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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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Llompart-Pou JA, Pérez-Bárcena J, Lagares A, Godoy DA. Twelve controversial questions in aneurysmal subarachnoid hemorrhage. Med Intensiva 2024; 48:92-102. [PMID: 37951804 DOI: 10.1016/j.medine.2023.09.003] [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: 07/06/2023] [Accepted: 09/28/2023] [Indexed: 11/14/2023]
Abstract
Critical care management of aneurysmal subarachnoid hemorrhage (aSAH) remains a major challenge. Despite the recent publication of guidelines from the American Heart Association/American Stroke Association and the Neurocritical Care Society, there are many controversial questions in the intensive care unit (ICU) management of this population. The authors provide an analysis of common issues in the ICU and provide guidance on the daily management of this specific population of neurocritical care patients.
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Affiliation(s)
- Juan Antonio Llompart-Pou
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain.
| | - Jon Pérez-Bárcena
- Servei de Medicina Intensiva. Hospital Universitari Son Espases. Institut d'Investigació Sanitària Illes Balears (IdISBa), Palma, Spain
| | - Alfonso Lagares
- Servicio de Neurocirugía. Hospital Universitario 12 de Octubre. Madrid. Spain
| | - Daniel Agustín Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina
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3
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Trofimov AO, Trofimova SY, Agarkova DI, Trofimova KA, Semyachkina-Glushkovskaya O, Atochin D, Bragina OA, Nemoto EM, Bragin DE. Intracranial dynamics biomarkers at traumatic cerebral vasospasm. BRAIN & SPINE 2023; 4:102727. [PMID: 38178989 PMCID: PMC10765010 DOI: 10.1016/j.bas.2023.102727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 01/06/2024]
Abstract
Introduction Patients who suffer severe traumatic brain injury (sTBI) and cerebral vasospasm (CVS) frequently have posttraumatic cerebral ischemia (PCI). The research question was to study changes in cerebral microcirculatory bed parameters in sTBI patients with CVS and with or without PCI. Material and methods A total of 136 severe TBI patients were recruited in the study. All patients underwent perfusion computed tomography, intracranial pressure monitoring, and transcranial Doppler. The levels of cerebrovascular resistance (CVR), cerebral arterial compliance (CAC), cerebrovascular time constant (CTC), and critical closing pressure (CCP) were measured using the neuromonitoring complex. Statistical analysis was performed using parametric and nonparametric methods and factor analysis. The patients were dichotomized into PCI-positive (n = 114) and PCI-negative (n = 22) groups. Data are presented as mean values (standard deviations). Results CVR was significantly increased, whereas CAC, CTC, and CCP were significantly decreased in sTBI patients with CVS and PCI development (p < 0.05). Factor analyses revealed that all studied microcirculatory bed parameters were significantly associated with the development of PCI (p < 0.05). Discussion and conclusion The changes in all studied microcirculatory bed parameters in TBI patients with CVS were significantly associated with PCI development, which enables us to regard them as the biomarkers of CVS and PCI development. The causes of the described microcirculatory bed parameters changes might include complex (cytotoxic and vasogenic) brain edema development, regional microvascular spasm, and dysfunction of pericytes. A further prospective study is warranted.
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Affiliation(s)
- Alexey O. Trofimov
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Svetlana Y. Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Darya I. Agarkova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | - Kseniia A. Trofimova
- Department of Neurological Diseases, Privolzhsky Research Medical University, Nizhny Novgorod, Russia
| | | | - Dmitriy Atochin
- Department of Psychiatry, Boston VA Medical Center West Roxbury, Veterans Affairs Boston Healthcare System and Harvard Medical School, West Roxbury, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Olga A. Bragina
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
| | - Edwin M. Nemoto
- Department of Neurology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
| | - Denis E. Bragin
- Lovelace Biomedical Research Institute, Albuquerque, NM, USA
- Department of Neurology, University of New Mexico, School of Medicine, Albuquerque, NM, USA
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4
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van der Harst JJ, Elting JWJ, Bokkers RPH, Veeger NJGM, van Donkelaar CE, van den Bergh WM, Metzemaekers JDM, Groen RJM, Mazuri A, Luijckx GJR, van Dijk JMC, Uyttenboogaart M. The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage. World Neurosurg 2023; 178:e202-e212. [PMID: 37454906 DOI: 10.1016/j.wneu.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Near-infrared spectroscopy (NIRS) is a noninvasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data are available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in patients with nontraumatic SAH with the occurrence of DCI and functional outcome at 2 months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, World Federation of Neurosurgical Societies after REsuscitation). METHODS In this study, the rSO2 distribution of patients with and without DCI after SAH was compared. The optimal cutoff points to predict DCI and outcome were assessed, and its predictive value was compared with the SAFIRE grade. RESULTS Of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve of 0.77 (95% confidence interval 0.62-0.92; P = 0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an area under the curve of 0.86 (95% confidence interval 0.74-0.98; P = 0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade. CONCLUSIONS NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.
