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Borghol AH, Alkhatib B, Zayat R, Ravikumar NPG, Munairdjy Debeh FG, Ghanem A, Mina J, Mao MA, Dahl NK, Hickson LJ, Aslam N, Torres VE, Brown RD, Tawk RG, Chebib FT. Intracranial Aneurysms in Autosomal Dominant Polycystic Kidney Disease: A Practical Approach to Screening and Management. Mayo Clin Proc 2025:S0025-6196(25)00080-1. [PMID: 40319406 DOI: 10.1016/j.mayocp.2025.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2024] [Revised: 01/22/2025] [Accepted: 02/07/2025] [Indexed: 05/07/2025]
Abstract
Autosomal dominant polycystic kidney disease (ADPKD), the most prevalent genetic kidney disorder, is characterized by diffuse kidney cysts, hypertension, and progressive kidney function decline, often leading to kidney failure by the age of 60 years. Compared with the general population, patients with ADPKD have an increased risk for development of saccular intracranial aneurysms (IAs), which can lead to intracranial bleeding and result in significant disability and mortality. Of both modifiable and nonmodifiable risk factors, the most significant is a family history of IAs or aneurysm rupture. Other contributing factors include hypertension, cigarette smoking, age, and sex. Most IAs currently detected during screening tests are small and located in the anterior circulation. Intracranial aneurysms can be manifested with thunderclap headache, which may be indicative of subarachnoid hemorrhage. Less commonly, IAs cause symptoms related to mass effect with focal neurologic deficits. Subarachnoid hemorrhage is particularly concerning, given its high case-fatality rate, which remains around 35% despite advances in neurologic care. Therefore, control of risk factors, early detection, and treatment when indicated are important to prevent adverse outcomes. Screening for IAs in ADPKD remains controversial and can be approached either universally (screening of all ADPKD patients) or selectively (screening of high-risk patients). The preferred imaging modality is brain magnetic resonance angiography without contrast enhancement or alternatively computed tomography angiography. This review provides a practical guide for medical teams managing patients with ADPKD, detailing the characteristics of IAs and their associated symptoms. It presents an algorithm for risk assessment and screening along with recommendations for treatment and follow-up care.
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Affiliation(s)
- Abdul Hamid Borghol
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL
| | - Bassel Alkhatib
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL
| | - Roaa Zayat
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL
| | | | - Fadi George Munairdjy Debeh
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL
| | - Ahmad Ghanem
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL
| | - Jonathan Mina
- Department of Internal Medicine, Staten Island University Hospital, Northwell Health, NY
| | - Michael A Mao
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Neera K Dahl
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - LaTonya J Hickson
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Nabeel Aslam
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL
| | - Vicente E Torres
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Robert D Brown
- Department of Neurology (R.D.B.), Mayo Clinic, Rochester, MN
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL
| | - Fouad T Chebib
- Division of Nephrology and Hypertension, Department of Medicine, Mayo Clinic, Jacksonville, FL; Mayo Clinic Florida PKD Center of Excellence, Jacksonville, FL.
