAPAs present with similar volume SAH, WFNS grade and hydrocephalus to other aneurysms. They are difficult to identify on CTA but enhance strikingly on VWI. The majority thrombosed. Initial conservative management reserving treatment for growth was associated with no rebleeds or complications.
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Affiliation(s)
- Antony Kaldas
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ardalan Zolnourian
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Frederick Ewbank
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ronneil Digpal
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK
| | - Ana Narata
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Adam Ditchfield
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Jason Macdonald
- Department of Interventional Neuroradiology, University Hospital Southampton, Southampton, UK
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Tremona Road, Southampton, SO16 6YD, UK.
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Bandyopadhyay S, Schwendinger N, Jahromi BR, Lad SP, Blackburn S, Wolf S, Bulters D, Galea I, Hugelshofer M. Red Blood Cells in the Cerebrospinal Fluid Compartment After Subarachnoid Haemorrhage: Significance and Emerging Therapeutic Strategies. Transl Stroke Res 2024:10.1007/s12975-024-01238-9. [PMID: 38418755 DOI: 10.1007/s12975-024-01238-9] [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: 12/29/2023] [Revised: 02/14/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
Subarachnoid haemorrhage (SAH) is a subtype of stroke that predominantly impacts younger individuals. It is associated with high mortality rates and can cause long-term disabilities. This review examines the contribution of the initial blood load and the dynamics of clot clearance to the pathophysiology of SAH and the risk of adverse outcomes. These outcomes include hydrocephalus and delayed cerebral ischaemia (DCI), with a particular focus on the impact of blood located in the cisternal spaces, as opposed to ventricular blood, in the development of DCI. The literature described underscores the prognostic value of haematoma characteristics, such as volume, density, and anatomical location. The limitations of traditional radiographic grading systems are discussed, compared with the more accurate volumetric quantification techniques for predicting patient prognosis. Further, the significance of red blood cells (RBCs) and their breakdown products in secondary brain injury after SAH is explored. The review presents novel interventions designed to accelerate clot clearance or mitigate the effects of toxic byproducts released from erythrolysis in the cerebrospinal fluid following SAH. In conclusion, this review offers deeper insights into the complex dynamics of SAH and discusses the potential pathways available for advancing its management.
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Affiliation(s)
- Soham Bandyopadhyay
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nina Schwendinger
- Department of Neurosurgery, Clinical Neuroscience Center, Universitätsspital and University of Zurich, Zurich, Switzerland
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Shivanand P Lad
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Spiros Blackburn
- Department of Neurosurgery, University of Texas Houston Health Science Center, Houston, TX, USA
| | - Stefan Wolf
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Diederik Bulters
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire, UK
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael Hugelshofer
- Department of Neurosurgery, University Hospital Mannheim, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany.
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Wenfei Z, Xiang T, Chen C, Yang T, Yun T, Zhibiao C, Ge Z. Isoliquiritigenin attenuates neuroinflammation after subarachnoid hemorrhage through inhibition of NF-κB-mediated NLRP3 inflammasome activation. Chem Biol Drug Des 2024; 103:e14436. [PMID: 38395608 DOI: 10.1111/cbdd.14436] [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: 11/02/2023] [Revised: 12/04/2023] [Accepted: 12/15/2023] [Indexed: 02/25/2024]
Abstract
Neuroinflammation contributes to neurological dysfunction in the patients who suffer from subarachnoid hemorrhage (SAH). Isoliquiritigenin (ISL) is a bioactive component extracted from Genus Glycyrrhiza. This work is to investigate whether ISL ameliorates neuroinflammation after SAH. In this study, intravascular perforation of male Sprague-Dawley rats was used to establish a SAH model. ISL was administered by intraperitoneal injection 6 h after SAH in rats. The mortality, SAH grade, neurological score, brain water content, and blood-brain barrier (BBB) permeability were examined at 24 h after the treatment. Expressions of tumor necrosis factor-α, interleukin-6, Iba-1, and MPO were measured by quantitative real-time polymerase chain reaction (qRT-PCR). Besides, the expression levels of NF-κB p65 and NLRP3, ASC, caspase-1, IL-1β, and IL-18 were analyzed by western blot. The experimental data suggested that ISL treatment could ameliorate neurological impairment, attenuate brain edema, and ameliorate BBB injury after SAH in rats. ISL treatment repressed the expression of proinflammatory cytokines TNF-α and IL-6, and meanwhile inhibited the expression of Iba-1 and MPO. ISL also repressed NF-κB p65 expression as well as the transport from the cytoplasm to the nucleus. In addition, ISL significantly suppressed the expression levels of NLR family pyrin domain containing 3 (NLRP3), ASC, caspase-1, IL-1β, and IL-18. These findings suggest that ISL inactivates NLRP3 pathway by inhibiting NF-κB p65 translocation, thereby repressing the neuroinflammation after SAH, and it is a potential drug for the treatment of SAH.
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Affiliation(s)
- Zhang Wenfei
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Tao Xiang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chen Chen
- Department of Orthodontics, Wuhan First Stomatological Hospital, Wuhan, China
| | - Tao Yang
- Department of Nursing, Renmin Hospital of Wuhan University, Wuhan, China
| | - Tao Yun
- Department of Stomatology, Wuhan Central Hospital, Wuhan, China
| | - Chen Zhibiao
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Zhang Ge
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
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Bandyopadhyay S, Garland P, Gaastra B, Zolnourian A, Bulters D, Galea I. The Haptoglobin Response after Aneurysmal Subarachnoid Haemorrhage. Int J Mol Sci 2023; 24:16922. [PMID: 38069244 PMCID: PMC10707007 DOI: 10.3390/ijms242316922] [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: 10/31/2023] [Revised: 11/21/2023] [Accepted: 11/25/2023] [Indexed: 12/18/2023] Open
Abstract
Haptoglobin is the body's first line of defence against the toxicity of extracellular haemoglobin released following a subarachnoid haemorrhage (SAH). We investigated the haptoglobin response after SAH in cerebrospinal fluid (CSF) and serum. Paired CSF and serum samples from 19 controls and 92 SAH patients were assayed as follows: ultra-performance liquid chromatography for CSF haemoglobin and haptoglobin, immunoassay for serum haptoglobin and multiplexed CSF cytokines, and colorimetry for albumin. There was marked CSF haptoglobin deficiency: 99% of extracellular haemoglobin was unbound. The quotients for both CSF/serum albumin (qAlb) and haptoglobin (qHp) were used to compute the CSF haptoglobin index (qHp/qAlb). CSF from SAH patients had a significantly lower haptoglobin index compared to controls, especially in Haptoglobin-1 allele carriers. Serum haptoglobin levels increased after SAH and were correlated with CSF cytokine levels. Haptoglobin variables were not associated with long-term clinical outcomes post-SAH. We conclude that: (1) intrathecal haptoglobin consumption occurs after SAH, more so in haptoglobin-1 allele carriers; (2) serum haptoglobin is upregulated after SAH, in keeping with the liver acute phase response to central inflammation; (3) haptoglobin in the CSF is so low that any variation is too small for this to affect long-term outcomes, emphasising the potential for therapeutic haptoglobin supplementation.
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Affiliation(s)
- Soham Bandyopadhyay
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (S.B.); (P.G.); (B.G.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
| | - Patrick Garland
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (S.B.); (P.G.); (B.G.)
| | - Ben Gaastra
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (S.B.); (P.G.); (B.G.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
| | - Ardalan Zolnourian
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
| | - Diederik Bulters
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (S.B.); (P.G.); (B.G.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
| | - Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO16 6YD, UK; (S.B.); (P.G.); (B.G.)
- Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK;
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Shan D, Wang J, Qi P, Lu J, Wang D. Non-Contrasted CT Radiomics for SAH Prognosis Prediction. Bioengineering (Basel) 2023; 10:967. [PMID: 37627852 PMCID: PMC10451737 DOI: 10.3390/bioengineering10080967] [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: 07/05/2023] [Revised: 08/04/2023] [Accepted: 08/14/2023] [Indexed: 08/27/2023] Open
Abstract
Subarachnoid hemorrhage (SAH) denotes a serious type of hemorrhagic stroke that often leads to a poor prognosis and poses a significant socioeconomic burden. Timely assessment of the prognosis of SAH patients is of paramount clinical importance for medical decision making. Currently, clinical prognosis evaluation heavily relies on patients' clinical information, which suffers from limited accuracy. Non-contrast computed tomography (NCCT) is the primary diagnostic tool for SAH. Radiomics, an emerging technology, involves extracting quantitative radiomics features from medical images to serve as diagnostic markers. However, there is a scarcity of studies exploring the prognostic prediction of SAH using NCCT radiomics features. The objective of this study is to utilize machine learning (ML) algorithms that leverage NCCT radiomics features for the prognostic prediction of SAH. Retrospectively, we collected NCCT and clinical data of SAH patients treated at Beijing Hospital between May 2012 and November 2022. The modified Rankin Scale (mRS) was utilized to assess the prognosis of patients with SAH at the 3-month mark after the SAH event. Based on follow-up data, patients were classified into two groups: good outcome (mRS ≤ 2) and poor outcome (mRS > 2) groups. The region of interest in NCCT images was delineated using 3D Slicer software, and radiomic features were extracted. The most stable and significant radiomic features were identified using the intraclass correlation coefficient, t-test, and least absolute shrinkage and selection operator (LASSO) regression. The data were randomly divided into training and testing cohorts in a 7:3 ratio. Various ML algorithms were utilized to construct predictive models, encompassing logistic regression (LR), support vector machine (SVM), random forest (RF), light gradient boosting machine (LGBM), adaptive boosting (AdaBoost), extreme gradient boosting (XGBoost), and multi-layer perceptron (MLP). Seven prediction models based on radiomic features related to the outcome of SAH patients were constructed using the training cohort. Internal validation was performed using five-fold cross-validation in the entire training cohort. The receiver operating characteristic curve, accuracy, precision, recall, and f-1 score evaluation metrics were employed to assess the performance of the classifier in the overall dataset. Furthermore, decision curve analysis was conducted to evaluate model effectiveness. The study included 105 SAH patients. A comprehensive set of 1316 radiomics characteristics were initially derived, from which 13 distinct features were chosen for the construction of the ML model. Significant differences in age were observed between patients with good and poor outcomes. Among the seven constructed models, model_SVM exhibited optimal outcomes during a five-fold cross-validation assessment, with an average area under the curve (AUC) of 0.98 (standard deviation: 0.01) and 0.88 (standard deviation: 0.08) on the training and testing cohorts, respectively. In the overall dataset, model_SVM achieved an accuracy, precision, recall, f-1 score, and AUC of 0.88, 0.84, 0.87, 0.84, and 0.82, respectively, in the testing cohort. Radiomics features associated with the outcome of SAH patients were successfully obtained, and seven ML models were constructed. Model_SVM exhibited the best predictive performance. The radiomics model has the potential to provide guidance for SAH prognosis prediction and treatment guidance.
