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Couret D, Boussen S, Cardoso D, Alonzo A, Madec S, Reyre A, Brunel H, Girard N, Graillon T, Dufour H, Bruder N, Boucekine M, Meilhac O, Simeone P, Velly L. Comparison of scales for the evaluation of aneurysmal subarachnoid haemorrhage: a retrospective cohort study. Eur Radiol 2024:10.1007/s00330-024-10814-4. [PMID: 38836940 DOI: 10.1007/s00330-024-10814-4] [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: 11/03/2023] [Revised: 04/05/2024] [Accepted: 04/14/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND/OBJECTIVES Aneurysmal subarachnoid haemorrhage (aSAH) is a life-threatening event with major complications. Delayed cerebral infarct (DCI) occurs most frequently 7 days after aSAH and can last for a prolonged period. To determine the most predictive radiological scales in grading subarachnoid or ventricular haemorrhage or both for functional outcome at 3 months in a large aSAH population, we conducted a single-centre retrospective study. METHODS A 3-year single-centre retrospective cohort study of 230 patients hospitalised for aSAH was analysed. Initial computed tomography (CT) scans in patients hospitalised for aSAH were blindly assessed using eight grading systems: the Fisher grade, modified Fisher grade, Barrow Neurological Institute scale, Hijdra scale, Intraventricular Haemorrhage (IVH) score, Graeb score and LeRoux score. RESULTS Of 200 patients with aSAH who survived to day 7 and were included for DCI analysis, 39% of cases were complicated with DCI. The Hijdra scale was the best predictor for DCI, with a receiver operating characteristic area under the curve (ROCAUC) of 0.80 (95% confidence interval (CI), 0.74-0.85). The IVH score was the most effective grading system for predicting acute hydrocephalus, with a ROCAUC of 0.85 (95% CI, 0.79-0.89). In multivariate analysis, the Hijdra scale was the best predictor of the occurrence of DCI (hazard ratio, 1.18; 95% CI, 1.10-1.25). CONCLUSIONS Although these results have yet to be prospectively confirmed, our findings suggest that the Hijdra scale may be a good predictor of DCI and could be useful in daily clinical practice. CLINICAL RELEVANCE STATEMENT Better assessment of subarachnoid haemorrhage patients would allow for better prognostication and management of expectations, as well as referral for appropriate services and helping to appropriate use limited critical care resources. KEY POINTS Aneurysmal subarachnoid haemorrhage is a life-threatening event that causes severe disability and leads to major complications such as delayed cerebral infarction. Accurate assessment of the amount of blood in the subarachnoid spaces on computed tomography with the Hijdra scale can better predict the risk of delayed cerebral infarct. The Hijdra scale could be a good triage tool for subarachnoid haemorrhage patients.
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Affiliation(s)
- David Couret
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France.
- Neurocritical Care Unit, University Hospital Saint Pierre, Réunion Univ, BP 350, Saint Pierre, 97448, La Réunion, France.
- Reunion Island University, INSERM, Diabète Athérothrombose Réunion Océan Indien (DéTROI), Saint Denis de la Réunion, France.
| | - Salah Boussen
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
| | - Dan Cardoso
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
| | - Audrey Alonzo
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
| | - Sylvain Madec
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
| | - Anthony Reyre
- Department of Radiology, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Hervé Brunel
- Department of Radiology, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Nadine Girard
- Department of Radiology, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Thomas Graillon
- Department of Neurosurgery, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Henry Dufour
- Department of Neurosurgery, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Nicolas Bruder
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
| | - Mohamed Boucekine
- Centre D'Etudes Et de Recherches Sur Les Services de Santé Et Qualité, Faculté de Médecine, Aix-Marseille Université, 13005, Marseille, France
| | - Olivier Meilhac
- Reunion Island University, INSERM, Diabète Athérothrombose Réunion Océan Indien (DéTROI), Saint Denis de la Réunion, France
| | - Pierre Simeone
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
- CNRS, INT, Inst Neurosci Timone, Aix Marseille Univ, Marseille, France
| | - Lionel Velly
- Department of Anaesthesiology and Critical Care Medicine, Aix Marseille Univ, University Hospital Timone, Marseille, France
- CNRS, INT, Inst Neurosci Timone, Aix Marseille Univ, Marseille, France
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Seyour M, Salvagno M, Rozenblum R, Macchini E, Anderloni M, Jodaitis L, Peluso L, Annoni F, Lolli V, Schuind S, Gaspard N, Taccone FS, Gouvea Bogossian E. The impact of perfusion computed tomography on the diagnosis and outcome of delayed cerebral ischemia after subarachnoid hemorrhage. Neurol Sci 2024; 45:1135-1144. [PMID: 37828386 DOI: 10.1007/s10072-023-07115-x] [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: 10/01/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is a preventable cause of poor neurological outcome in aneurysmal subarachnoid hemorrhage (aSAH). Advances in radiological methods, such as cerebral perfusion computed tomography (CTP), could help diagnose DCI earlier and potentially improve outcomes in aSAH. The objective of this study was to assess whether the use of CTP to diagnose DCI early could reduce the risk of infarction related to DCI. METHODS Retrospective cohort study of patients in the intensive care unit of Erasme Hospital (Brussels, Belgium) between 2004 and 2021 with aSAH who developed DCI. Patients were classified as: "group 1" - DCI diagnosed based on clinical deterioration or "group 2" - DCI diagnosed using CTP. The primary outcome was the development of infarction unrelated to the initial bleeding or surgery. RESULTS 211 aSAH patients were diagnosed with DCI during the study period: 139 (66%) in group 1 and 72 (34%) in group 2. In group 1, 109 (78%) patients developed a cerebral infarction, compared to 45 (63%) in group 2 (p = 0.02). The adjusted cumulative incidence of DCI over time was lower in group 2 than in group 1 [hazard ratio 0.65 (95% CI 0.48-0.94); p = 0.02]. The use of CTP to diagnose DCI was not independently associated with mortality or neurological outcome. CONCLUSIONS The use of CTP to diagnose DCI might help reduce the risk of developing cerebral infarction after aSAH, although the impact of such an approach on patient outcomes needs to be further demonstrated.