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Zorko Garbajs N, Nasr DM, Bellolio F, Howick AS, Vanmeter DE, Mullan AF, Rabinstein AA. Etiology and characteristics of non-aneurysmal thunderclap headache presenting to an acute setting. Am J Emerg Med 2024; 85:217-224. [PMID: 39303457 DOI: 10.1016/j.ajem.2024.09.031] [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: 01/16/2024] [Revised: 09/03/2024] [Accepted: 09/10/2024] [Indexed: 09/22/2024] Open
Abstract
OBJECTIVES To describe the characteristics and causes of non-aneurysmal thunderclap headache (TCH) and compare serious from benign underlying causes. METHODS Retrospective cohort study of consecutive adult patients with TCH presenting to a tertiary care academic medical center between 2010 and 2020. Aneurysmal subarachnoid hemorrhage cases were excluded. Cases were categorized into serious or benign; serious TCH was defined as any condition in which delayed diagnosis and treatment could result in neurological disability or death. Risk factors for serious TCH were analyzed. We adhere to standardized guidelines for reporting observational studies. RESULTS A total of 932 patients presented with TCH. After exclusion of 393 patients with aneurysmal-type subarachnoid hemorrhage, 539 were included in the analysis. One-half (n = 275, 51.0 %) had a serious cause. Median age was 51 years, 69.0 % were female. Most frequent diagnoses were intracranial hemorrhage (n = 102, 18.9 %), reversible cerebral vasoconstriction syndrome (n = 97, 18.0 %), and idiopathic TCH (n = 102, 38.6 %). A multivariable logistic regression model for prediction of serious TCH included age, hypertension, migraines, recurrent TCH, level of consciousness and other clinical exam findings, and achieved an AUROC of 0.732. This score had a sensitivity of 79.9 % (95 % CI 73.5-83.5 %) for the identification of serious TCH. A 0.5-point increase in the risk score was associated with a 73 % increase in the odds of serious TCH (odds ratio 1.73, 95 % CI 1.53-1.95, p < 0.001). CONCLUSION Our study describes the relative frequency of presentation and etiologies among patients with TCH This score can aide clinicians in recognising patients with potentially serious cause of TCH, for whom additional imaging and neurological consultation is necessary.
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Affiliation(s)
- Nika Zorko Garbajs
- Department of Medicine, Division of Critical Care and Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA; Department of Vascular Neurology and Intensive Therapy, University Medical Centre Ljubljana, 1000, Slovenia; Medical Faculty, University of Ljubljana, 1000, Slovenia.
| | - Deena M Nasr
- Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA
| | - Fernanda Bellolio
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Annelise S Howick
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Derek E Vanmeter
- Department of Emergency Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - Aidan F Mullan
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN 55905, USA
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Wijeratne T, Wijeratne C, Korajkic N, Bird S, Sales C, Riederer F. Secondary headaches - red and green flags and their significance for diagnostics. eNeurologicalSci 2023; 32:100473. [PMID: 37456555 PMCID: PMC10339125 DOI: 10.1016/j.ensci.2023.100473] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 04/22/2023] [Accepted: 06/28/2023] [Indexed: 07/18/2023] Open
Abstract
A small percentage of patients suffer from a secondary headache syndrome. It is imperative that clinicians are able to differentiate primary headache syndromes from secondary headache syndromes, as failure to do so significantly worsens morbidity and mortality. Recent advances in our understanding of pathobiological mechanisms offer useful information on these enigmatic disorders. We now understand that the causes of secondary headache syndromes can vary significantly - these may be infectious, inflammatory, vascular, traumatic or structural in origin. A well-taken history and targeted physical examination coupled with appropriate investigations can enable these syndromes to be recognized consistently and thus allow their timely and appropriate treatment. Along with their epidemiology, some of their key characteristics shall thus be discussed in this review so as to aid the busy clinician at the bedside. Red flags including sudden onset, high pain intensity, pattern of change of a preexisting headache, focal neurological signs or seizure, systemic signs and precipitation by physical activity can guide the clinician to suspect a secondary headache. Importantly a preexisting headache is not an exclusion of a secondary headache - it might even be a predisposition in certain cases.