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Affiliation(s)
- Dezhi Shan
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China; (D.S.)
- Graduate School, Peking Union Medical College, Beijing 100730, China
| | - Junjie Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China; (D.S.)
| | - Peng Qi
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China; (D.S.)
| | - Jun Lu
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China; (D.S.)
| | - Daming Wang
- Department of Neurosurgery, Beijing Hospital, National Center of Gerontology, Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing 100730, China; (D.S.)
- Graduate School, Peking Union Medical College, Beijing 100730, China
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11
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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: 135] [Impact Index Per Article: 135.0] [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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12
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Zhang J, He L, Xia X, Zhang L, Yu K. Braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in patients with unruptured complex intracranial aneurysms. Clinics (Sao Paulo) 2023; 78:100202. [PMID: 37130488 PMCID: PMC10172744 DOI: 10.1016/j.clinsp.2023.100202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Revised: 03/30/2023] [Accepted: 04/05/2023] [Indexed: 05/04/2023] Open
Abstract
PURPOSES Braided and laser-cut stents both are efficacious and safe for coiling intracranial aneurysms. The study aimed to compare outcomes following braided stent-assisted coil embolization versus laser engraved stent-assisted coil embolization in 266 patients who were diagnosed with unruptured intracranial aneurysms of different types and locations. METHODS Patients with unruptured complex intracranial aneurysms underwent braided (BSE cohort, n = 125) or laser engraved (LSE cohort, n = 141) stent-assisted embolization. RESULTS The deployment success rate was higher for patients of the LSE cohort than those of the BSE cohort (140 [99%] vs. 117 [94%], p = 0.0142). Seventy-one (fifty-seven percentages) and 73 (52%) were coil embolization procedure success rates of the BSE and the LSE cohorts. Periprocedural intracranial hemorrhage was higher in patients of the BSE cohort than those of the LSE cohort (8 [6%] vs. 1 [1%], p = 0.0142). Four (three percentages) patients from the LSE cohort and 3 (2%) patients from the BSE cohort had in-stent thrombosis during embolization. Permanent morbidities were higher in patients of the LSE cohort than those of the BSE cohort (8 [6%] vs. 1 [1%], p = 0.0389). Higher successful procedures (76% vs. 68%) and fewer postprocedural intracranial hemorrhage (0% vs. 5%) and mortality (0% vs. 5%) were reported for patients of the BSE cohort in posterior circulation aneurysmal location than those of the LSE cohort. Laser engraved stent has fewer problems with deployment and may have better periprocedural and follow-up outcomes after embolization. CONCLUSIONS Braided stent-assisted embolization should be preferred when the aneurysm is present in the posterior circulation.
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Affiliation(s)
- Jie Zhang
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
| | - Ling He
- The First Affiliated Hospital of Chengdu Medical College, Department of Hematology, Chengdu, Sichuan, China
| | - Xun Xia
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China.
| | - Lie Zhang
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
| | - Kai Yu
- The First Affiliated Hospital of Chengdu Medical College, Department of Neurosurgery, Chengdu, Sichuan, China
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13
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Hemoglobin Derived from Subarachnoid Hemorrhage-Induced Pyroptosis of Neural Stem Cells via ROS/NLRP3/GSDMD Pathway. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2023; 2023:4383332. [PMID: 36703912 PMCID: PMC9871413 DOI: 10.1155/2023/4383332] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 12/13/2022] [Accepted: 12/15/2022] [Indexed: 01/17/2023]
Abstract
Accumulating evidence has demonstrated that neural stem cells (NSCs) have regenerative capacity after brain injuries, such as in aneurysmal subarachnoid hemorrhage (SAH). The reactive oxygen species (ROS)-induced NOD-like receptor thermal protein domain associated protein 3 (NLRP3) inflammasome triggers inflammatory responses and pyroptosis of cells; however, whether ROS-induced neuroinflammation modulates the fate of endogenous NSCs after SAH remains largely unknown. In this study, the level of IL-1β was increased in the cerebrospinal fluid (CSF) of patients with SAH. In an endovascular perforation model of SAH in mice, the secretion of IL-1β increased to a peak at 24 h following SAH, and the expression of Caspase1 and NLRP3 was elevated in the hippocampus. Primary cultured NSCs were incubated with hemoglobin (Hb) to mimic SAH in vitro. The cell viability, LDH release, intracellular ROS levels, scanning electron microscopy (SEM), and the expression of NLRP3 and pyroptosis indicators (GSDMD, ASC, and Caspase-1) in NSCs after SAH were examined to investigate the process of pyroptosis. We found that pyroptotic death featuring cellular swelling, cell membrane pore formation and elevated IL-1β was increased in cultured primary NSCs after Hb treatment, as was the expression of NLRP3, ASC, Caspase-1, and GSDMD. In addition, we found that ROS-induced pyroptosis of NSCs by activating the NLRP3/GSDMD pathway. These findings suggest that pyroptosis of NSCs induced by Hb can impede neural regeneration after SAH.
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14
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Ziebart A, Abdulazim A, Wenz F, Kleindienst N, Mocarz-Kleindienst M, Galea I, Rinkel GJE, Etminan N. Validation of the German version of the subarachnoid haemorrhage outcome tool (SAHOT). Eur Stroke J 2022; 8:320-327. [PMID: 37021152 PMCID: PMC10069186 DOI: 10.1177/23969873221144813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 11/16/2022] [Indexed: 12/23/2022] Open
Abstract
Objective: The subarachnoid haemorrhage (SAH) outcome tool (SAHOT) is the first SAH-specific patient reported outcome measure, and was developed in the UK. We aimed to validate the SAHOT outside the UK, and therefore endeavored to adapt the SAHOT into German and to test its psychometric properties. Methods: We adapted and pilot tested the German version. We applied the SAHOT, Quality of Life after Brain Injury, Hospital Anxiety and Depression Scale, and EuroQol questionnaires in a cohort of 89 patients with spontaneous SAH after discharge. We assessed internal consistency by Cronbach’s α, test-retest reliability by intraclass correlation, and validity by Pearson correlations with established measures. Sensitivity to change was evaluated following neurorehabilitation by effect sizes. Results: The translation of SAHOT resulted in a German version that is semantically and conceptually equivalent to the English version. Internal consistency was good regarding the physical domain (α = 0.83) and excellent for the other domains (α = 0.92–0.93). Test–retest reliability indicated a high level of stability with an intraclass correlation of 0.85 (95% CI: 0.83–0.86). All domains correlated moderately or strongly with established measures ( r = 0.41–0.74; p < 0.01). SAHOT total scores showed moderate sensitivity to change (Cohen’s d = −0.68), while mRS and GOSE showed no significant sensitivity to change. Conclusion: The SAHOT can be adapted to other health care systems and societies than the UK. The German version of the SAHOT is a reliable and valid instrument, and can be used in future clinical studies and individual assessment after spontaneous SAH.