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Affiliation(s)
- J Joep van der Harst
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jan Willem J Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlina E van Donkelaar
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan D M Metzemaekers
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aryan Mazuri
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert-Jan R Luijckx
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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5
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Hafiz BE, Sheikh BY, Alautabi AS, Najjar AA. Severe Cerebral Vasospasm Caused by Acute on Top of Chronic Spontaneous Subdural Hematoma: A Case Report and Review of the Literature. Cureus 2023; 15:e38004. [PMID: 37223176 PMCID: PMC10204000 DOI: 10.7759/cureus.38004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2023] [Indexed: 05/25/2023] Open
Abstract
Cerebral vasospasm is a well-known phenomenon that has been associated with subarachnoid hemorrhage due to aneurysmal bleeding. It can lead to serious outcomes if not recognized and treated promptly. It happens most frequently following cases of aneurysmal subarachnoid hemorrhage. Other causes include traumatic brain injury, reversible cerebral vasoconstriction syndrome, post-tumor resection, and non-aneurysmal subarachnoid hemorrhage. We describe a case of severe clinical vasospasm following acute on top of chronic spontaneous subdural hematoma in a patient with corpus callosum agenesis. Also, a small literature review of the possible risk factors of such occurrence is discussed.
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Affiliation(s)
| | - Bassem Y Sheikh
- Neurosurgery, College of Medicine, Taibah University, Medina, SAU
| | | | - Ahmed A Najjar
- Neurosurgery, College of Medicine, Taibah University, Medina, SAU
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Khawaja AM, McNulty J, Thakur UV, Chawla S, Devi S, Liew A, Mirshahi S, Du R, Mekary RA, Gormley W. Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 46:3. [PMID: 36471088 DOI: 10.1007/s10143-022-01913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, Wayne State University, Detroit, MI, 48201, USA
| | - Jack McNulty
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
| | | | - Shreya Chawla
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shervin Mirshahi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA.
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - William Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
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7
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Shen Y, van der Harst JJ, Wei Y, Bokkers RPH, van Dijk JMC, Uyttenboogaart M. Validation of a cerebral hemodynamic model with personalized calibration in patients with aneurysmal subarachnoid hemorrhage. Front Bioeng Biotechnol 2022; 10:1031600. [PMID: 36507259 PMCID: PMC9732662 DOI: 10.3389/fbioe.2022.1031600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/08/2022] [Indexed: 11/27/2022] Open
Abstract
This study aims to validate a numerical model developed for assessing personalized circle of Willis (CoW) hemodynamics under pathological conditions. Based on 66 computed tomography angiography images, investigations were obtained from 43 acute aneurysmal subarachnoid hemorrhage (aSAH) patients from a local neurovascular center. The mean flow velocity of each artery in the CoW measured using transcranial Doppler (TCD) and simulated by the numerical model was obtained for comparison. The intraclass correlation coefficient (ICC) over all cerebral arteries for TCD and the numerical model was 0.88 (N = 561; 95% CI 0.84-0.90). In a subgroup of patients who had developed delayed cerebral ischemia (DCI), the ICC had decreased to 0.72 but remained constant with respect to changes in blood pressure, Fisher grade, and location of ruptured aneurysm. Our numerical model showed good agreement with TCD in assessing the flow velocity in the CoW of patients with aSAH. In conclusion, the proposed model can satisfactorily reproduce the cerebral hemodynamics under aSAH conditions by personalizing the numerical model with TCD measurements. Clinical trial registration: [http://www.trialregister.nl/], identifier [NL8114].