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Affiliation(s)
- Tissa Wijeratne
- School of Psychology and Public Health, La Trobe University, Melbourne, Australia
- Department of Neurology, Western Health & University Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans 3021, Australia
- Department of Medicine, Faculty of Medicine, University of Rajarata, Saliyapura, Anuradhapura, Sri Lanka
| | - Chanith Wijeratne
- Monash Medical School, Clayton, Victoria, Australia
- Migraine Foundation & Australian Institute of Migraine, 522, Bell Street, Pascoe Vale South, Victoria, Australia
| | - Nadja Korajkic
- Department of Neurology, Western Health & University Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans 3021, Australia
| | - Stefanie Bird
- Department of Neurology, Western Health & University Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans 3021, Australia
- Migraine Foundation & Australian Institute of Migraine, 522, Bell Street, Pascoe Vale South, Victoria, Australia
| | - Carmela Sales
- Department of Neurology, Western Health & University Melbourne, AIMSS, Level Three, WHCRE, Sunshine Hospital, St Albans 3021, Australia
| | - Franz Riederer
- Department of Neurology, Clinic Hietzing and Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology, Vienna, Austria
- Faculty of Medicine, University of Zurich, Switzerland
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Sorrentino ZA, Laurent D, Hernandez J, Davidson C, Small C, Dodd W, Lucke-Wold B. Headache persisting after aneurysmal subarachnoid hemorrhage: A narrative review of pathophysiology and therapeutic strategies. Headache 2022; 62:1120-1132. [PMID: 36112096 DOI: 10.1111/head.14394] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/30/2022] [Accepted: 07/04/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This narrative review of the literature concerns persistent headache attributed to past non-traumatic subarachnoid hemorrhage (SAH), based off demographic and clinical features, what are pathophysiologic mechanisms by which these headaches occur, which medical and interventional treatments have the most evidence for pain alleviation, and what pre-clinical evidence is there for emerging treatments for these patients. BACKGROUND Following initial stabilization and treatment of spontaneous SAH, most commonly due to aneurysmal rupture, headache in the immediate inpatient setting and persisting after discharge are an important cause of morbidity. These headaches often receive heterogenous treatment of uncertain efficacy, and the risk factors and pathophysiology of their development has received little study. METHODS A narrative review of current literature discussing post-SAH headache was conducted using a literature search in PubMed with search term combinations including "post subarachnoid hemorrhage pain", "subarachnoid hemorrhage headache", and "post subarachnoid hemorrhage headache". Clinical studies mentioning headache after SAH and/or treatment in the abstract/title were included through March, 2022. RESULTS AND CONCLUSION Post-SAH headaches are shown to decrease quality of life, have a multi-modal pathophysiology in their occurrence, and only a select few medications (reviewed herein) have been demonstrated to have efficacy in alleviation of these headaches, while also harboring possible risks including vasospasm and re-bleeding. An effective treatment paradigm of these headaches will include trials of evidence-based therapeutics, rapid reduction of opioid medications if not effective, and consideration of multi-modal pain control strategies including nerve blocks.
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Affiliation(s)
- Zachary A Sorrentino
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dimitri Laurent
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jairo Hernandez
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Caroline Davidson
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Coulter Small
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - William Dodd
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 97] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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Abstract
Headache is a common reason for seeking medical attention. Most cases are benign primary headache disorders; however, there is significant overlap between symptoms of these disorders and secondary headaches. Differentiating these clinical scenarios requires a careful history with attention to red flag symptoms and a neurologic examination. These details can identify dangerous disorders: subarachnoid hemorrhage, reversible cerebral vasoconstriction syndrome, elevated intracranial pressure, hydrocephalus, cerebral venous sinus thrombosis, arterial dissection, central nervous system infection, and inflammatory vasculitis. Older, pregnant, or immunocompromised patients have a higher risk for secondary disorders; clinicians should have a different threshold to conduct evaluations in such patients.
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Affiliation(s)
- David Kopel
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA
| | - Crandall Peeler
- Department of Ophthalmology and Neurology, 85 East Concord Street 8th Floor, Boston, MA 02118, USA
| | - Shuhan Zhu
- Department of Neurology, 725 Albany Street, Suite 7B, Boston, MA 02118, USA.