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Affiliation(s)
- Andreas Ziebart
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Amr Abdulazim
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Wenz
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nikolaus Kleindienst
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Maria Mocarz-Kleindienst
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
- Department of Translation Studies and Slavic Languages, The John Paul II Catholic University of Lublin, Lublin, Poland
| | - Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gabriel JE Rinkel
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Nima Etminan
- Department of Neurosurgery, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
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15
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Gaastra B, Ren D, Alexander S, Awad IA, Blackburn S, Doré S, Hanley D, Nyquist P, Bulters D, Galea I. Evidence-based interconversion of the Glasgow Outcome and modified Rankin scales: pitfalls and best practices. J Stroke Cerebrovasc Dis 2022; 31:106845. [PMID: 36309002 PMCID: PMC11295112 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 10/10/2022] [Accepted: 10/11/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to provide the evidence base to guide interconversion of the modified Rankin Scale (mRS) and Glasgow Outcome Scale (GOS) in neurological research. METHODS A retrospective analysis of paired mRS and GOS recordings was conducted using datasets with the following selection criteria: (1) patients had haemorrhagic stroke, (2) simultaneous mRS and GOS measurements were available, and (3) data sharing was possible. The relationship between mRS and GOS was assessed using correlation analysis. The optimum dichotomisation thresholds for agreement between the mRS and GOS were identified using Cohen's kappa coefficient. Two-way conversion tables between mRS and GOS were developed based on the highest agreement between scores. Finally, to identify which direction of conversion (mRS to GOS or vice versa) was better, the Kolmogorov-Smirnov D statistic was calculated. RESULTS Using 3474 paired recordings the mRS and GOS were shown to be highly correlated (ρ = 0.90, p < 0.0001). The greatest agreement between the two scoring systems occurred when mRS=0-2 and GOS=4-5 was used to define good outcome (κ=0.83, 95% confidence interval: 0.81-0.85). Converting from mRS to GOS was better than the reverse direction as evidenced by a lower Kolmogorov-Smirnov statistic (D=0.054 compared to D=0.157). CONCLUSIONS This study demonstrates that the mRS and GOS are highly correlated, establishes the optimum dichotomisation threshold for agreement, provides a method for interconversion and shows that mRS to GOS conversion is superior to the reverse direction if a choice is available.
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Affiliation(s)
- Ben Gaastra
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 6YD, UK; Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Dianxu Ren
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, United States
| | - Issam A Awad
- University of Chicago, Chicago, IL, United States
| | - Spiros Blackburn
- University of Texas Houston Health Science Center, Houston, TX, United States
| | - Sylvain Doré
- Departments of Anesthesiology, Neurology, Psychiatry, Pharmaceutics, and Neuroscience, College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, United States
| | - Dan Hanley
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Paul Nyquist
- Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton SO17 6YD, UK.
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16
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Wenneberg SB, Block L, Sörbo A, Naredi S, Oras J, Hendén PL, Ljungqvist J, Liljencrantz J, Hergès HO. Long-term outcomes after aneurysmal subarachnoid hemorrhage: A prospective observational cohort study. Acta Neurol Scand 2022; 146:525-536. [PMID: 35852005 PMCID: PMC9796482 DOI: 10.1111/ane.13674] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/27/2022] [Accepted: 07/10/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The survival rates for patients affected by aneurysmal subarachnoid hemorrhage (aSAH) have increased in recent years; however, many patients continue to develop cognitive dysfunctions that affect their quality of life. The commonly used outcome measures often fail to identify these cognitive dysfunctions. This study aimed to evaluate the long-term outcomes at 1 and 3 years after aSAH to assess changes over time and relate outcomes to patient characteristics and events during the acute phase. MATERIALS AND METHODS This prospective observational study included patients that experienced aSAH. Patients were assessed according to the extended Glasgow Outcome Scale, Life Satisfaction Questionnaire, Mayo-Portland Adaptability inventory-4, and Mental Fatigue scale. RESULTS Patients were assessed after 1 year (n = 62) and 3 years (n = 54). At 3 years, the extended Glasgow Outcome Scale score improved in 15% and worsened in 12% of the patients. Mental fatigue was observed in 57% of the patients at 1 year. Patients <60 years of age at the time of aSAH had more self-assessed problems, including pain/headache (p < .01), than patients >60 years of age. Patients with delayed cerebral ischemia during the acute phase reported more dissatisfaction at 3 years, whereas no significant result was seen at 1 year. CONCLUSIONS Cognitive dysfunction, especially mental fatigue, is common in patients with aSAH, which affects quality of life and recovery. Patient outcome is a dynamic process developing throughout years after aSAH, involving both improvement and deterioration. This study indicates the importance of longer follow-up periods with broad outcome assessments.
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Affiliation(s)
- Sandra Bjerkne Wenneberg
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Linda Block
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Ann Sörbo
- Department of Neurology and Rehabilitation and Department of Research, Education and InnovationSödra Älvsborg HospitalBoråsSweden,Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Silvana Naredi
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Jonatan Oras
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Pia Löwhagen Hendén
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Johan Ljungqvist
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of NeurosurgerySahlgrenska University HospitalGothenburgSweden
| | - Jaquette Liljencrantz
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
| | - Helena Odenstedt Hergès
- Department of Anaesthesiology and Intensive Care, Institute of Clinical Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden,Department of Anaesthesiology and Intensive Care, Region Västra GötalandSahlgrenska University HospitalGothenburgSweden
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17
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Galea I. Microglial heterogeneity after subarachnoid haemorrhage. CLINICAL AND TRANSLATIONAL DISCOVERY 2022; 2:e61. [PMID: 35692217 PMCID: PMC7612833 DOI: 10.1002/ctd2.61] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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18
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Zhang Z, Zhao Y, Liu Y, Wang X, Xu H, Fang Y, Zhang A, Lenahan C, Luo Y, Chen S. Effect of stress-induced hyperglycemia after non-traumatic non-aneurysmal subarachnoid hemorrhage on clinical complications and functional outcomes. CNS Neurosci Ther 2022; 28:942-952. [PMID: 35290717 PMCID: PMC9062555 DOI: 10.1111/cns.13826] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/19/2022] [Accepted: 02/28/2022] [Indexed: 12/17/2022] Open
Abstract
Background Despite having an overall benign course, non‐traumatic non‐aneurysmal subarachnoid hemorrhage (naSAH) is still accompanied by a risk of clinical complications and poor outcomes. Risk factors and mechanisms of complications and poor outcomes after naSAH remain unknown. Our aim was to explore the effect of stress‐induced hyperglycemia (SIH) on complication rates and functional outcomes in naSAH patients. Methods We retrospectively reviewed patients with naSAH admitted to our institution between 2013 and 2018. SIH was identified according to previous criterion. Symptomatic vasospasm, delayed cerebral infarction, and hydrocephalus were identified as main complications. Outcomes were reviewed using a modified Rankin Scale (mRS) at discharge, 3 months, and 12 months. A statistical analysis was conducted to reveal the associations of SIH with complications and outcomes. Results A total of 244 naSAH patients were included in the cohort with 74 (30.3%) SIH. After adjusting for age, gender, hypertension, Hunt and Hess (HH) grade, modified Fisher Scale (mFS), intraventricular hemorrhage (IVH), and subarachnoid blood distribution, SIH was significantly associated with symptomatic vasospasm (p < 0.001, 12.176 [4.904–30.231]), delayed cerebral infarction (p < 0.001, 12.434 [3.850–40.161]), hydrocephalus (p = 0.008, 5.771 [1.570–21.222]), and poor outcome at 12 months (p = 0.006, 5.506 [1.632–18.581]), whereas the correlation between SIH and poor outcome at discharge (p = 0.064, 2.409 [0.951–6.100]) or 3 months (p = 0.110, 2.029 [0.852–4.833]) was not significant. Incorporation of SIH increased the area under curve (AUC) of ROC in the combined model for predicting symptomatic vasospasm (p = 0.002), delayed cerebral infarction (p = 0.024), hydrocephalus (p = 0.037), and 12‐month poor outcome (p = 0.087). Conclusions SIH is a significant and independent risk factor for symptomatic vasospasm, delayed cerebral infarction, hydrocephalus, and long‐term poor outcome in naSAH patients. Identifying SIH early after naSAH is important for decision‐making and treatment planning.
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Affiliation(s)
- Zeyu Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yue Zhao
- Department of Stomatology, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Health, Hangzhou, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuanjian Fang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Cameron Lenahan
- Center for Neuroscience Research, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Yujie Luo
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Sheng Chen
- Department of Neurosurgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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19
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Regnier-Golanov AS, Gulinello M, Hernandez MS, Golanov EV, Britz GW. Subarachnoid Hemorrhage Induces Sub-acute and Early Chronic Impairment in Learning and Memory in Mice. Transl Stroke Res 2022; 13:625-640. [PMID: 35260988 DOI: 10.1007/s12975-022-00987-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 01/06/2022] [Accepted: 01/11/2022] [Indexed: 12/20/2022]
Abstract
Subarachnoid hemorrhage (SAH) leads to significant long-term cognitive deficits, so-called the post-SAH syndrome. Existing neurological scales used to assess outcomes of SAH are focused on sensory-motor functions. To better evaluate short-term and chronic consequences of SAH, we explored and validated a battery of neurobehavioral tests to gauge the functional outcomes in mice after the circle of Willis perforation-induced SAH. The 18-point Garcia scale, applied up to 4 days, detected impairment only at 24-h time point and showed no significant difference between the Sham and SAH group. A decrease in locomotion was detected at 4-days post-surgery in the open field test but recovered at 30 days in Sham and SAH groups. However, an anxiety-like behavior undetected at 4 days developed at 30 days in SAH mice. At 4-days post-surgery, Y-maze revealed an impairment in working spatial memory in SAH mice, and dyadic social interactions showed a decrease in the sociability in SAH mice, which spent less time interacting with the stimulus mouse. At 30 days after ictus, SAH mice displayed mild spatial learning and memory deficits in the Barnes maze as they committed significantly more errors and used more time to find the escape box but still were able to learn the task. We also observed cognitive dysfunction in the SAH mice in the novel object recognition test. Taken together, these data suggest dysfunction of the limbic system and hippocampus in particular. We suggest a battery of 5 basic behavioral tests allowing to detect neurocognitive deficits in a sub-acute and chronic phase following the SAH.