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Affiliation(s)
- Mohamed Seyour
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Michele Salvagno
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raphael Rozenblum
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisabetta Macchini
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Anderloni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Filippo Annoni
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Valentina Lolli
- Department of Radiology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Thilak S, Brown P, Whitehouse T, Gautam N, Lawrence E, Ahmed Z, Veenith T. Diagnosis and management of subarachnoid haemorrhage. Nat Commun 2024; 15:1850. [PMID: 38424037 PMCID: PMC10904840 DOI: 10.1038/s41467-024-46015-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 02/12/2024] [Indexed: 03/02/2024] Open
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) presents a challenge to clinicians because of its multisystem effects. Advancements in computed tomography (CT), endovascular treatments, and neurocritical care have contributed to declining mortality rates. The critical care of aSAH prioritises cerebral perfusion, early aneurysm securement, and the prevention of secondary brain injury and systemic complications. Early interventions to mitigate cardiopulmonary complications, dyselectrolytemia and treatment of culprit aneurysm require a multidisciplinary approach. Standardised neurological assessments, transcranial doppler (TCD), and advanced imaging, along with hypertensive and invasive therapies, are vital in reducing delayed cerebral ischemia and poor outcomes. Health care disparities, particularly in the resource allocation for SAH treatment, affect outcomes significantly, with telemedicine and novel technologies proposed to address this health inequalities. This article underscores the necessity for comprehensive multidisciplinary care and the urgent need for large-scale studies to validate standardised treatment protocols for improved SAH outcomes.
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Affiliation(s)
- Suneesh Thilak
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Poppy Brown
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Tony Whitehouse
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Nandan Gautam
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
| | - Errin Lawrence
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, B15 2GW, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK
| | - Tonny Veenith
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, B15 2TT, UK.
- Centre for Trauma Sciences Research, University of Birmingham, Birmingham, B15 2TT, UK.
- Department of Critical Care Medicine and Anaesthesia, The Royal Wolverhampton NHS Foundation Trust, New Cross Hospital, Wolverhampton, WV10 0QP, UK.
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Rojas-Panta G, Reyes-Narro GF, Toro-Huamanchumo C, Choque-Velasquez J, Saal-Zapata G. Prognostic value of scales for aneurysmal subarachnoid hemorrhage: Report of a reference center in Peru. NEUROCIRUGIA (ENGLISH EDITION) 2024; 35:1-5. [PMID: 37295495 DOI: 10.1016/j.neucie.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 05/16/2023] [Indexed: 06/12/2023]
Abstract
INTRODUCTION Multiple scales have been designed to stratify the severity and predict the prognosis in the initial evaluation of patients with aneurysmal subarachnoid hemorrhage (aSAH). Our study aimed to validate the most commonly used prognostic scales for aSAH in our population: Hunt-Hess, modified Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH), and Barrow Aneurysm Institute (BAI) scales. METHODS This study includes all aSAH cases treated at our institution between June 2019 and December 2020. We developed a retrospective cohort by reviewing medical records and radiologic images performed during hospitalization. The outcome was evaluated using the modified Rankin scale (mRS). It was defined as a poor outcome (mRS 4-5) and mortality (mRS 6). The ROC curves and the area under the curve (AUC) of each of the prognostic scales were calculated to evaluate their prognostic prediction capacity. RESULTS A total of 142 patients were diagnosed with aSAH. A poor outcome occurred in 52.1% of the patients, whereas mortality was 27.5%. The AUC of the scales studied was similar and no significant difference was found between them for predicting a poor outcome (P = .709) or mortality (P = .715). CONCLUSION We determined that the prognostic scales for aSAH had a similar predictive value for poor clinical outcomes and mortality in our institution, with no significant difference. Thus, we recommend the most simple and well-known scale used institutionally.
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Affiliation(s)
- Giuseppe Rojas-Panta
- Departamento de Neurocirugía, Servicio de Neurocirugía Vascular y Tumores, Hospital Nacional Guillermo Almenar Irigoyen-EsSalud, Lima, Peru.
| | - Gian F Reyes-Narro
- Departamento de Neurocirugía, Servicio de Neurocirugía Vascular y Tumores, Hospital Nacional Guillermo Almenar Irigoyen-EsSalud, Lima, Peru
| | - Carlos Toro-Huamanchumo
- Unidad de Investigación para la Generación y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Perú
| | - Joham Choque-Velasquez
- Unidad de Neurocirugía, Hospital Regional del Cusco, Cusco, Peru; Facultad de Ciencias de la Salud, Escuela Profesional de Medicina Humana, Universidad Andina del Cusco, Cusco, Peru
| | - Giancarlo Saal-Zapata
- Departamento de Neurocirugía, Servicio de Neurocirugía Endovascular, Hospital Nacional Guillermo Almenar Irigoyen-EsSalud, Lima, Peru; Clínica Angloamericana, San Isidro, Lima, Peru
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Zhu G, Yuan A, Yu D, Zha A, Wu H. Machine learning to predict mortality for aneurysmal subarachnoid hemorrhage (aSAH) using a large nationwide EHR database. PLOS DIGITAL HEALTH 2023; 2:e0000400. [PMID: 38055677 DOI: 10.1371/journal.pdig.0000400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 10/29/2023] [Indexed: 12/08/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) develops quickly once it occurs and threatens the life of patients. We aimed to use machine learning to predict mortality for SAH patients at an early stage which can help doctors make clinical decisions. In our study, we applied different machine learning methods to an aSAH cohort extracted from a national EHR database, the Cerner Health Facts EHR database (2000-2018). The outcome of interest was in-hospital mortality, as either passing away while still in the hospital or being discharged to hospice care. Machine learning-based models were primarily evaluated by the area under the receiver operating characteristic curve (AUC). The population size of the SAH cohort was 6728. The machine learning methods achieved an average of AUCs of 0.805 for predicting mortality with only the initial 24 hours' EHR data. Without losing the prediction power, we used the logistic regression to identify 42 risk factors, -examples include age and serum glucose-that exhibit a significant correlation with the mortality of aSAH patients. Our study illustrates the potential of utilizing machine learning techniques as a practical prognostic tool for predicting aSAH mortality at the bedside.