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Mahta A, Anderson MN, Azher AI, Mahmoud LN, Dakay K, Abdulrazeq H, Abud A, Moody S, Reznik ME, Yaghi S, Thompson BB, Wendell LC, Rao SS, Potter NS, Cutting S, Mac Grory B, Stretz C, Doberstein CE, Furie KL. Short- and long-term opioid use in survivors of subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 207:106770. [PMID: 34182238 DOI: 10.1016/j.clineuro.2021.106770] [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: 12/30/2020] [Revised: 03/03/2021] [Accepted: 06/17/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Opioids are frequently used for analgesia in patients with acute subarachnoid hemorrhage (SAH) due to a high prevalence of headache and neck pain. However, it is unclear if this practice may pose a risk for opioid dependence, as long-term opioid use in this population remains unknown. We sought to determine the prevalence of opioid use in SAH survivors, and to identify potential risk factors for opioid utilization. METHODS We analyzed a cohort of consecutive patients admitted with non-traumatic and suspected aneurysmal SAH to an academic referral center. We included patients who survived hospitalization and excluded those who were not opioid-naïve. Potential risk factors for opioid prescription at discharge, 3 and 12 months post-discharge were assessed. RESULTS Of 240 SAH patients who met our inclusion criteria (mean age 58.4 years [SD 14.8], 58% women), 233 (97%) received opioids during hospitalization and 152 (63%) received opioid prescription at discharge. Twenty-eight patients (12%) still continued to use opioids at 3 months post-discharge, and 13 patients (6%) at 12-month follow up. Although patients with poor Hunt and Hess grades (odds ratio 0.19, 95% CI 0.06-0.57) and those with intraventricular hemorrhage (odds ratio 0.38, 95% CI 0.18-0.87) were less likely to receive opioid prescriptions at discharge, we did not find significant differences between patients who had long-term opioid use and those who did not. CONCLUSION Opioids are regularly used in both the acute SAH setting and immediately after discharge. A considerable number of patients also continue to use opioids in the long-term. Opioid-sparing pain control strategies should be explored in the future.
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Affiliation(s)
- Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States.
| | - Matthew N Anderson
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Aidan I Azher
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, United States
| | - Leana N Mahmoud
- Department of Pharmacy, Rhode Island Hospital, Providence, RI, United States
| | - Katarina Dakay
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Alexander Abud
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Scott Moody
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Michael E Reznik
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurology, NYU Langone, New York, NY, United States
| | - Bradford B Thompson
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Linda C Wendell
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Shyam S Rao
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Nicholas S Potter
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Shawna Cutting
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC, United States
| | - Christoph Stretz
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Curtis E Doberstein
- Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, United States
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Patel S, Parikh A, Okorie ON. Subarachnoid hemorrhage in the emergency department. Int J Emerg Med 2021; 14:31. [PMID: 33980142 PMCID: PMC8117305 DOI: 10.1186/s12245-021-00353-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/22/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Subarachnoid hemorrhage accounts for more than 30,000 cases of stroke annually in North America and encompasses a 4.4% mortality rate. Since a vast number of subarachnoid hemorrhage cases present in a younger population and can range from benign to severe, an accurate diagnosis is imperative to avoid premature morbidity and mortality. Here, we present a straightforward approach to evaluating, risk stratifying, and managing subarachnoid hemorrhages in the emergency department for the emergency medicine physician. DISCUSSION The diversities of symptom presentation should be considered before proceeding with diagnostic modalities for subarachnoid hemorrhage. Once a subarachnoid hemorrhage is suspected, a computed tomography of the head with the assistance of the Ottawa subarachnoid hemorrhage rule should be utilized as an initial diagnostic measure. If further investigation is needed, a CT angiography of the head or a lumbar puncture can be considered keeping risks and limitations in mind. Initiating timely treatment is essential following diagnosis to help mitigate future complications. Risk tools can be used to assess the complications for which the patient is at greatest. CONCLUSION Subarachnoid hemorrhages are frequently misdiagnosed; therefore, we believe it is imperative to address the diagnosis and initiation of early management in the emergency medicine department to minimize poor outcomes in the future.