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Affiliation(s)
| | - M Gulinello
- Rodent Behavior Core, Department of Neuroscience, Albert Einstein University, Bronx, NY, 10461, USA
| | - M S Hernandez
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA
| | - E V Golanov
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA
| | - G W Britz
- Department of Neurosurgery, Houston Methodist Hospital, Houston, USA.
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20
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Galea I, Durnford A, Glazier J, Mitchell S, Kohli S, Foulkes L, Norman J, Darekar A, Love S, Bulters DO, Nicoll JAR, Boche D. Iron Deposition in the Brain After Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:1633-1642. [PMID: 35196874 DOI: 10.1161/strokeaha.121.036645] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND After aneurysmal subarachnoid hemorrhage (SAH), thrombus forms over the cerebral cortex and releases hemoglobin. When extracellular, hemoglobin is toxic to neurones. High local hemoglobin concentration overwhelms the clearance capacity of macrophages expressing the hemoglobin-haptoglobin scavenger receptor CD163. We hypothesized that iron is deposited in the cortex after SAH and would associate with outcome. METHODS Two complementary cross-sectional studies were conducted. Postmortem brain tissue from 39 SAH (mean postictal interval of 9 days) and 22 control cases was studied with Perls' staining for iron and immunolabeling for CD163, ADAM17 (a disintegrin and metallopeptidase domain 17), CD68, and Iba1 (ionized calcium binding adaptor molecule 1). In parallel, to study the persistence of cortical iron and its relationship to clinical outcome, we conducted a susceptibility-weighted imaging study of 21 SAH patients 6 months postictus and 10 control individuals. RESULTS In brain tissue from patients dying soon after SAH, the distribution of iron deposition followed a gradient that diminished with distance from the brain surface. Iron was located intracellularly (mainly in macrophages, and occasionally in microglia, neurones, and glial cells) and extracellularly. Microglial activation and motility markers were increased after SAH, with a similar inward diminishing gradient. In controls, there was a positive correlation between CD163 and iron, which was lost after SAH. In SAH survivors, iron-sensitive imaging 6 months post-SAH confirmed persistence of cortical iron, related to the size and location of the blood clot immediately after SAH, and associated with cognitive outcome. CONCLUSIONS After SAH, iron deposits in the cortical gray matter in a pattern that reflects proximity to the brain surface and thrombus and is related to cognitive outcome. These observations support therapeutic manoeuvres which prevent the permeation of hemoglobin into the cortex after SAH.
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Affiliation(s)
- Ian Galea
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
| | - Andrew Durnford
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.).,Wessex Neurological Centre (A. Durnford, D.O.B.), University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - James Glazier
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
| | - Sophie Mitchell
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
| | - Suraj Kohli
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
| | | | - Jeanette Norman
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
| | - Angela Darekar
- Medical Physics (A. Darekar), University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Seth Love
- Dementia Research Group, Bristol Medical School, University of Bristol, United Kingdom (S.L.)
| | - Diederik O Bulters
- Wessex Neurological Centre (A. Durnford, D.O.B.), University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - James A R Nicoll
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.).,Department of Cellular Pathology (J.A.R.N.), University Hospital Southampton NHS Foundation Trust, United Kingdom
| | - Delphine Boche
- Clinical Neurosciences, Clinical & Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G., A. Durnford, J.G., S.M., S.K., J.N., J.A.R.N., D.B.)
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21
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Gaastra B, Alexander S, Bakker MK, Bhagat H, Bijlenga P, Blackburn S, Collins MK, Doré S, Griessenauer C, Hendrix P, Hong EP, Hostettler IC, Houlden H, IIhara K, Jeon JP, Kim BJ, Kumar M, Morel S, Nyquist P, Ren D, Ruigrok YM, Werring D, Galea I, Bulters D, Tapper W. Genome-Wide Association Study of Clinical Outcome After Aneurysmal Subarachnoid Haemorrhage: Protocol. Transl Stroke Res 2022; 13:565-576. [PMID: 34988871 PMCID: PMC9232474 DOI: 10.1007/s12975-021-00978-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 11/26/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) results in persistent clinical deficits which prevent survivors from returning to normal daily functioning. Only a small fraction of the variation in clinical outcome following aSAH is explained by known clinical, demographic and imaging variables; meaning additional unknown factors must play a key role in clinical outcome. There is a growing body of evidence that genetic variation is important in determining outcome following aSAH. Understanding genetic determinants of outcome will help to improve prognostic modelling, stratify patients in clinical trials and target novel strategies to treat this devastating disease. This protocol details a two-stage genome-wide association study to identify susceptibility loci for clinical outcome after aSAH using individual patient-level data from multiple international cohorts. Clinical outcome will be assessed using the modified Rankin Scale or Glasgow Outcome Scale at 1–24 months. The stage 1 discovery will involve meta-analysis of individual-level genotypes from different cohorts, controlling for key covariates. Based on statistical significance, supplemented by biological relevance, top single nucleotide polymorphisms will be selected for replication at stage 2. The study has national and local ethical approval. The results of this study will be rapidly communicated to clinicians, researchers and patients through open-access publication(s), presentation(s) at international conferences and via our patient and public network.
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Affiliation(s)
- Ben Gaastra
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK.,Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, SO16 6YD, UK
| | - Sheila Alexander
- School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA, 15261, USA
| | - Mark K Bakker
- Department of Neurology, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Heidelberlaan 100, 3584, CX, Utrecht, the Netherlands
| | - Hemant Bhagat
- Division of Neuroanaesthesia, Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Philippe Bijlenga
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Spiros Blackburn
- University of Texas Houston Health Science Center, Houston, TX, USA
| | - Malie K Collins
- Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Sylvain Doré
- Departments of Anesthesiology, Neurology, Psychiatry, Pharmaceutics, and Neuroscience, College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - Christoph Griessenauer
- Department of Neurosurgery, Geisinger, Danville, PA, USA.,Department of Neurosurgery, Christian-Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger, Danville, PA, USA.,Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
| | - Eun Pyo Hong
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Isabel C Hostettler
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Henry Houlden
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Koji IIhara
- National Cerebral and Cardiovascular Center Hospital, 6-1 Kishibe-Shimmachi, Suita, Osaka, Japan
| | - Jin Pyeong Jeon
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea.,Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, South Korea
| | - Bong Jun Kim
- Institute of New Frontier Research, Hallym University College of Medicine, Chuncheon, South Korea
| | - Munish Kumar
- Division of Neuroanaesthesia, Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sandrine Morel
- Neurosurgery Division, Department of Clinical Neurosciences, Faculty of Medicine, Geneva University Hospitals, Geneva, Switzerland.,Department of Pathology and Immunology, Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Paul Nyquist
- Departments of Neurology, Anesthesia/Critical Care Medicine, Neurosurgery and General Internal Medicine, Johns Hopkins School of Medicine, Baltimore, MD, 21287, USA
| | - Dianxu Ren
- School of Nursing, University of Pittsburgh, 3500 Victoria Street, Pittsburgh, PA, 15261, USA
| | - Ynte M Ruigrok
- Department of Neurology, University Medical Center Utrecht Brain Center, University Medical Center Utrecht, Heidelberlaan 100, 3584, CX, Utrecht, the Netherlands
| | - David Werring
- Stroke Research Centre, University College London, Institute of Neurology, London, UK
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK.
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, Southampton, SO16 6YD, UK
| | - Will Tapper
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, SO17 1BJ, UK
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22
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Auditory outcome following aneurysmal subarachnoid haemorrhage. J Neurol Sci 2021; 434:120125. [PMID: 34995980 DOI: 10.1016/j.jns.2021.120125] [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: 11/04/2021] [Revised: 12/23/2021] [Accepted: 12/24/2021] [Indexed: 01/02/2023]
Abstract
Auditory deficits are increasingly recognised following aneurysmal subarachnoid haemorrhage (aSAH) and are thought to be of central rather than peripheral origin. Central hearing impairment, also known as auditory processing disorder (APD), often coexists with cognitive deficits and it is thought that APD has both auditory and cognitive elements. The aim of this study was to assess auditory outcome following aSAH and its relationship with cognition. A retrospective case-controlled study design was employed with aSAH cases and matched controls identified from the UK Biobank. Auditory and cognitive outcomes were assessed using the digit triplet test (DTT) and a test of psychomotor reaction time, respectively. Best DTT score was compared between cases and controls using the t-test. A regression-based mediation analysis was performed to assess whether cognition mediated auditory outcome. 270 aSAH patients with auditory outcomes were identified with an average follow-up of 106 months. A matched control cohort of 1080 individuals was also identified. The aSAH cohort had significantly impaired best DTT scores compared to matched controls (p = 0.002). Cognition significantly mediated auditory outcome following aSAH, accounting for 9.8% of the hearing impairment after aSAH. In conclusion significant hearing impairment follows aSAH. The deficit is bilateral and non-progressive. There is a link with cognitive deficit, pointing to a central rather than peripheral source, in keeping with an auditory processing disorder. All aSAH patients should be asked about hearing difficulty at follow-up and when present it should be investigated with peripheral and central auditory assessments, as well as cognitive tests.