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Affiliation(s)
- Yuanyuan Shen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Joep van der Harst
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yanji Wei
- Eastern Institute for Advanced Study, Yongriver Institute of Technology, Ningbo, China
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Marc C. van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands,Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands,*Correspondence: Maarten Uyttenboogaart,
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Muacevic A, Adler JR, Wahlster S, Keen J, Walters AM, Fong CT, Dhulipala VB, Athiraman U, Moore A, Vavilala MS, Kim LJ, Levitt MR. Associations Between Transcranial Doppler Vasospasm and Clinical Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Retrospective Observational Study. Cureus 2022; 14:e31789. [PMID: 36569681 PMCID: PMC9777349 DOI: 10.7759/cureus.31789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE The objective is to examine the relationship between transcranial Doppler cerebral vasospasm (TCD-vasospasm), and clinical outcomes in aneurysmal subarachnoid hemorrhage (aSAH). METHODS In a retrospective cohort study, using univariate and multivariate analysis, we examined the association between TCD-vasospasm (defined as Lindegaard ratio >3) and patient's ability to ambulate without assistance, the need for tracheostomy and gastrostomy tube placement, and the likelihood of being discharged home from the hospital. RESULTS We studied 346 patients with aSAH; median age 55 years (Interquartile range IQR 46,64), median Hunt and Hess 3 [IQR 1-5]. Overall, 68.6% (n=238) had TCD-vasospasm, and 28% (n=97) had delayed cerebral ischemia. At hospital discharge, 54.3% (n=188) were able to walk without assistance, 5.8% (n=20) had received a tracheostomy, and 12% (n=42) had received a gastrostomy tube. Fifty-three percent (n=183) were discharged directly from the hospital to their home. TCD-vasospasm was not associated with ambulation without assistance at discharge (adjusted odds ratio, aOR 0.54, 95% 0.19,1.45), tracheostomy placement (aOR 2.04, 95% 0.23,18.43), gastrostomy tube placement (aOR 0.95, 95% CI 0.28,3.26), discharge to home (aOR 0.36, 95% CI 0.11,1.23). CONCLUSION This single-center retrospective study finds that TCD-vasospasm is not associated with clinical outcomes such as ambulation without assistance, discharge to home from the hospital, tracheostomy, and gastrostomy feeding tube placement. Routine screening for cerebral vasospasm and its impact on vasospasm diagnostic and therapeutic interventions and their associations with improved clinical outcomes warrant an evaluation in large, prospective, case-controlled, multi-center studies.
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Association of pre-admission antihypertensive agents and outcomes in aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2022; 103:119-123. [PMID: 35868228 DOI: 10.1016/j.jocn.2022.07.013] [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: 05/15/2022] [Revised: 06/18/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) and poor functional outcome are common complications in patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). It has been proposed that pre-admission beta-blocker therapy may lower cerebral vasospasm (cVSP) risk after aSAH; however, this association with other antihypertensives is unknown. We sought to determine the association between antihypertensives and clinical outcomes in aSAH patients. METHODS We performed a retrospective study on a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2021. Association between pre-admission use of antihypertensives and patient outcomes was determined. Primary outcomes included DCI and poor functional outcome at 3 months after discharge defined as modified Rankin scale [mRS] 4-6. The secondary outcome was cVSP identified using transcranial Doppler (TCD). RESULTS The cohort consisted of 306 aSAH patients with mean age 57.1 (SD 13.6) years with 187 females (61 %). Although pre-admission use of beta-blockers (OR 0.40, 95 % CI 0.21-80, p = 0.02), calcium channel blockers (OR 0.43, 95 % CI 0.19-0.93, p = 0.035), and thiazide (OR 0.31, 95 % CI 0.11-0.86, p = 0.025) were associated with lower risk of cVSP in univariate analysis, we did not find any association in a multivariate model after adjusting for age. There was no association between any class of antihypertensives and DCI or functional outcome. CONCLUSION Pre-admission use of antihypertensive agents may affect TCD findings, however, none of them appear to be independently associated with DCI or functional outcome. Larger prospective studies are needed to establish any potential association.