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Affiliation(s)
- Sima Patel
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA.
| | - Amay Parikh
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA
| | - Okorie Nduka Okorie
- Division of Neurocritical Care, Department of Critical Care Medicine, AdventHealth, 601 E Rollins St, Orlando, FL, 32803, USA
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Liu X, Yu Z, Wen D, Ma L, You C. Prognostic value of albumin-fibrinogen ratio in subarachnoid hemorrhage patients. Medicine (Baltimore) 2021; 100:e25764. [PMID: 33907173 PMCID: PMC8084098 DOI: 10.1097/md.0000000000025764] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/30/2021] [Accepted: 04/13/2021] [Indexed: 02/05/2023] Open
Abstract
ABSTRACT Inflammation plays an important role in the pathophysiology of subarachnoid hemorrhage (SAH). Recent studies have indicated that the albumin to fibrinogen ratio (AFR) is a useful biomarker of inflammation.This research aimed to determine the ability of AFR to predict the prognosis of patients with SAH.A total of 440 patients with SAH who had been diagnosed within 72 hours of symptom onset were retrospectively reviewed. Clinical findings and laboratory data were retrieved from the hospital database. Functional outcome was measured according to the modified Rankin scale at 30 days. Logistic regression analysis was used to evaluate the correlation between AFR and the prognosis of patients with SAH. Receiver operating characteristic (ROC) analysis was performed to determine the prognostic ability of AFR at admission to predict the 30-day outcomes.The average age of all 440 patients with SAH was 56.75 ± 11.19 years and 31.4% (138) were male. Of these patients, 161 exhibited unfavorable outcomes at 30 days. According to the multivariate logistic regression analysis, the AFR was positively correlated with the outcome of patients with SAH (odds ratio 0.939, 95% confidence interval 0.885-0.996, P = .038). The ROC analysis revealed an area under the curve of 0.713 for AFR's ability to predict the 30-day outcomes.AFR is independently associated with the outcome of SAH patients. As a parameter that can be easily assessed at admission, AFR could be used to help the decision-making of clinical treatment.
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García-Azorín D, González-García N, Abelaira-Freire J, Marcos-Dolado A, Guerrero ÁL, Martín-Sanchez FJ, Porta-Etessam J. Management of thunderclap headache in the emergency room: A retrospective cohort study. Cephalalgia 2021; 41:711-720. [PMID: 33412894 DOI: 10.1177/0333102420981721] [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] [Indexed: 12/27/2022]
Abstract
INTRODUCTION The evaluation of red flags is crucial for the accurate the diagnosis of headache disorders, especially for thunderclap headache. We analysed if secondary headache disorders were adequately ruled out in patients that presented to the emergency room with thunderclap headache. METHODS In this retrospective cohort study, we screened all patients that visited the emergency room for headache, including those that described thunderclap headache. We measured the frequency with which secondary causes were not adequately ruled out. We analysed the order of the exams, the final diagnosis, and the time elapsed between arrival, initial request for imaging, and the completion of the imaging. RESULTS We screened 2132 patients, and 42 (1.9%) fulfilled eligibility criteria. Mean age was 43.1 ± 17.1 years, and 57% of patients were female. For 22 (52.4%) patients, the work-up was incomplete. Vascular study was missing in 16 (38.1%) patients, cerebrospinal fluid evaluation in nine (21.4%), and magnetic resonance imaging in seven (16.7%), with multiple assessments missing in six (14.3%). There were ten different combinations in which the exams were performed, with the most frequent being the second exam's cerebral spinal fluid evaluation in 18 (52.9%) and the computed tomography angiogram in 10 (29.4%). A secondary cause of thunderclap headache was found in 16 (38.1%) patients, and four (9.5%) had a primary headache diagnosis after an adequate and complete study. CONCLUSIONS Thunderclap onset was described in one of every 50 patients that visited the emergency room for headache. More than half of these patients were not adequately managed. More than a third of thunderclap headache patients had a secondary cause.