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Affiliation(s)
- Gen Zhu
- Global Health & Analytics, Development, Novartis Pharmaceuticals, East Hanover, New Jersey, United States of America
| | - Anthony Yuan
- Department of Internal Medicine, The University of Texas Southwestern, Texas, United States of America
| | - Duo Yu
- Division of Biostatistics, Institute for Health & Equity, Medical College of Wisconsin, Milwaukee, Wisconsin, United States of America
| | - Alicia Zha
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, Ohio, United States of America
| | - Hulin Wu
- Department of Biostatistics and Data Science, The University of Texas Health Science Center at Houston, Houston, Texas, United States of America
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Hori S, Masuoka T, Hamada H, Okamoto S, Kubo M, Horie Y, Kuroda S. Walk-In Hospital Admission of Patients with Subarachnoid Hemorrhage: Clinical Presentation and Outcome. World Neurosurg 2023; 179:e421-e427. [PMID: 37659750 DOI: 10.1016/j.wneu.2023.08.112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 08/29/2023] [Indexed: 09/04/2023]
Abstract
OBJECTIVE Neurosurgeons occasionally encounter cases of subarachnoid hemorrhage (SAH) in admitted walk-in patients, termed "walk-in SAH." However, their clinical characteristics have not been fully understood. We thus, aimed to investigate several characteristics of patients with walk-in SAH and compare them with those of patients with good grade SAH who arrived at the hospital by ambulance. METHODS Between January 2011 and January 2018, consecutive patients with World Federation of Neurosurgical Society (WFNS) grade I and II aneurysmal SAH were enrolled. They were dichotomized into walk-in and ambulance groups, and their demographic and disease-related characteristics were compared. Furthermore, predictors associated with unfavorable outcomes were investigated in patients with walk-in SAH. RESULTS Of 171 patients with World Federation of Neurosurgical Society grade I and II SAH, 68 (39.8%) were categorized as walk-in SAH. The mean time for diagnosis in patients with walk-in SAH was significantly longer than that in patients who arrived by ambulance (P < 0.01). Multivariate analysis demonstrated that a lower rate of hypertension, high grades on the Barrow Neurological Institute scale, and Early Brain Edema Score were significantly associated with walk-in SAH (odds ratio [OR] 0.44, 95% confidence interval [CI] 0.21-0.91, P = 0.03; OR 0.32, 95% CI 0.13-0.76, P = 0.007; OR 0.11, 95% CI 0.02-0.51, P < 0.0001, respectively). Additionally, severe angiographic vasospasm was a significant predictor of unfavorable outcomes in walk-in SAH (OR 37.7, 95% CI 1.10-1290.90, P = 0.04). CONCLUSIONS Patients with walk-in SAH exhibit radiological characteristics associated with a more favorable outcome among patients with good grade SAH. Therefore, these patients may have a positive prognosis.
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Affiliation(s)
- Satoshi Hori
- Department of Neurosurgery, Tonami General Hospital, Toyama, Japan; Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan.
| | - Toru Masuoka
- Department of Neurosurgery, Tonami General Hospital, Toyama, Japan
| | - Hideo Hamada
- Department of Neurosurgery, Tonami General Hospital, Toyama, Japan
| | - Soshi Okamoto
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Michiya Kubo
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Yukio Horie
- Department of Neurosurgery, Saiseikai Toyama Hospital, Toyama, Japan
| | - Satoshi Kuroda
- Department of Neurosurgery, Graduate School of Medicine and Pharmaceutical Science, University of Toyama, Toyama, Japan
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Qiu W, Li W, Xu K, Zhu G, Luo H, Deng Y, Qin Z, Zeng K, Wei Y, Lin X. Prognostic significance of fibrinogen and neutrophil/lymphocyte ratio score and D-dimer/Albumin ratio for prognosis in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107338. [PMID: 37690163 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Recent research indicates that systemic inflammation significantly affects the overall prognosis of individuals with aneurysmal subarachnoid hemorrhage. To delve deeper into this issue, a retrospective study was undertaken. The study aimed to investigate the relationship between fibrinogen and neutrophil/lymphocyte ratio scores, D-dimer/Albumin ratios, and the Glasgow Outcome Scale at 6 months post-discharge for patients with aSAH. METHODS A retrospective analysis was conducted on 321 patients who experienced aneurysmal subarachnoid hemorrhage. These patients were monitored using the Glasgow Outcome Scale six months after being discharged from Huizhou Central People's Hospital. Patients with GOS scores between 1 and 3 were classified as having a poor prognosis, while those with scores ranging from 4 to 5 were considered to have a good prognosis. To create distinct sets, patients were randomly divided into both training and validation groups. The best cut-off value for the D-dimer/Albumin ratio was established through ROC curves, and the scores for fibrinogen and the neutrophil/lymphocyte ratio were calculated. Utilizing multivariate logistic regression analysis, independent risk factors linked to an unfavorable prognosis in aSAH patients were identified. A nomogram model was developed and validated based on these findings, providing an improved approach for evaluating the prognostic influence of risk factors. To gauge the model's predictive performance, several analytical tools such as ROC curves, calibration curves, and decision curve analysis were employed. This comprehensive approach ensured a thorough assessment of the prognostic prediction capabilities of the model. RESULTS Multivariate regression analysis revealed that Age (OR=3.87, 95%CI=1.54-9.73, p=0.004), Pneumonia (OR=3.54, 95%CI=1.41-8.86, p=0.007), WFNS (OR=3.24, 95%CI=1.23-8.54, p=0.017), DAR (OR=2.88, 95%CI=1.13-7.34, p=0.027), and F-NLR (OR=3.12, 95%CI=1.22-7.97, p=0.017) were identified as independent risk factors influencing the prognosis of patients with aSAH. Additionally, the area under the ROC curve was 0.866 (95%CI=0.805-0.927) for the training set and 0.924 (95%CI=0.849-0.999) for the validation set. The calibration curve analysis demonstrated a minor error of 0.02 for the training set and 0.051 for the validation set. Furthermore, both the training set and validation set displayed significant clinical benefits according to the DCA curves, underscoring the meaningful utility of the developed nomogram. CONCLUSIONS Fibrinogen and neutrophil/lymphocyte ratio scores, and the D-dimer/Albumin ratio emerged as significant independent risk factors for prognosticating the outcomes of patients with aSAH. Leveraging these factors, a robust nomogram model was meticulously developed, showcasing its impressive precision in prognostic predictions. These results underscore the promising clinical applicability of these biomarkers as effective prognostic indicators for individuals afflicted by aSAH.