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10
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Vasospasm Surveillance by a Simplified Transcranial Doppler Protocol in Traumatic Brain Injury. World Neurosurg 2022; 164:e318-e325. [PMID: 35504479 DOI: 10.1016/j.wneu.2022.04.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To detect post-traumatic vasospasm in patients with traumatic brain injury (TBI), we implemented a simplified transcranial Doppler (TCD) surveillance protocol in a neurointensive care setting. In this study, we evaluate the yield of this protocol. METHODS Adult patients with TBI admitted to the neurointensive care unit were examined with TCD by 2 intensive care nurses trained in TCD examinations. Flow velocities of the middle cerebral arteries were recorded. TCD suspected vasospasm was defined as the mean flow velocity >120 cm/s, and when detected, the protocol recommended a supplementary computed tomography angiography. The rate of detection of TCD suspected vasospasm and the subsequent rate of radiological diagnosis of vasospasm were recorded. In multivariate logistic regression analysis, we evaluated age, initial Glasgow Coma Scale, craniotomy, and decompressive craniectomy as potential predictors of developing increased TCD velocity. RESULTS A total of 84 patients with TBI with a median initial Glasgow Coma Scale score of 6 were examined by TCD. TCD suspected vasospasm was found in the middle cerebral arteries of 18% of examined patients. Two-thirds of patients with TCD suspected vasospasm were investigated with a subsequent computed tomography angiography, and 80% of these patients received a radiological diagnosis of vasospasm. In logistic regression analysis, decompressive craniectomy was significantly associated with increased risk of developing TCD suspected vasospasm (odds ratio: 11.57, 95% confidence interval: 2.59-51.73, P = 0.001). CONCLUSIONS The implementation of a simplified TCD surveillance protocol in a neurointensive care setting yielded an 18% detection rate of TCD suspected vasospasm. In our cohort of patients with TBI, decompressive craniectomy was associated with increased risk of developing TCD suspected vasospasm.
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11
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Shen Y, Wei Y, Bokkers RPH, Uyttenboogaart M, Van Dijk JMC. Patient-Specific Cerebral Blood Flow Simulation Based on Commonly Available Clinical Datasets. Front Bioeng Biotechnol 2022; 10:835347. [PMID: 35309980 PMCID: PMC8931461 DOI: 10.3389/fbioe.2022.835347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/31/2022] [Indexed: 11/13/2022] Open
Abstract
Cerebral hemodynamics play an important role in the development of cerebrovascular diseases. In this work, we propose a numerical framework for modeling patient-specific cerebral blood flow, using commonly available clinical datasets. Our hemodynamic model was developed using Simscape Fluids library in Simulink, based on a block diagram language. Medical imaging data obtained from computerized tomography angiography (CTA) in 59 patients with aneurysmal subarachnoid hemorrhage was used to extract arterial geometry parameters. Flow information obtained from transcranial Doppler (TCD) measurement was employed to calibrate input parameters of the hemodynamic model. The results show that the proposed numerical model can reproduce blood flow in the circle of Willis (CoW) per patient per measurement set. The resistance at the distal end of each terminal branch was the predominant parameter for the flow distribution in the CoW. The proposed model may be a promising tool for assessing cerebral hemodynamics in patients with cerebrovascular disease.
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Affiliation(s)
- Yuanyuan Shen
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Yanji Wei
- Faculty of Science and Engineering, University of Groningen, Groningen, Netherlands
| | - Reinoud P. H. Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Maarten Uyttenboogaart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - J. Marc C. Van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- *Correspondence: J. Marc C. Van Dijk,
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12
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Alexopoulos G, Zhang J, Karampelas I, Khan M, Quadri N, Patel M, Patel N, Almajali M, Mattei TA, Kemp J, Coppens J, Mercier P. Applied forecasting for delayed cerebral ischemia prediction post subarachnoid hemorrhage: Methodological fallacies. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2021.100817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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13
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Maegawa T, Sasahara A, Ohbuchi H, Chernov M, Kasuya H. Cerebral vasospasm and hypoperfusion after traumatic brain injury: Combined CT angiography and CT perfusion imaging study. Surg Neurol Int 2021; 12:361. [PMID: 34345501 PMCID: PMC8326138 DOI: 10.25259/sni_859_2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 06/17/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Timely identification of the cerebral perfusion abnormalities after traumatic brain injury (TBI) is highly important. The objective of this study was the evaluation of the post traumatic vasospasm and cerebral hypoperfusion with the serial combined CT angiography (CTA) and CT perfusion (CTP) imaging examinations. Methods: The case series comprised 25 adult patients with closed TBI accompanied by various types of intracranial hematoma. Emergency surgery was done in 15 cases (60%). Combined CTA and CTP were performed on days 0 (D0) and 7 ± 1 (D7) after trauma. Results: CTA on D0 did not demonstrate vasospasm in any case but revealed it on D7 in 9 patients (36%). In the multivariate analysis, only the presence of subarachnoid hemorrhage (SAH) on D7 had confirmed a significant association with the development of vasospasm (P = 0.0201). Cerebral hypoperfusion at least in one evaluated brain region was noted on D0 and D7 in 76% and 60% of patients, respectively, and showed highly variable spatial distribution and temporal development. Treatment results were not associated with the presence of vasospasm (P = 0.7337) or the number of brain regions affected by hypoperfusion on D0 (P = 0.2285), but the number of brain regions affected by hypoperfusion on D7 was significantly greater in cases of unfavorable outcome (P = 0.0187). Conclusion: Vasospasm is merely related to SAH sustained at the subacute stage of TBI, but its spatial and temporary interrelationships with the post traumatic cerebral hypoperfusion are complex. Serial combined CTA and CTP examinations may facilitate monitoring of perfusion abnormalities and treatment guidance.