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23
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Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 36:662-681. [PMID: 34940927 DOI: 10.1007/s12028-021-01372-4] [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: 03/18/2021] [Accepted: 10/04/2021] [Indexed: 12/20/2022]
Abstract
One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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24
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Long-Term Cognitive Outcome following Aneurysmal Subarachnoid Haemorrhage. J Stroke Cerebrovasc Dis 2021; 31:106184. [PMID: 34773754 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106184] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/05/2021] [Accepted: 10/17/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Survivors of aneurysmal subarachnoid haemorrhage (aSAH) frequently suffer from cognitive dysfunction. The aim of this study was to assess, in a large sample size with long term follow-up, the characteristics of cognitive dysfunction following aSAH and explore whether cognitive deficits mediate employment outcome. MATERIALS AND METHODS In this retrospective case-controlled study, aSAH survivors (n = 884) were identified from the UK Biobank and compared to matched controls (n = 3536). Controls were propensity score matched according to age, sex, Townsend deprivation score, educational status and relevant medications known to influence cognition. Cognitive outcomes and employment status were compared between cases and controls using group comparison and cross-tabulation tests. A regression-based mediation analysis was performed to assess whether cognitive deficits mediate employment status following aSAH. RESULTS Psychomotor reaction time and employment status significantly differed between aSAH cases and controls with slower reaction times (p < 0.001) and more unemployment or inability to work due to illness (p < 0.001) in the aSAH cohort at a mean follow-up of 125 months. Psychomotor slowing was estimated to mediate a significant proportion (6.59%) of the effect of aSAH on employment status. CONCLUSIONS Psychomotor reaction time and employment status differed significantly between aSAH cases and control matched individuals in the UK Biobank. Psychomotor slowing following aSAH had a discernible impact on employment status. Psychomotor reaction time and employment status are practical to acquire and can be used as surrogate measures of outcome in future studies of aSAH survivors.
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25
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Louie DR, Simpson LA, Mortenson WB, Field TS, Yao J, Eng JJ. Prevalence of Walking Limitation After Acute Stroke and Its Impact on Discharge to Home. Phys Ther 2021; 102:6408936. [PMID: 34718796 PMCID: PMC8787995 DOI: 10.1093/ptj/pzab246] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 07/05/2021] [Accepted: 09/15/2021] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The purpose of this study was to provide contemporary estimates of the prevalence of lower extremity motor impairment and walking limitation after first-ever stroke and to characterize the predictive nature of early walking ability for being discharged home after acute hospitalization. METHODS In this cohort study, data were collected from a metropolitan acute care hospital in Canada at admission for 487 adults with first-ever acute ischemic or hemorrhagic stroke. Lower extremity motor impairment and walking limitation were measured using the National Institutes of Health Stroke Scale and AlphaFIM, respectively. Parallel multivariable logistic regression models were built to predict discharge home after acute hospitalization compared with further hospitalization. RESULTS For patients surviving a first-ever stroke, 44.1% presented with some degree of lower extremity motor impairment and 46.0% were unable to walk. In a multivariable model built around a binary classification of walking (Nagelkerke R2 = 0.41), those with any ability to walk at admission (with or without therapist assistance) had 9.48 times greater odds of being discharged home (odds ratio = 9.48, 95% CI = 6.11-14.92) than those who were unable. In a parallel multivariable model built around an ordinal classification of walking (Nagelkerke R2 = 0.49), patients had 2.07 times greater odds (odds ratio = 2.07, 95% CI = 1.82-2.38) of being discharged home for each increment on a 6-point walking scale (total dependence to complete independence) assessed at acute admission. CONCLUSION Approximately one-half of patients with first-ever stroke present with lower extremity weakness and walking limitation. Early walking ability is a significant predictor of returning home after acute hospitalization, independent of stroke severity. Discharge planning may be facilitated early after stroke with the familiar assessment of walking ability. IMPACT An early assessment of walking function within days of stroke admission can help to streamline discharge planning. LAY SUMMARY Nearly one-half of all individuals who experience a first-time stroke have walking difficulty when they arrive at the hospital. The severity of the walking limitation can predict whether a patient will eventually be discharged home or go on to further hospitalization.
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Affiliation(s)
- Dennis R Louie
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - Lisa A Simpson
- Graduate Program in Rehabilitation Sciences, Faculty of Medicine, University of British Columbia, Vancouver, Canada,Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada
| | - W Ben Mortenson
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada,Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Thalia S Field
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada,Vancouver Stroke Program, Vancouver General Hospital, Vancouver Coastal Health, Vancouver, Canada
| | - Jennifer Yao
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada,GF Strong Rehabilitation Centre, Vancouver Coastal Health, Vancouver, Canada
| | - Janice J Eng
- Rehabilitation Research Program, Vancouver Coastal Health Research Institute, Vancouver, Canada,Department of Physical Therapy, Faculty of Medicine, University of British Columbia, Vancouver, Canada,Address all correspondence to Dr Eng at:
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26
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You L, Huang J, Zhang J, Jiang Z. Multiple overlapping stent-assisted coiling improves efficacy and safety of treatment for complex intracranial aneurysms: a randomized trial. Biomed Eng Online 2021; 20:100. [PMID: 34627265 PMCID: PMC8501645 DOI: 10.1186/s12938-021-00936-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 09/19/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intracranial aneurysm rupture is the main cause of subarachnoid hemorrhage, leading to high disability and mortality. This study aimed to evaluate the clinical treatment effects of multiple overlapping stent-assisted coiling for complex intracranial aneurysms. METHODS We conducted a randomized, controlled, single-blinded clinical trial among 168 patients diagnosed with complex intracranial aneurysms. Treatment allocation to either single stent (SS) group or multiple stent (MS) group was randomized at 1:1 ratio using a Web-based platform. The O'Kelly-Marotta (OKM) grading scale was used to evaluate the degree of aneurysm occlusion after operation and during follow-up. Good aneurysm occlusion was defined as OKM grade C-D. The modified Rankin Scale (mRS) was used to evaluate the neurological status and the clinical outcome of patients. RESULTS Efficacy comparative analysis demonstrated that major recurrence of aneurysms was significantly reduced in the MS group (P = 0.012). In addition, the MS group displayed significantly reduced number of patients with mRS between 3 and 6 (P = 0.007) and increased number of patients with mRS between 0 and 1 (P = 0.034). Furthermore, the MS group showed increased percentage of patients with OKM grade C-D (P = 0.041). Compared with the SS group, the MS group exhibited decreased mortality (P = 0.037) and morbidity (P = 0.035). CONCLUSIONS Multiple overlapping stent-assisted coiling significantly improved the clinical treatment effects and provided a new method for complex intracranial aneurysms.
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Affiliation(s)
- Lingtong You
- Inpatient Department District N13, Quanzhou First Hospital Affiliated to Fujian Medical University, Chendong Branch of Quanzhou 1st Hospital, Quanzhou, 362000, Fujian, China
| | - Jiaxin Huang
- Inpatient Department District N13, Quanzhou First Hospital Affiliated to Fujian Medical University, Chendong Branch of Quanzhou 1st Hospital, Quanzhou, 362000, Fujian, China
| | - Jinning Zhang
- Inpatient Department District N13, Quanzhou First Hospital Affiliated to Fujian Medical University, Chendong Branch of Quanzhou 1st Hospital, Quanzhou, 362000, Fujian, China
| | - Zhixian Jiang
- Inpatient Department District N13, Quanzhou First Hospital Affiliated to Fujian Medical University, Chendong Branch of Quanzhou 1st Hospital, Quanzhou, 362000, Fujian, China.
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27
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Patient-Reported Outcome for Endovascular Treatment versus Microsurgical Clipping in Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2021; 155:e695-e703. [PMID: 34500096 DOI: 10.1016/j.wneu.2021.08.131] [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: 07/10/2021] [Revised: 08/26/2021] [Accepted: 08/27/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage has a high mortality with significant impact on quality of life despite effective management strategies including endovascular treatment and/or microsurgical clipping. Although the modalities have undergone clinical comparison, they have not been evaluated on patient-reported outcomes (PROs). This study compared endovascular versus microsurgical treatment using a PRO measure. METHODS We conducted a cross-sectional telephonic survey of adult patients conducted at Hamad General Hospital, Doha, Qatar between 2017 and 2019. Candidate study participants were identified from procedure logs and hospital electronic health records for endovascular treatment (N = 32) versus microsurgical clipping (N = 32) of cerebral aneurysm. The primary outcome measure was the short version of the Stroke-Specific Quality of Life (SS-QoL) measure. The secondary outcome measure was the screened clinician-reported modified Rankin Scale (mRS) for all screened patients (n = 137). Mean scores were compared for the 2 treatment groups. RESULTS The SS-QoL mean score was 4.23 (standard deviation ± 0.77) in endovascular treatment and 4.19 ± 0.19 in surgical clipping (P = 0.90). In exploratory analysis, mean physical domain score was 3.17 ± 0.60 versus 2.98 ± 0.66 in endovascular treatment and surgical clipping groups, respectively. Mean psychosocial domain scores were 4.43 ± 0.85 versus 4.18 ± 0.0.92, respectively. In multivariable analysis, none of the clinical variables were significantly related to SS-QoL except vasospasm irrespective of intervention received. In secondary outcome analysis, modified Rankin Scale score was higher for endovascular treatment (P = 0.04). CONCLUSIONS Published evidence has supported clinical benefits of endovascular treatment for cerebral aneurysm treatment, but this study did not find any difference in PROs. Future studies of treatments should include PRO to identify potential differences from the patient's perspective.