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Affiliation(s)
- David García-Azorín
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
| | - Nuria González-García
- Headache Unit, Department of Neurology, Institute of Neurosciences, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain
| | - Jaime Abelaira-Freire
- Department of Emergency Medicine, Hospital Clínico San Carlos, IdiSSC, Madrid, Spain
| | - Alberto Marcos-Dolado
- Department of Neurology, Hospital Clínico San Carlos, Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
| | - Ángel Luis Guerrero
- Headache Unit, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain.,Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.,Department of Medicine, School of Medicine, Universidad de Valladolid, Valladolid, Spain
| | | | - Jesús Porta-Etessam
- Headache Unit, Department of Neurology, Institute of Neurosciences, Hospital Clínico San Carlos, Instituto de Investigación Sanitaria San Carlos (IdISSC), Madrid, Spain.,Department of Medicine, Universidad Complutense de Madrid, Madrid, Spain
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Barpujari A, Patel C, Zelmonovich R, Clark A, Patel D, Pierre K, Scott K, Lucke Wold B. Pharmaceutical Management for Subarachnoid Hemorrhage. RECENT TRENDS IN PHARMACEUTICAL SCIENCES AND RESEARCH 2021; 3:16-30. [PMID: 34984419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 09/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage can have deleterious consequences. Vasospasm, delayed cerebral ischemia, and re-hemorrhage can all cause delayed sequelae. Furthermore, severe headaches are common and require careful modulation of pain medications. Limited treatment options currently exist and are becoming more complex with the rising use of oral anticoagulants needing reversal. In this review, we highlight the current treatment options currently employed and address avenues of future discovery based on emerging preclinical data. Furthermore, we dive into the best treatment approach for managing headaches following subarachnoid hemorrhage. The review is designed to serve as a catalyst for further prospective investigation into this important topic.
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Affiliation(s)
- Arnav Barpujari
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Chhaya Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | | | - Alec Clark
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Devan Patel
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kevin Pierre
- Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Kyle Scott
- Department of Neurosurgery, University of Florida, Gainesville, Florida
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García-Azorín D, Aparicio-Cordero L, Talavera B, Johnson A, Schytz HW, Guerrero-Peral ÁL. Clinical characterization of delayed alcohol-induced headache. Neurology 2020; 95:e2161-e2169. [DOI: 10.1212/wnl.0000000000010607] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/08/2020] [Indexed: 12/13/2022] Open
Abstract
ObjectiveTo evaluate the International Classification of Headache Disorders (ICHD) criteria and to characterize the clinical phenotype of delayed alcohol-induced headache (DAIH).MethodsWe conducted a cross-sectional study of university students who voluntarily consumed alcohol and experienced headache. Participants completed a survey that included demographic and clinical data. We analyzed the phenotype of the headache, validated ICHD phenotype criteria for DAIH, and analyzed whether participants fulfilled criteria for low-CSF-pressure headache or migraine.ResultsA total of 1,108 participants were included (58% female, mean age 23 years, 41% with headache history). Mean alcohol intake was 158 g; spirits were consumed by 60% of the participants; beer was consumed by 41%; and wine was consumed by 18%. The ICHD criteria for DAIH were met in 95% of the participants. Headache duration (mean, 6.7 hours) correlated with total grams of alcohol consumed (r = 0.62, p = 0.03). Pain was bilateral in 85% of patients with predominantly frontal topography (43%). Pain quality was mainly pressing (60%) or pulsatile (39%) and was aggravated by physical activity in 83% of participants. ICHD low-CSF pressure-headache criteria were fulfilled in 58% of patients, and migraine criteria were fulfilled by 36%.ConclusionsDAIH is a moderate-intensity headache, is typically bilateral, and presents with frontal predominance and a pressing quality. The phenotype of DAIH combines features of both migraine and low-CSF-pressure headaches.