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Affiliation(s)
- Wenjie Qiu
- Guangdong Medical University, Zhanjiang, China
| | - Wencai Li
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Ke Xu
- Guangdong Medical University, Zhanjiang, China
| | - Gang Zhu
- Guangdong Medical University, Zhanjiang, China; Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China.
| | - Honghai Luo
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Yifan Deng
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Zhongzong Qin
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
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Nguyen TA, Mai TD, Vu LD, Dao CX, Ngo HM, Hoang HB, Tran TA, Pham TQ, Pham DT, Nguyen MH, Nguyen LQ, Dao PV, Nguyen DN, Vuong HTT, Vu HD, Nguyen DD, Vu TD, Nguyen DT, Do ALN, Nguyen CD, Do SN, Nguyen HT, Nguyen CV, Nguyen AD, Luong CQ. Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage. PLoS One 2023; 18:e0289267. [PMID: 37607172 PMCID: PMC10443875 DOI: 10.1371/journal.pone.0289267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 07/16/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Evaluating the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) who may be at risk of poor outcomes using grading systems is one way to make a better decision on treatment for these patients. This study aimed to compare the accuracy of the modified World Federation of Neurosurgical Societies (WFNS), WFNS, and Hunt and Hess (H&H) Grading Scales in predicting the outcomes of patients with aSAH. METHODS From August 2019 to June 2021, we conducted a multicenter prospective cohort study on adult patients with aSAH in three central hospitals in Hanoi, Vietnam. The primary outcome was the 90-day poor outcome, measured by a score of 4 (moderately severe disability) to 6 (death) on the modified Rankin Scale (mRS). We calculated the areas under the receiver operator characteristic (ROC) curve (AUROCs) to determine how well the grading scales could predict patient prognosis upon admission. We also used ROC curve analysis to find the best cut-off value for each scale. We compared AUROCs using Z-statistics and compared 90-day mean mRS scores among intergrades using the pairwise multiple-comparison test. Finally, we used logistic regression to identify factors associated with the 90-day poor outcome. RESULTS Of 415 patients, 32% had a 90-day poor outcome. The modified WFNS (AUROC: 0.839 [95% confidence interval, CI: 0.795-0.883]; cut-off value≥2.50; PAUROC<0.001), WFNS (AUROC: 0.837 [95% CI: 0.793-0.881]; cut-off value≥3.5; PAUROC<0.001), and H&H scales (AUROC: 0.836 [95% CI: 0.791-0.881]; cut-off value≥3.5; PAUROC<0.001) were all good at predicting patient prognosis on day 90th after ictus. However, there were no significant differences between the AUROCs of these scales. Only grades IV and V of the modified WFNS (3.75 [standard deviation, SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), WFNS (3.75 [SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), and H&H scales (2.96 [SD: 2.60] vs 4.97 [SD: 1.87], p<0.001, respectively) showed a significant difference in the 90-day mean mRS scores. In multivariable models, with the same set of confounding variables, the modified WFNS grade of III to V (adjusted odds ratio, AOR: 9.090; 95% CI: 3.494-23.648; P<0.001) was more strongly associated with the increased risk of the 90-day poor outcome compared to the WFNS grade of IV to V (AOR: 6.383; 95% CI: 2.661-15.310; P<0.001) or the H&H grade of IV to V (AOR: 6.146; 95% CI: 2.584-14.620; P<0.001). CONCLUSIONS In this study, the modified WFNS, WFNS, and H&H scales all had good discriminatory abilities for the prognosis of patients with aSAH. Because of the better effect size in predicting poor outcomes, the modified WFNS scale seems preferable to the WFNS and H&H scales.