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Bartlett M, Bulters D, Hou R. Psychological distress after subarachnoid haemorrhage: A systematic review and meta-analysis. J Psychosom Res 2021; 148:110559. [PMID: 34246015 DOI: 10.1016/j.jpsychores.2021.110559] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVE Psychological distress is a common complication in patients after Subarachnoid haemorrhage (SAH) which often has significant impact on the prognosis. The objective of this study was to determine the pooled prevalence of anxiety symptoms and depressive symptoms in patients after SAH and identify relevant risk factors. METHODS The study adopted a systematic review and meta-analysis protocol. Multiple databases including EMBASE, Medline, PsychInfo, and Web of Science were searched for publications before 1st January 2020. Screening, data extraction, and quality assessment were undertaken following the PRISMA guidelines for preferred reporting of systematic reviews and meta-analysis. The random-effects model was used to calculate pooled prevalence rates. Meta-analysis was conducted using Comprehensive Meta-analysis software. The review protocol was registered on PROSPERO (CRD42020182594). RESULTS 42 studies reporting anxiety symptoms and 64 studies reporting depressive symptoms were included. The pooled short term(<3 years) and long term(≥3 years) prevalence rates of anxiety symptoms were 31.4%(95% CI: 23.6%, 40.4%) and 40.4%(95% CI: 31.6%, 49.8%), respectively, whereas the pooled short term and long term prevalence rates of depressive symptoms were 25.2%(95%CI: 17.8%, 34.5%) and 35.8%(95%CI: 28.6%, 43.6%), respectively. Gender and pre-existing psychiatric conditions were identified as potential risk factors. CONCLUSIONS The high prevalence of anxiety symptoms and depressive symptoms after SAH highlights the need for appropriate assessment and management of psychological stress in patients after SAH. Further research is warranted to explore potential underlying mechanisms and to develop holistic interventions that incorporate understanding of both the biological and psychological impact of SAH.
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Affiliation(s)
- Maeve Bartlett
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Diederik Bulters
- Wessex Neurosciences Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ruihua Hou
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
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29
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Gaastra B, Barron P, Newitt L, Chhugani S, Turner C, Kirkpatrick P, MacArthur B, Galea I, Bulters D. CRP (C-Reactive Protein) in Outcome Prediction After Subarachnoid Hemorrhage and the Role of Machine Learning. Stroke 2021; 52:3276-3285. [PMID: 34238015 DOI: 10.1161/strokeaha.120.030950] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Outcome prediction after aneurysmal subarachnoid hemorrhage (aSAH) is challenging. CRP (C-reactive protein) has been reported to be associated with outcome, but it is unclear if this is independent of other predictors and applies to aSAH of all grades. Therefore, the role of CRP in aSAH outcome prediction models is unknown. The purpose of this study is to assess if CRP is an independent predictor of outcome after aSAH, develop new prognostic models incorporating CRP, and test whether these can be improved by application of machine learning. METHODS This was an individual patient-level analysis of data from patients within 72 hours of aSAH from 2 prior studies. A panel of statistical learning methods including logistic regression, random forest, and support vector machines were used to assess the relationship between CRP and modified Rankin Scale. Models were compared with the full Subarachnoid Hemmorhage International Trialists' (SAHIT) prediction tool of outcome after aSAH and internally validated using cross-validation. RESULTS One thousand and seventeen patients were included for analysis. CRP on the first day after ictus was an independent predictor of outcome. The full SAHIT model achieved an area under the receiver operator characteristics curve (AUC) of 0.831. Addition of CRP to the predictors of the full SAHIT model improved model performance (AUC, 0.846, P=0.01). This improvement was not enhanced when learning was performed using a random forest (AUC, 0.807), but was with a support vector machine (AUC of 0.960, P <0.001). CONCLUSIONS CRP is an independent predictor of outcome after aSAH. Its inclusion in prognostic models improves performance, although the magnitude of improvement is probably insufficient to be relevant clinically on an individual patient level, and of more relevance in research. Greater improvements in model performance are seen with support vector machines but these models have the highest classification error rate on internal validation and require external validation and calibration.
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Affiliation(s)
- Ben Gaastra
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, United Kingdom (B.G., D.B.)
| | - Peter Barron
- University of Southampton Faculty of Medicine, United Kingdom (P.B., L.N., S.C.)
| | - Laura Newitt
- University of Southampton Faculty of Medicine, United Kingdom (P.B., L.N., S.C.)
| | - Simran Chhugani
- University of Southampton Faculty of Medicine, United Kingdom (P.B., L.N., S.C.)
| | - Carole Turner
- Department of Neurosurgery, Cambridge University Hospital, United Kingdom (C.T., P.K.)
| | - Peter Kirkpatrick
- Department of Neurosurgery, Cambridge University Hospital, United Kingdom (C.T., P.K.)
| | - Ben MacArthur
- Mathematical Sciences, University of Southampton, United Kingdom (B.M.)
| | - Ian Galea
- Clinical Neurosciences, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, United Kingdom (I.G.)
| | - Diederik Bulters
- Department of Neurosurgery, Wessex Neurological Centre, University Hospital Southampton, United Kingdom (B.G., D.B.)
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Nobels-Janssen E, Abma IL, Verhagen WIM, Bartels RHMA, van der Wees PJ, Boogaarts JD. Development of a patient-reported outcome measure for patients who have recovered from a subarachnoid hemorrhage: the "questionnaire for the screening of symptoms in aneurysmal subarachnoid hemorrhage" (SOS-SAH). BMC Neurol 2021; 21:162. [PMID: 33863304 PMCID: PMC8051103 DOI: 10.1186/s12883-021-02184-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 04/06/2021] [Indexed: 01/07/2023] Open
Abstract
Background Patients who have been successfully treated for an aneurysmal subarachnoid hemorrhage (aSAH) often retain multiple health complaints, including mood disorders, cognitive complaints, fatigue, and problems with social participation. These problems are not always fully addressed during hospital visits or in current outcome measures, such as the modified Rankin score and the Glasgow Outcome Scale. Here, we present the development of the “Questionnaire for the Screening of Symptoms in aneurysmal Subarachnoid Hemorrhage” (SOS-SAH), which screens for the self-reported symptoms of patients with mild disabilities. Methods During the development of the SOS-SAH we adhered to the PROM-cycle framework for the selection and implementation of patient-reported outcome measures (PROMs). The SOS-SAH was developed in an iterative process informed by a literature study. Patients and healthcare professionals were involved in the development process through participating in a working group, interviews, and a cognitive validation study. Results and conclusions Relevant patient-reported outcomes (PROs) were identified for patients with aSAH. The SOS-SAH was developed primarily using domains and items from existing PROMs and, if necessary, by developing new items. The SOS-SAH consists of 40 items and covers 14 domains: cognitive abilities, hypersensitivity to stimuli, anxiety, depression, fatigue, social roles, personality change, language, vision, taste, smell, hearing, headache, and sexual function. It also includes a proxy measurement for use by family members to assess cognitive functioning and personality change.
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Affiliation(s)
- Edith Nobels-Janssen
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands. .,Department of Neurosurgery, Radboud University Medical Center, HB, 6500, Nijmegen, the Netherlands.
| | - Inger L Abma
- IQ Healthcare and Rehabilitation, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Wim I M Verhagen
- Department of Neurology, Canisius Wilhelmina Hospital, Nijmegen, the Netherlands
| | - Ronald H M A Bartels
- Department of Neurosurgery, Radboud University Medical Center, HB, 6500, Nijmegen, the Netherlands
| | - Philip J van der Wees
- IQ Healthcare and Rehabilitation, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, the Netherlands
| | - Jeroen D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, HB, 6500, Nijmegen, the Netherlands
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Neifert SN, Chapman EK, Martini ML, Shuman WH, Schupper AJ, Oermann EK, Mocco J, Macdonald RL. Aneurysmal Subarachnoid Hemorrhage: the Last Decade. Transl Stroke Res 2020; 12:428-446. [PMID: 33078345 DOI: 10.1007/s12975-020-00867-0] [Citation(s) in RCA: 172] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/09/2020] [Accepted: 10/12/2020] [Indexed: 12/12/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.
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Affiliation(s)
- Sean N Neifert
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Emily K Chapman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - Michael L Martini
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - William H Shuman
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | | | - Eric K Oermann
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Health System, New York, NY, 10029, USA
| | - R Loch Macdonald
- University Neurosciences Institutes, University of California San Francisco, Fresno Campus, Fresno, CA, 93701-2302, USA.
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Schupper AJ, Eagles ME, Neifert SN, Mocco J, Macdonald RL. Lessons from the CONSCIOUS-1 Study. J Clin Med 2020; 9:jcm9092970. [PMID: 32937959 PMCID: PMC7564635 DOI: 10.3390/jcm9092970] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 09/02/2020] [Accepted: 09/09/2020] [Indexed: 12/25/2022] Open
Abstract
After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.