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Affiliation(s)
- Tatsuya Maegawa
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Atsushi Sasahara
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hidenori Ohbuchi
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Mikhail Chernov
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hidetoshi Kasuya
- Department of Neurosurgery, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
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14
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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15
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Breville G, Bailly A, Fisch L, Kulcsar Z, Pugin D, Carrera E. Case Report and Review of the Literature: Fatal Reversible Cerebral Vasoconstriction Syndrome. Front Neurol 2021; 12:589062. [PMID: 33658973 PMCID: PMC7917125 DOI: 10.3389/fneur.2021.589062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 01/14/2021] [Indexed: 01/13/2023] Open
Abstract
Background: A fatal outcome occurs in 2% of patients with Reversible Cerebral Vasoconstriction Syndrome (RCVS). Due to its rarity, guidelines for the management of the most severe forms of RCVS are lacking. Case presentation: Here, we describe the case of a 55 year-old woman who died from complications of RCVS and reviewed patients with fatal outcome reported in the literature. In our patient, the first episode of neurological deterioration was preceded by an increase of cerebral blood flow velocities assessed with transcranial Doppler. A fatal evolution could not be prevented despite therapeutic escalation consisting of multiple non-invasive and invasive treatments including cervical sympathetic bloc and continuous arterial infusion of nimodipine at the site of severe vasoconstriction. Conclusion: This case and the review of literature illustrate the challenges in the management of patients with severe RCVS. We describe here how monitoring of cerebral blood flow might help anticipate clinical worsening at the beginning of the disease and propose novel invasive and non-invasive therapeutic strategies based on monitoring of neurophysiological parameters.
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Affiliation(s)
- Gautier Breville
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Amelie Bailly
- Intensive Care Unit, Department of APSI, Geneva University Hospitals, Geneva, Switzerland
| | - Loraine Fisch
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland.,Neurovascular Unit, Department of Neurology, Groupement Hospitalier de l'Ouest Lémanique, Nyon, Switzerland
| | - Zsolt Kulcsar
- Division of Interventional Neuroradiology, Diagnostic Department, Zurich University Hospitals, Zurich, Switzerland
| | - Deborah Pugin
- Intensive Care Unit, Department of APSI, Geneva University Hospitals, Geneva, Switzerland
| | - Emmanuel Carrera
- Division of Neurology, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
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16
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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: 130] [Impact Index Per Article: 32.5] [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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17
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Shen Y, Wei Y, Bokkers RPH, Uyttenboogaart M, van Dijk JMC. Study protocol of validating a numerical model to assess the blood flow in the circle of Willis. BMJ Open 2020; 10:e036404. [PMID: 32503872 PMCID: PMC7279649 DOI: 10.1136/bmjopen-2019-036404] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 02/12/2020] [Accepted: 05/18/2020] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION We developed a zero-dimensional (0D) model to assess the patient-specific haemodynamics in the circle of Willis (CoW). Similar numerical models for simulating the cerebral blood flow (CBF) had only been validated qualitatively in healthy volunteers by magnetic resonance (MR) angiography and transcranial Doppler (TCD). This study aims to validate whether a numerical model can simulate patient-specific blood flow in the CoW under pathological conditions. METHODS AND ANALYSIS This study is a diagnostic accuracy study. We aim to collect data from a previously performed prospective study that involved patients with aneurysmal subarachnoid haemorrhage (aSAH) receiving both TCD and brain Computerd Tomography angiography (CTA) at the same day. The cerebral flow velocities are calculated by the 0D model, based on the vessel diameters measured on the CTA of each patient. In this study, TCD is considered the gold standard for measuring flow velocity in the CoW. The agreement will be analysed using Pearson correlation coefficients. ETHICS AND DISSEMINATION This study protocol has been approved by the Medical Ethics Review Board of the University Medical Center Groningen: METc2019/103. The results will be submitted to an international scientific journal for peer-reviewed publication. TRIAL REGISTRATION NUMBER NL8114.
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Affiliation(s)
- Yuanyuan Shen
- Department of Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Yanji Wei
- Engineering and Technology Institute Groningen, Faculty of Science & Engineering, University of Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University Medical Center Groningen, Groningen, The Netherlands
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