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Affiliation(s)
- Tuan Anh Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Ton Duy Mai
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Luu Dang Vu
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Co Xuan Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hung Manh Ngo
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Hai Bui Hoang
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Tuan Anh Tran
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Trang Quynh Pham
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Dung Thi Pham
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - My Ha Nguyen
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Linh Quoc Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Phuong Viet Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | | | - Hien Thi Thu Vuong
- Emergency Department, Vietnam-Czechoslovakia Friendship Hospital, Hai Phong, Vietnam
| | - Hung Dinh Vu
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Dong Duc Nguyen
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
| | - Thanh Dang Vu
- Emergency Department, Agriculture General Hospital, Hanoi, Vietnam
| | | | - Anh Le Ngoc Do
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Cuong Duy Nguyen
- Department of Emergency and Critical Care Medicine, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Son Ngoc Do
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hao The Nguyen
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Chi Van Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Anh Dat Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Center for Emergency Medicine, Bach Mai Hospital, Hanoi, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
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9
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Nwafor DC, Kirby BD, Ralston JD, Colantonio MA, Ibekwe E, Lucke-Wold B. Neurocognitive Sequelae and Rehabilitation after Subarachnoid Hemorrhage: Optimizing Outcomes. JOURNAL OF VASCULAR DISEASES 2023; 2:197-211. [PMID: 37082756 PMCID: PMC10111247 DOI: 10.3390/jvd2020014] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Abstract
Subarachnoid hemorrhage (SAH) is a medical emergency that requires immediate intervention. The etiology varies between cases; however, rupture of an intracranial aneurysm accounts for 80% of medical emergencies. Early intervention and treatment are essential to prevent long-term complications. Over the years, treatment of SAH has drastically improved, which is responsible for the rapid rise in SAH survivors. Post-SAH, a significant number of patients exhibit impairments in memory and executive function and report high rates of depression and anxiety that ultimately affect daily living, return to work, and quality of life. Given the rise in SAH survivors, rehabilitation post-SAH to optimize patient outcomes becomes crucial. The review addresses the current rehabilitative strategies to combat the neurocognitive and behavioral issues that may arise following SAH.
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Affiliation(s)
- Divine C. Nwafor
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Brandon D. Kirby
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
- Rockefeller Neuroscience Institute, West Virginia University, Morgantown, WV 26506, USA
| | - Jacob D. Ralston
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Mark A. Colantonio
- Department of Neuroscience, West Virginia University Health Science Center, Morgantown, WV 26506, USA
| | - Elochukwu Ibekwe
- Department of Neurology and Neurocritical Care, The Ohio State University, Columbus, OH 43210, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32611, USA
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10
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Kevci R, Lewén A, Ronne-Engström E, Velle F, Enblad P, Svedung Wettervik T. Lumbar puncture-verified subarachnoid hemorrhage: bleeding sources, need of radiological examination, and functional recovery. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05640-4. [PMID: 37227503 DOI: 10.1007/s00701-023-05640-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 05/15/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND The primary aim was to determine the diagnostic yield of vascular work-up, the clinical course during neurointensive care (NIC), and rate of functional recovery for patients with computed tomography (CT)-negative, lumbar puncture (LP)-verified SAH. METHODS In this retrospective study, 1280 patients with spontaneous SAH, treated at our NIC unit, Uppsala University Hospital, Sweden, between 2008 and 2018, were included. Demography, admission status, radiological examinations (CT angiography (CTA) and digital subtraction angiography (DSA)), treatments, and functional outcome (GOS-E) at 12 months were evaluated. RESULTS Eighty (6%) out of 1280 SAH patients were computed tomography (CT)-negative, LP-verified cases. Time between ictus and diagnosis was longer for the LP-verified SAH cohort in comparison to the CT-positive patients (median 3 vs 0 days, p < 0.001). One fifth of the LP-verified SAH patients exhibited an underlying vascular pathology (aneurysm/AVM), which was significantly less common than for the CT-verified SAH cohort (19% vs. 76%, p < 0.001). The CTA- and DSA-findings were consistent in all of the LP-verified cases. The LP-verified SAH patients exhibited a lower rate of delayed ischemic neurological deficits, but no difference in rebleeding rate, compared to the CT-verified cohort. At 1-year post-ictus, 89% of the LP-verified SAH patients had recovered favorably, but 45% of the cases did not reach good recovery. Having an underlying vascular pathology and an external ventricular drainage were associated with worse functional recovery (p = 0.02) in this cohort. CONCLUSIONS LP-verified SAH constituted a small proportion of the entire SAH population. Having an underlying vascular pathology was less frequent in this cohort, but still occurred in one out of five patients. Despite the small initial bleeding in the LP-verified cohort, many of these patients did not reach good recovery at 1 year, this calls for more attentive follow-up and rehabilitation in this cohort.
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Affiliation(s)
- Rozerin Kevci
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden.
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11
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Nguyen TA, Vu LD, Mai TD, Dao CX, Ngo HM, Hoang HB, Do SN, Nguyen HT, Pham DT, Nguyen MH, Nguyen DN, Vuong HTT, Vu HD, Nguyen DD, Nguyen LQ, Dao PV, Vu TD, Nguyen DT, Tran TA, Pham TQ, Van Nguyen C, Nguyen AD, Luong CQ. Predictive validity of the prognosis on admission aneurysmal subarachnoid haemorrhage scale for the outcome of patients with aneurysmal subarachnoid haemorrhage. Sci Rep 2023; 13:6721. [PMID: 37185953 PMCID: PMC10130082 DOI: 10.1038/s41598-023-33798-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/19/2023] [Indexed: 05/17/2023] Open
Abstract
This multicentre prospective cohort study aimed to compare the accuracy of the PAASH, WFNS, and Hunt and Hess (H&H) scales in predicting the outcomes of adult patients with aneurysmal SAH presented to three central hospitals in Hanoi, Vietnam, from August 2019 to June 2021. Of 415 eligible patients, 32.0% had a 90-day poor outcome, defined as an mRS score of 4 (moderately severe disability) to 6 (death). The PAASH, WFNS and H&H scales all have good discriminatory abilities for predicting the 90-day poor outcome. There were significant differences in the 90-day mean mRS scores between grades I and II (p = 0.001) and grades II and III (p = 0.001) of the PAASH scale, between grades IV and V (p = 0.026) of the WFNS scale, and between grades IV and V (p < 0.001) of the H&H scale. In contrast to a WFNS grade of IV-V and an H&H grade of IV-V, a PAASH grade of III-V was an independent predictor of the 90-day poor outcome. Because of the more clearly significant difference between the outcomes of the adjacent grades and the more strong effect size for predicting poor outcomes, the PAASH scale was preferable to the WFNS and H&H scales.