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Ois A, Vivas E, Figueras-Aguirre G, Guimaraens L, Cuadrado-Godia E, Avellaneda C, Bertran-Recasens B, Rodríguez-Campello A, Gracia MP, Villalba G, Saldaña J, Capellades J, Fernández-Candil JL, Roquer J. Misdiagnosis Worsens Prognosis in Subarachnoid Hemorrhage With Good Hunt and Hess Score. Stroke 2019; 50:3072-3076. [PMID: 31597551 DOI: 10.1161/strokeaha.119.025520] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background and Purpose- Our aim was to describe variables associated with initial misdiagnosis of subarachnoid hemorrhage (SAH). We also analyzed the relationship of misdiagnosis with poor outcome and complications in good Hunt and Hess (HH) cases. Methods- In a prospective cohort of 401 patients with SAH, misdiagnosis was defined as failure to correctly identify, at first physician contact, a subsequently documented SAH; this meant no urgent radiological study and lumbar puncture was performed. Poor outcome was defined as modified Rankin Scale score 3 to 6 at 3-month follow-up. We recorded age, sex, hypertension, diabetes mellitus, current smoking, previous antithrombotic treatment, initial HH and radiological severity, presence of aneurysm, first therapeutic procedure, hydrocephalus, delayed cerebral ischemia (DCI), rebleeding, and procedure-related complications. Results- Misdiagnosis was confirmed in 104/401 (25.9%) patients, who also had a longer time-to-admission to hospital. Misdiagnosis was associated with less clinical and radiological severity, compared with a correct diagnosis; the 2 groups did not differ in age or cardiovascular risk factor profile. Poor outcome was registered in 167/401 patients (41.6%). Age, misdiagnosis, and greater clinical and radiological initial severity were independent predictors of poor outcome. In the 236 patients (58.8% of cohort) with HH 1-2, misdiagnosis was associated with poor outcome in univariate and multivariate analysis, respectively (odds ratio=3.89; 95% CI, 1.89-8.01). Delayed cerebral ischemia (odds ratio=2.47; 95% CI, 1.2-5.09) and procedure-related complications (odds ratio=2.27; 95% CI, 1.07-4.82) were independently associated with misdiagnosis. Conclusions- Misdiagnosis is an unresolved problem in SAH, and it is a missed opportunity for good outcome in patients with HH 1-2. The poor outcome is partially explained by a higher risk of delayed cerebral ischemia and procedure-related complications in misdiagnosed patients. There is a need to improve the diagnostic strategy in patients reporting only a headache (HH 1-2) after SAH.
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Affiliation(s)
- Angel Ois
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.).,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain (A.O., E.C.-G., C.A., A.R.-C., J.R.).,Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain (A.O., E.C.-G., A.R.-C., J.R.)
| | - Elio Vivas
- J.J. Merland Department of Therapeutic Neuroangiography of Hospital del Mar and Hospital Universitari General de Catalunya, Spain (E.V., L.G., J.S.)
| | - Georgina Figueras-Aguirre
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.)
| | - Leopoldo Guimaraens
- J.J. Merland Department of Therapeutic Neuroangiography of Hospital del Mar and Hospital Universitari General de Catalunya, Spain (E.V., L.G., J.S.)
| | - Elisa Cuadrado-Godia
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.).,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain (A.O., E.C.-G., C.A., A.R.-C., J.R.).,Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain (A.O., E.C.-G., A.R.-C., J.R.)
| | - Carla Avellaneda
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.).,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain (A.O., E.C.-G., C.A., A.R.-C., J.R.)
| | - Bernat Bertran-Recasens
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.)
| | - Ana Rodríguez-Campello
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.).,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain (A.O., E.C.-G., C.A., A.R.-C., J.R.).,Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain (A.O., E.C.-G., A.R.-C., J.R.)
| | - Maria-Pilar Gracia
- Department of Intensive Care (M.-P.G.), Hospital del Mar, Barcelona, Spain
| | - Gloria Villalba
- Department of Neurosurgery (G.V.), Hospital del Mar, Barcelona, Spain
| | - Jesus Saldaña
- J.J. Merland Department of Therapeutic Neuroangiography of Hospital del Mar and Hospital Universitari General de Catalunya, Spain (E.V., L.G., J.S.)
| | - Jaume Capellades
- Department of Radiology (J.C.), Hospital del Mar, Barcelona, Spain
| | | | - Jaume Roquer
- From the Department of Neurology, Hospital del Mar, Barcelona, Spain (A.O., G.F.-A., E.C.-G., C.A., B.B.-R., A.R.-C., J.R.).,Neurovascular Research Group, IMIM (Institut Hospital del Mar d'Investigacions Mèdiques), Barcelona, Spain (A.O., E.C.-G., C.A., A.R.-C., J.R.).,Universitat Autònoma de Barcelona/DCEXS-Universitat Pompeu Fabra, Barcelona, Spain (A.O., E.C.-G., A.R.-C., J.R.)