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Affiliation(s)
- Alexander J. Schupper
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - Matthew E. Eagles
- Department of Clinical Neurosciences, Division of Neurosurgery, Alberta Children’s Hospital, University of Calgary, Alberta, AB T3B 6A8, Canada;
| | - Sean N. Neifert
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; (A.J.S.); (S.N.N.); (J.M)
| | - R. Loch Macdonald
- Department of Neurological Surgery, UCSF Fresno, Fresno, CA 93701, USA
- Correspondence: ; Tel.: +1 (559) 459-3705
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Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older. PLoS One 2020; 15:e0230953. [PMID: 32271814 PMCID: PMC7145106 DOI: 10.1371/journal.pone.0230953] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.
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Zolnourian AH, Franklin S, Galea I, Bulters DO. Study protocol for SFX-01 after subarachnoid haemorrhage (SAS): a multicentre randomised double-blinded, placebo controlled trial. BMJ Open 2020; 10:e028514. [PMID: 32217557 PMCID: PMC7170552 DOI: 10.1136/bmjopen-2018-028514] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Subarachnoid haemorrhage (SAH) from a ruptured cerebral aneurysm carries high morbidity and mortality. Despite huge advances in techniques to secure the aneurysm, there has been little progress in the treatment of the deleterious effects of the haemorrhage.Sulforaphane is an Nrf2 inducer with anti-oxidant and anti-inflammatory properties. It has been shown to improve clinical outcome in experimental models of SAH, but is unstable. SFX-01 (Evgen Pharma) is a novel composition comprised of synthetic sulforaphane stabilised within an α-cyclodextrin complex. On ingestion, the complex releases sulforaphane making SFX-01 an ideal vehicle for delivery of sulforaphane. METHODS AND ANALYSIS The objective of the study is to assess the safety, pharmacokinetics and efficacy of SFX-01. This is a prospective, multicentre, randomised, double-blind placebo-controlled trial in patients aged 18-80 years with aneurysmal subarachnoid haemorrhage in the previous 48 hours. 90 patients will be randomised to receive SFX-01 (300 mg) or placebo two times per day for up to 28 days.Safety will be assessed using blood tests and adverse event reporting.Pharmacokinetics will be assessed based on paired blood and cerebrospinal fluid (CSF) sulforaphane levels on day 7. A subgroup will have hourly samples taken during 6 hours post-dosing on days 1 and 7. Pharmacodynamics will be assessed by haptoglobin and malondialdehyde levels, and maximum flow velocity of middle cerebral artery will be measured by transcranial Doppler ultrasound.Clinical outcomes will be assessed at days 28, 90 and 180 with modified Rankin Scale, Glasgow Outcome Score, SAH Outcome Tool, Short Form-36, Brain Injury Community Rehabilitation Outcome Scales and Check List for Cognitive and Emotional consequences following stroke. MRI at 6 months including quantitative susceptibility mapping and volumetric T1 will measure iron deposition and cortical volume.Safety, CSF sulforaphane concentration and middle cerebral artery flow velocity will be primary outcomes and all others secondary. ETHICS AND DISSEMINATION Ethical approval was obtained from South Central Hampshire A committee. Outcomes of the trial will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT02614742.
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Affiliation(s)
- Ardalan H Zolnourian
- Department of Clinical Neurosciences, University of Southampton, Southampton, UK
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Ian Galea
- Department of Clinical Neurosciences, University of Southampton, Southampton, UK
- Department of Experimental Neurology, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Diederik Oliver Bulters
- Department of Clinical Neurosciences, University of Southampton, Southampton, UK
- Department of Neurosurgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Scullen T, Amenta PS, Nerva JD, Dumont AS. Commentary: Predicting Long-Term Outcomes After Poor-Grade Aneurysmal Subarachnoid Hemorrhage Using Decision Tree Modeling. Neurosurgery 2020; 87:E293-E295. [DOI: 10.1093/neuros/nyaa074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
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Maher M, Schweizer TA, Macdonald RL. Treatment of Spontaneous Subarachnoid Hemorrhage: Guidelines and Gaps. Stroke 2020; 51:1326-1332. [PMID: 31964292 DOI: 10.1161/strokeaha.119.025997] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Tom A Schweizer
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, Institute of Medical Science (T.A.S.)
| | - R Loch Macdonald
- Division of Neurosurgery, Departments of Surgery and Physiology, Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Ontario, Canada (R.L.M.)
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Nobels-Janssen E, van der Wees PJ, Verhagen WIM, Westert GP, Bartels RHMA, Boogaarts JD. Patient-reported outcome measures in subarachnoid hemorrhage: A systematic review. Neurology 2019; 92:1096-1112. [PMID: 31076533 PMCID: PMC6556093 DOI: 10.1212/wnl.0000000000007618] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 03/11/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Patient-reported outcomes (PROs) are aspects of a patient's health status and are considered important for stimulating patient-centered care. Current outcome measures in clinical care for patients with aneurysmal subarachnoid hemorrhage (aSAH) are insufficient to capture PROs. In this systematic review, we aimed to summarize the evidence regarding the quality of patient-reported outcome measures (PROMs) in aSAH patients. METHODS We performed a systematic review of the literature published from inception until October 29, 2018, in PubMed, the Cochrane Central Register of Controlled Trials, and EMBASE. Eligible studies had to evaluate measurement properties and capture PROs in aSAH patients. The quality of the studies and measurement properties were assessed using the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist. The review protocol was registered with PROSPERO (CRD42018058566). RESULTS We identified 9 articles that reported the assessment of 7 different disease-specific and generic PROMs used for aSAH patients, including 5 that focused on the Stroke-Specific Quality of Life Scale (SS-QoL). The methodologic quality of the validation processes used was generally doubtful. None of the PROMs complied with current standards for content validity. CONCLUSIONS Due to the low quality of evidence for the measurement properties, the evidence base for selecting a suitable PROM for use with aSAH patients is insufficient. Given the specific long-term consequences of aSAH, we consider a disease-specific PROM the most appropriate, with SS-QoL the most suitable PROM currently available.
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Affiliation(s)
- Edith Nobels-Janssen
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands.
| | - Philip J van der Wees
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Wim I M Verhagen
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Gert P Westert
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ronald H M A Bartels
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - Jeroen D Boogaarts
- From the Department of Neurology (E.N.-J., W.I.M.V.), Canisius Wilhelmina Hospital; and Department of Neurosurgery (E.N.-J., R.H.M.A.B., J.D.B.) and Radboud Institute of Health Sciences, IQ Health care (P.J.v.d.W., G.P.W.), Radboud University Medical Center, Nijmegen, the Netherlands
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Neuroprotective Role of the Nrf2 Pathway in Subarachnoid Haemorrhage and Its Therapeutic Potential. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2019; 2019:6218239. [PMID: 31191800 PMCID: PMC6525854 DOI: 10.1155/2019/6218239] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 02/17/2019] [Accepted: 03/20/2019] [Indexed: 12/11/2022]
Abstract
The mechanisms underlying poor outcome following subarachnoid haemorrhage (SAH) are complex and multifactorial. They include early brain injury, spreading depolarisation, inflammation, oxidative stress, macroscopic cerebral vasospasm, and microcirculatory disturbances. Nrf2 is a global promoter of the antioxidant and anti-inflammatory response and has potential protective effects against all of these mechanisms. It has been shown to be upregulated after SAH, and Nrf2 knockout animals have poorer functional and behavioural outcomes after SAH. There are many agents known to activate the Nrf2 pathway. Of these, the actions of sulforaphane, curcumin, astaxanthin, lycopene, tert-butylhydroquinone, dimethyl fumarate, melatonin, and erythropoietin have been studied in SAH models. This review details the different mechanisms of injury after SAH including the contribution of haemoglobin (Hb) and its breakdown products. It then summarises the evidence that the Nrf2 pathway is active and protective after SAH and finally examines the evidence supporting Nrf2 upregulation as a therapy after SAH.
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Gaastra B, Ren D, Alexander S, Bennett ER, Bielawski DM, Blackburn SL, Borsody MK, Doré S, Galea J, Garland P, He T, Iihara K, Kawamura Y, Leclerc JL, Meschia JF, Pizzi MA, Tamargo RJ, Yang W, Nyquist PA, Bulters DO, Galea I. Haptoglobin genotype and aneurysmal subarachnoid hemorrhage: Individual patient data analysis. Neurology 2019; 92:e2150-e2164. [PMID: 30952792 DOI: 10.1212/wnl.0000000000007397] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/04/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To perform an individual patient-level data (IPLD) analysis and to determine the relationship between haptoglobin (HP) genotype and outcomes after aneurysmal subarachnoid hemorrhage (aSAH). METHODS The primary outcome was favorable outcome on the modified Rankin Scale or Glasgow Outcome Scale up to 12 months after ictus. The secondary outcomes were occurrence of delayed ischemic neurologic deficit, radiologic infarction, angiographic vasospasm, and transcranial Doppler evidence of vasospasm. World Federation of Neurological Surgeons (WFNS) scale, Fisher grade, age, and aneurysmal treatment modality were covariates for both primary and secondary outcomes. As preplanned, a 2-stage IPLD analysis was conducted, followed by these sensitivity analyses: (1) unadjusted; (2) exclusion of unpublished studies; (3) all permutations of HP genotypes; (4) sliding dichotomy; (5) ordinal regression; (6) 1-stage analysis; (7) exclusion of studies not in Hardy-Weinberg equilibrium (HWE); (8) inclusion of studies without the essential covariates; (9) inclusion of additional covariates; and (10) including only covariates significant in univariate analysis. RESULTS Eleven studies (5 published, 6 unpublished) totaling 939 patients were included. Overall, the study population was in HWE. Follow-up times were 1, 3, and 6 months for 355, 516, and 438 patients. HP genotype was not associated with any primary or secondary outcome. No trends were observed. When taken through the same analysis, higher age and WFNS scale were associated with an unfavorable outcome as expected. CONCLUSION This comprehensive IPLD analysis, carefully controlling for covariates, refutes previous studies showing that HP1-1 associates with better outcome after aSAH.