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Affiliation(s)
- Tuan Anh Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Luu Dang Vu
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Ton Duy Mai
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Co Xuan Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hung Manh Ngo
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
| | - Hai Bui Hoang
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Son Ngoc Do
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
- Center for Critical Care Medicine, Bach Mai Hospital, Hanoi, Vietnam
| | - Hao The Nguyen
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Dung Thi Pham
- Department of Nutrition and Food Safety, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - My Ha Nguyen
- Department of Health Organization and Management, Faculty of Public Health, Thai Binh University of Medicine and Pharmacy, Thai Binh, Vietnam
| | - Duong Ngoc Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam
| | - Hien Thi Thu Vuong
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Emergency Department, Vietnam-Czechoslovakia Friendship Hospital, Hai Phong, Vietnam
| | - Hung Dinh Vu
- Emergency and Critical Care Department, Hanoi Medical University Hospital, Hanoi Medical University, Hanoi, Vietnam
| | - Dong Duc Nguyen
- Department of Neurosurgery II, Neurosurgery Center, Vietnam-Germany Friendship Hospital, Hanoi, Vietnam
| | - Linh Quoc Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Phuong Viet Dao
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Thanh Dang Vu
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
- Emergency Department, Agriculture General Hospital, Hanoi, Vietnam
| | | | - Tuan Anh Tran
- Radiology Centre, Bach Mai Hospital, Hanoi, Vietnam
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam
| | - Trang Quynh Pham
- Department of Surgery, Hanoi Medical University, Hanoi, Vietnam
- Department of Neurosurgery, Bach Mai Hospital, Hanoi, Vietnam
| | - Chi Van Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Anh Dat Nguyen
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam
| | - Chinh Quoc Luong
- Center for Emergency Medicine, Bach Mai Hospital, 78 Giai Phong Road, Phuong Mai Ward, Dong Da District, Hanoi, 100000, Vietnam.
- Department of Emergency and Critical Care Medicine, Hanoi Medical University, Hanoi, Vietnam.
- Faculty of Medicine, University of Medicine and Pharmacy, Vietnam National University, Hanoi, Vietnam.
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12
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Lång M, Jakob SM, Takala R, Lyngbakken MN, Turpeinen A, Omland T, Merz TM, Wiegand J, Grönlund J, Rahi M, Valtonen M, Koivisto T, Røsjø H, Bendel S. The prevalence of cardiac complications and their impact on outcomes in patients with non-traumatic subarachnoid hemorrhage. Sci Rep 2022; 12:20109. [PMID: 36418906 PMCID: PMC9684538 DOI: 10.1038/s41598-022-24675-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/18/2022] [Indexed: 11/24/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a serious condition, and a myocardial injury or dysfunction could contribute to the outcome. We assessed the prevalence and prognostic impact of cardiac involvement in a cohort with SAH. This is a prospective observational multicenter study. We included 192 patients treated for non-traumatic subarachnoid hemorrhage. We performed ECG recordings, echocardiographic examinations, and blood sampling within 24 h of admission and on days 3 and 7 and at 90 days. The primary endpoint was the evidence of cardiac involvement at 90 days, and the secondary endpoint was to examine the prevalence of a myocardial injury or dysfunction. The median age was 54.5 (interquartile range [IQR] 48.0-64.0) years, 44.3% were male and the median World Federation of Neurological Surgeons (WFNS) score was 2 (IQR 1-4). At day 90, 22/125 patients (17.6%) had left ventricular ejection fractions ≤ 50%, and 2/121 patients (1.7%) had evidence of a diastolic dysfunction as defined by mitral peak E-wave velocity by peak e' velocity (E/e') > 14. There was no prognostic impact from echocardiographic evidence of cardiac complications on neurological outcomes. The overall prevalence of cardiac dysfunction was modest. We found no demographic or SAH-related factors associated with 90 days cardiac dysfunction.
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Affiliation(s)
- Maarit Lång
- grid.9668.10000 0001 0726 2490Department of Intensive Care Medicine, Kuopio University Hospital, University of Eastern Finland, PO BOX 100, 70029 KYS Kuopio, Finland
| | - Stephan M. Jakob
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Riikka Takala
- grid.1374.10000 0001 2097 1371Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland
| | - Magnus N. Lyngbakken
- grid.5510.10000 0004 1936 8921Division of Medicine, Department of Cardiology, Akershus University Hospital, Lørenskog, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anu Turpeinen
- grid.410705.70000 0004 0628 207XDepartment of Cardiology, Kuopio University Hospital, University of Eastern Finad, Kuopio, Finland
| | - Torbjørn Omland
- grid.5510.10000 0004 1936 8921Division of Medicine, Department of Cardiology, Akershus University Hospital, Lørenskog, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tobias M. Merz
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, University Hospital of Bern, University of Bern, Bern, Switzerland ,grid.414055.10000 0000 9027 2851Present Address: Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Jan Wiegand