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Abstract
PURPOSE OF REVIEW This article is intended to assist clinicians in distinguishing benign primary headache syndromes from serious headache presentations that arise from exogenous causes. RECENT FINDINGS Although most cases of severe headache are benign, it is essential to recognize the signs and symptoms of potentially life-threatening conditions. Patients with primary headache disorders can also acquire secondary conditions that may present as a change in their baseline headache patterns and characteristics. Clinical clues in the history and examination can help guide the diagnosis and management of secondary headache disorders. Furthermore, advances in the understanding of basic mechanisms of headache may offer insight into the proposed pathophysiology of secondary headaches. SUMMARY Several structural, vascular, infectious, inflammatory, and traumatic causes of headache are highlighted. Careful history taking and examination can enable prompt identification and treatment of underlying serious medical disorders causing secondary headache syndromes.
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Abstract
PURPOSE FOR REVIEW Subarachnoid hemorrhage is a serious and life-threatening medical condition which commonly presents with an acute headache. Unfortunately, it remains frequently misdiagnosed at initial presentation with dire consequences in terms of patient morbidity and mortality. The goal of this paper is to review salient features in the clinical history, as well as recently developed clinical decision rules, which can help determine which patients warrant further investigation for subarachnoid hemorrhage when the initial presentation is that of an acute headache. RECENT FINDINGS A recent prospective observational study showed that occipital location, stabbing quality, presence of meningism, and onset of headache during exertion were characteristics in the clinical history that can distinguish the headache of SAH from other causes. The Ottawa headache rule is a clinical decision tool which was developed to help identify patients presenting to the ED with acute non-traumatic headache who require investigation to rule out subarachnoid hemorrhage. Using this tool, it is recommended that patients who meet any one of the following 6 criteria are investigated further: Onset greater than or equal to 40 years, presence of neck pain or stiffness, witnessed loss of consciousness, onset during exertion, thunder clap headache (pain peaking within 1 s), or limited neck flexion on exam. An informed and thoughtful approach that takes into account the timing, presentation, risk factors, and resources, as discussed here, should help distinguish between the patient that warrants further evaluation and intervention for SAH and one who does not. The Ottawa SAH rule is a useful clinical decision tool for young inexperienced clinicians in order to avoid missed diagnoses. However, its clinical value is limited by its low specificity. Clinical decision tools with higher specificity are needed.
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Affiliation(s)
| | - Robert Cowan
- Neurology and Division of Headache Medicine, Stanford University, Stanford, CA, USA
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Chinthapalli K, Logan AM, Raj R, Nirmalananthan N. Assessment of acute headache in adults - what the general physician needs to know. Clin Med (Lond) 2018; 18:422-427. [PMID: 30287441 PMCID: PMC6334100 DOI: 10.7861/clinmedicine.18-5-422] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Headache is common. Up to 5% of attendances to emergency departments and acute medical units are due to headache. Headache is classified as either primary (eg migraine, cluster headache) or secondary to another cause (eg meningitis, subarachnoid haemorrhage). Even in the acute setting the majority of cases are due to primary causes. The role of the attending physician is to take a comprehensive history to diagnose and treat benign headache syndromes while ruling out sinister aetiologies. This brief article summarises the approach to assessment of headache presenting in acute and emergency care.
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Affiliation(s)
| | - Anne-Marie Logan
- Atkinson Morley Regional Neurosciences Centre, St George's Hospital, London, UK
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