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Affiliation(s)
- Ben Gaastra
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dianxu Ren
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sheila Alexander
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ellen R Bennett
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Dawn M Bielawski
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Spiros L Blackburn
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Mark K Borsody
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Sylvain Doré
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - James Galea
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Patrick Garland
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Tian He
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Koji Iihara
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Yoichiro Kawamura
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jenna L Leclerc
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - James F Meschia
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Michael A Pizzi
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Rafael J Tamargo
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Wuyang Yang
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Paul A Nyquist
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Diederik O Bulters
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ian Galea
- From the Wessex Neurological Centre (B.G., D.O.B., I.G.), University Hospital Southampton NHS Foundation Trust, UK; School of Nursing (D.R., S.A.) and Department of Biostatistics (D.R., T.E.), University of Pittsburgh, PA; Department of Neurology (E.R.B.), Duke University School of Medicine, Durham, NC; NeuroSpring (D.M.B., M.K.B.), Dover, DE; Department of Neurosurgery (S.L.B.), University of Texas Health Science Center at Houston; Department of Anesthesiology, Neurology, Psychiatry, Psychology, Pharmaceutics, and Neuroscience (S.D., J.L.L.), College of Medicine, Center for Translational Research in Neurodegenerative Disease, McKnight Brain Institute, University of Florida, Gainesville; Brain Injury Research Group (J.G.), Division of Cardiovascular Sciences (University of Manchester), Salford Royal NHS Foundation Trust, UK; Clinical Neurosciences, Clinical & Experimental Sciences (P.G., I.G.), Faculty of Medicine, University of Southampton, UK; Department of Neurosurgery (K.I., Y.K.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Department of Neurology (J.F.M., M.A.P.), Mayo Clinic, Jacksonville, FL; and Division of Cerebrovascular Neurosurgery (R.J.T.) and Departments of Neurology, Anesthesia/Critical Care Medicine, and Neurosurgery (W.Y., P.A.N.), Johns Hopkins University School of Medicine, Baltimore, MD.
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Campbell N, Verschuur C, Mitchell S, McCaffrey O, Deane L, Taylor H, Smith R, Foulkes L, Glazier J, Darekar A, Haacke ME, Bulters D, Galea I. Hearing impairment after subarachnoid hemorrhage. Ann Clin Transl Neurol 2019; 6:420-430. [PMID: 30911566 PMCID: PMC6414479 DOI: 10.1002/acn3.714] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 12/02/2018] [Indexed: 12/12/2022] Open
Abstract
Background Subarachnoid hemorrhage (SAH) survivors experience significant neurological disability, some of which is under-recognized by neurovascular clinical teams. We set out to objectively determine the occurrence of hearing impairment after SAH, characterize its peripheral and/or central origin, and investigate likely pathological correlates. Methods In a case-control study (n = 41), participants were asked about new onset hearing difficulty 3 months post-SAH, compared with pre-SAH. Formal audiological assessment included otoscopy, pure tone audiometry, a questionnaire identifying symptoms of peripheral hearing loss and/or auditory processing disorder, and a test of speech understanding in noise. A separate cohort (n = 21) underwent quantitative susceptibility mapping (QSM) of the auditory cortex 6 months after SAH, for correlation with hearing difficulty. Results Twenty three percent of SAH patients reported hearing difficulty that was new in onset post-SAH. SAH patients had poorer pure tone thresholds compared to controls. The proportion of patients with peripheral hearing loss as defined by the World Health Organization and British Audiological Society was however not increased, compared to controls. All SAH patients experienced symptoms of auditory processing disorder post-SAH, with speech-in-noise test scores significantly worse versus controls. Iron deposition in the auditory cortex was higher in patients reporting hearing difficulty versus those who did not. Conclusion This study firmly establishes hearing impairment as a frequent clinical feature after SAH. It primarily consists of an auditory processing disorder, mechanistically linked to iron deposition in the auditory cortex. Neurovascular teams should inquire about hearing, and refer SAH patients for audiological assessment and management.
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Affiliation(s)
- Nicci Campbell
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Carl Verschuur
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Sophie Mitchell
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Orlaith McCaffrey
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Lewis Deane
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Hannah Taylor
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Rory Smith
- Auditory Implant ServiceFaculty of Engineering and the EnvironmentUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Lesley Foulkes
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
| | - James Glazier
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Angela Darekar
- Medical PhysicsUniversity Hospital Southampton NHS Foundation TrustSouthamptonUnited Kingdom
| | - Mark E. Haacke
- Department of RadiologyWayne State UniversityDetroitMichigan
| | - Diederik Bulters
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
| | - Ian Galea
- Clinical NeurosciencesClinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUnited Kingdom
- Wessex Neurological CentreUniversity Hospital Southampton NHS Foundation TrustUniversity of SouthamptonSouthamptonUnited Kingdom
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41
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Cognitive Impairment, Functional Outcome, and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 124:e558-e562. [PMID: 30639483 DOI: 10.1016/j.wneu.2018.12.152] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 12/27/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Measures such as modified Rankin Scale (mRS) may not reflect cognitive outcome following aneurysmal subarachnoid hemorrhage. The aim of this study was to assess the relationship between functional outcome, measured by mRS, and cognition, measured by mini-mental state examination (MMSE), after aSAH. A secondary analysis evaluated the impact of delayed cerebral ischemia (DCI) on the proportion of patients who had cognitive impairment. METHODS We performed a post hoc analysis of the Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1) trial data. MMSE and mRS scores were compared using Kruskal-Wallis equality-of-populations rank test with pairwise comparison post hoc analysis. Cognitive impairment was defined as MMSE score <27. A stepwise logistic regression model evaluated whether DCI was a predictor of cognitive impairment. RESULTS CONSCIOUS-1 comprised 413 patients. Of these, 337 took an MMSE at their 12-week follow-up. Mean MMSE score was 27 with a median of 29 (range, 0-30; SD 5.4). There were no significant differences between MMSE scores of patients who had 12-week mRS scores of 0-2. On multivariate analysis, DCI was independently associated with cognitive impairment after aSAH. CONCLUSIONS Patients considered to have a good outcome on mRS had varying degrees of cognitive function on MMSE, whereas development of DCI was an independent predictor of cognitive impairment after aSAH. MMSE may not be sensitive enough to discern subtle defects in cognition, as the median score was 29 out of 30.
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42
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Saigle V, Asad S, Presseau J, Chassé M, McIntyre L, English SW. Do patient-reported outcome measures for SAH include patient, family, and caregiver priorities? A scoping review. Neurology 2019; 92:281-295. [PMID: 30626652 DOI: 10.1212/wnl.0000000000006883] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 10/03/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To systematically describe literature that identified patient/family/caregiver priorities for subarachnoid hemorrhage (SAH)-specific patient-reported outcome measures (PROMs), developed novel SAH PROMs by incorporating patient/family/caregiver perspectives, or involved patient/family/caregiver perspectives in evaluating existing SAH PROMs. METHODS We conducted a scoping review using Embase and Ovid MEDLINE from inception to February 6, 2018. Study eligibility and data extraction was performed independently and in duplicate. For each eligible citation, we abstracted information about study population, design, type of patient involvement, and outcome measures. We planned a descriptive summary of all included studies. RESULTS Our search yielded 4,961 citations, of which 15 met our eligibility criteria. Four of these included duplicate data, so our final sample consisted of 12 articles. There were 879 patients with SAH and 241 carers from the 11/12 articles that reported these data. One additional study involved 70 individuals but did not specify the number of carers or patients. We did not find any studies where SAH survivors or their families were directly involved in the full continuum of PROM outcome conceptualization from development to evaluation. We found 41 measures identified by patients with SAH. We identified only 2 PROMs developed with patients and only one that was a post hoc evaluation by patients. These 3 PROMs are subarachnoid hemorrhage outcome tool, Wessex Patient Carer Questionnaire, and Functional Status Examination, respectively. CONCLUSION We identified 3 PROMs that have involved patients in some way, but the extent to which they reflect patient priorities remains unclear. More work is needed to ensure SAH research is not overlooking outcomes that are important to patients.
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Affiliation(s)
- Victoria Saigle
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Sarah Asad
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Justin Presseau
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Michaël Chassé
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Lauralyn McIntyre
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada
| | - Shane W English
- From the Clinical Epidemiology Program (Centre for Transfusion Research) (V.S., S.A., L.M., S.W.E.), Ottawa Hospital Research Institute (J.P.); School of Epidemiology and Public Health (J.P., S.W.E.) and Department of Medicine (Critical Care) (S.W.E., L.M.), University of Ottawa; and Department of Medicine (Critical Care) (M.C.), University of Montreal Hospital, Canada.
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