- grid.5734.50000 0001 0726 5157Department of Intensive Care Medicine, University Hospital of Bern, University of Bern, Bern, Switzerland ,grid.415941.c0000 0004 0509 4333Present Address: Intensive Care Unit, Lindenhofspital, Bern, Switzerland
| | - Juha Grönlund
- grid.1374.10000 0001 2097 1371Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland
| | - Melissa Rahi
- grid.1374.10000 0001 2097 1371Neurocenter, Department of Neurosurgery, Turku University Hospital, University of Turku, Turku, Finland
| | - Mika Valtonen
- grid.1374.10000 0001 2097 1371Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, Anaesthesiology, Intensive Care, Emergency Care and Pain Medicine, University of Turku, Turku, Finland
| | - Timo Koivisto
- grid.9668.10000 0001 0726 2490Department of Neurosurgery, Kuopio University Hospital, University of Eastern Finland, Kuopio, Finland
| | - Helge Røsjø
- grid.5510.10000 0004 1936 8921Division for Research and Innovation, Akershus University Hospital, Lørenskog, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stepani Bendel
- grid.9668.10000 0001 0726 2490Department of Intensive Care Medicine, Kuopio University Hospital, University of Eastern Finland, PO BOX 100, 70029 KYS Kuopio, Finland
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13
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Endovascular Treatment of Patients with Ruptured Intracranial Aneurysms: A Series of 468 Patients Treated Over a 14-Year Period. J Belg Soc Radiol 2022; 106:11. [PMID: 35434517 PMCID: PMC8973758 DOI: 10.5334/jbsr.2550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 01/31/2022] [Indexed: 11/29/2022] Open
Abstract
Purpose: Non-traumatic subarachnoid hemorrhage (SAH) is an emergency usually caused by the rupture of a saccular intracranial aneurysm. Endovascular treatment (EVT) is now considered as the first therapeutic option. The aim of our study is to evaluate, over a 14-year period in a single center, the result of EVT of ruptured intracranial aneurysms. Methods: From the retrospective analysis of our prospectively maintained database, we collected data of 457 patients successfully treated by endovascular approach for a SAH. Descriptive statistics and percentages were used to report clinical and anatomical outcomes, procedure-related complications, post procedural events, morbidity and mortality. Results: EVT was unsuccessful in eleven patients but effective in 457 patients with two patients who experienced a rebleeding (0.4%). In 6.3% of cases, a second EVT was necessary. The final aneurysm occlusion was complete (65.7%), with a neck remnant (28.2%) or incomplete (6.1%). Procedure-related complications occurred in 5.9% of patients and were associated with five clinical worsening and one death. Overall EVT-related morbidity and mortality were thus of 1.3% and 0.4% respectively. At discharge, 71% of patients had a good recovery (mRS 0–2), 11.2% had a poor outcome (mRS 3–5), and 17.8% died. Conclusion: This study seems to prove that high-volume centers with experienced interventional neuroradiologists carry low rates of technical failure and complication from EVT of ruptured intracranial aneurysm.
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14
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Calviere L, Gathier CS, Rafiq M, Koopman I, Rousseau V, Raposo N, Albucher JF, Viguier A, Geeraerts T, Cognard C, Rinkel GJE, Vergouwen MDI, Olivot JM. Rebleeding After Aneurysmal Subarachnoid Hemorrhage in Two Centers Using Different Blood Pressure Management Strategies. Front Neurol 2022; 13:836268. [PMID: 35280266 PMCID: PMC8905619 DOI: 10.3389/fneur.2022.836268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background High systolic blood pressure (SBP) after aneurysmal subarachnoid hemorrhage (aSAH) has been associated with an increased risk of rebleeding. It remains unclear if an SBP lowering strategy before aneurysm treatment decreases this risk without increasing the risk of a delayed cerebral ischemia (DCI). Therefore, we compared the rates of in-hospital rebleeding and DCI among patients with aSAH admitted in two tertiary care centers with different SBP management strategies. Methods Retrospective cohort study. Consecutive patients from Utrecht and Toulouse admitted within 24 h after the aSAH onset were enrolled. In Toulouse, the target SBP before aneurysm treatment was ≤140 mm Hg, while, in Utrecht, an increased SBP was only treated in extreme situations. We compared SBP levels, the incidence of rebleeding within 24 h after admission, and DCI during hospitalization. Results We enrolled 373 patients in Utrecht and 149 in Toulouse. The mean SBP on admission was similar but lower in Toulouse 4 h after admission (127.3 ± 17.4 vs. 138. ± 25.7 mmHg; p < 0.0001). After a median delay of 3.7 h (IQR, 2.3-7.4) from admission, 4 patients (3%) in Toulouse vs. 29 (8%) in Utrecht experienced a rebleeding. After adjustment for Prognosis on Admission of Aneurysmal Subarachnoid Hemorrhage (PAASH) score, aneurysm size, age, and delay from ictus to admission, the HR was 0.66 (95% CI: 0.23-1.92). Incidence of DCI was 18% in Toulouse and 25% in Utrecht (adjusted OR, 0.68; 95% CI: 0.41-1.11). Conclusion Our results suggest that an intensive SBP lowering strategy between admission and aneurysm treatment does not decrease the risk of rebleeding and does not increase the risk of DCI compared to a more conservative strategy.
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Affiliation(s)
- Lionel Calviere
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Celine S. Gathier
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | | | - Inez Koopman
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Vanessa Rousseau
- MeDatAS-CIC, CIC1436, Centre Hospitalier Universitaire, Toulouse, France
| | - Nicolas Raposo
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Jean François Albucher
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Alain Viguier
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
| | - Thomas Geeraerts
- Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France.,Department of Anesthesiology and Critical Care, CHU Toulouse, Toulouse, France
| | | | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Jean-Marc Olivot
- Stroke Unit, CHU Toulouse, Toulouse, France.,Toulouse Neuroimaging Center, INSERM, UPS, Toulouse, France
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15
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Adams HP. Clinical Scales to Assess Patients With Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00021-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Bershad EM, Suarez JI. Aneurysmal Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00029-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Rehman S, Chandra RV, Lai LT, Asadi H, Dubey A, Froelich J, Thani N, Nichols L, Blizzard L, Smith K, Thrift AG, Stirling C, Callisaya M, Breslin M, Reeves MJ, Gall S. Adherence to evidence-based processes of care reduces one-year mortality after aneurysmal subarachnoid hemorrhage (aSAH). J Neurol Sci 2021; 428:117613. [PMID: 34418669 DOI: 10.1016/j.jns.2021.117613] [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: 05/03/2021] [Revised: 08/01/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND There is limited research on the provision of evidence-based care and its association with outcomes after aneurysmal subarachnoid hemorrhage (aSAH). AIMS We examined adherence to evidence-based care after aSAH and associations with survival and discharge destination. Also, factors associated with evidence-based care including age, sex, Charlson comorbidity index, severity scores, and delayed cerebral ischemia and infarction were examined for association with survival and discharge destination. METHODS In a retrospective cohort (2010-2016) of all aSAH cases across two comprehensive cerebrovascular centres, we extracted 3 indicators of evidence-based aSAH care from medical records: (1) antihypertensives prior to aneurysm treatment, (2) nimodipine, and (3) aneurysm treatment (coiling/clipping). We defined 'optimal care' as receiving all eligible processes of care. Survival at 1 year was obtained by data linkage. We estimated (1) proportion of patients and characteristics associated with receiving processes of care, (2) associations between processes of care with 1-year mortality using cox-proportional hazard model and discharge destination with log binomial regression adjusting for age, sex, severity of aSAH, delayed cerebral ischemia and/or cerebral infarction and comorbidities. Sensitivity analyses explored effect modification of the association between processes of care and outcome by management type (active versus comfort measures). RESULTS Among 549 patients (69% women), 59% were managed according to the guidelines. Individual indicators were associated with lower 1-year mortality but not discharge destination. Optimal care reduced mortality at 1 year in univariable (HR 0.24 95% CI 0.17-0.35) and multivariable analyses (HR 0.51 95% CI 0.34-0.77) independent of age, sex, severity, comorbidities, and hospital network. CONCLUSION Adherence to processes of care reduced 1-year mortality after aSAH. Many patients with aSAH do not receive evidence-based care and this must be addressed to improve outcomes.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Leon T Lai
- Neurosurgery, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Hamed Asadi
- NeuroInterventional Radiology, Monash Health, Clayton, Victoria, Australia
| | - Arvind Dubey
- Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Jens Froelich
- NeuroInterventional Radiology, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Nova Thani
- Neurosurgery, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Linda Nichols
- School of Nursing, University of Tasmania, Hobart, Tasmania, Australia
| | - Leigh Blizzard
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Karen Smith
- Centre for Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
| | - Amanda G Thrift
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at, Monash Health, Monash University, Clayton, Victoria, Australia
| | | | - Michele Callisaya
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Peninsula Clinical School, Monash University, Clayton, Victoria, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Mathew J Reeves
- Department of Epidemiology, Michigan State University, East Lansing, MI, USA
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia; Monash University, Clayton, Victoria, Australia.
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18
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Chen XY, Chen Y, Lin N, Chen JY, Ding CY, Kang DZ, Wang DL, Fang WH. A Nomogram for Predicting the Need of Postoperative Tracheostomy in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2021; 12:711468. [PMID: 34512523 PMCID: PMC8429806 DOI: 10.3389/fneur.2021.711468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/27/2021] [Indexed: 01/22/2023] Open
Abstract
Objective: Early identification for the need of tracheostomy (TT) in aneurysmal subarachnoid hemorrhage (aSAH) patients remains one of the main challenges in clinical practice. Our study aimed to establish and validate a nomogram model for predicting postoperative TT in aSAH patients. Methods: Patients with aSAH receiving active treatment (interventional embolization or clipping) in our institution between June 2012 and December 2018 were retrospectively included. The effects of patients' baseline information, aneurysm features, and surgical factors on the occurrence of postoperative TT were investigated for establishing a nomogram in the training cohort with 393 patients. External validation for the nomogram was performed in the validation cohort with 242 patients. Results: After multivariate analysis, higher age, high neutrophil-to-lymphocyte ratio (NLR), high World Federation of Neurological Surgeons Scale (WFNS), and high Barrow Neurological Institute (BNI) grade were left in the final logistic regression model. The predictive power of the model was excellent in both training cohort and validation cohort [area under the curve (AUC): 0.924, 95% confidence interval [CI]: 0.893–0.948; AUC: 0.881, 95% CI: 0.833–0.919]. A nomogram consisting of these factors had a C-index of 0.924 (95% CI: 0.869–0.979) in the training cohort and was validated in the validation cohort (C-index: 0.881, 95% CI: 0.812–0.950). The calibration curves suggested good match between prediction and observation in both training and validation cohorts. Conclusion: Our study established and validated a nomogram model for predicting postoperative TT in aSAH patients.
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Affiliation(s)
- Xiao-Yong Chen
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yue Chen
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Ni Lin
- The School of Medical Technology and Engineering, Fujian Medical University, Fuzhou, China
| | - Jin-Yuan Chen
- Department of Ophthalmology, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Chen-Yu Ding
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Fujian Key Laboratory of Precision Medicine for Cancer, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China.,Key Laboratory of Fujian Higher Education Institutions, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Deng-Liang Wang
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wen-Hua Fang
- Department of Neurosurgery, Neurosurgical Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
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19
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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: 59] [Impact Index Per Article: 19.7] [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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20
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Abstract
Anesthesia for intracranial vascular procedures is complex because it requires a balance of several competing interests and potentially can result in significant morbidity and mortality. Frequently, periods of ischemia, where perfusion must be maintained, are combined with situations that are high risk for hemorrhage. This review discusses the basic surgical approach to several common pathologies (intracranial aneurysms, arteriovenous malformations, and moyamoya disease) along with the goals for anesthetic management and specific high-yield recommendations.
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Affiliation(s)
- William L Gross
- Department of Anesthesiology, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53132, USA.
| | - Raphael H Sacho
- Department of Neurosurgery, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53132, USA
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21
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Etminan N, Macdonald RL. Neurovascular disease, diagnosis, and therapy: Subarachnoid hemorrhage and cerebral vasospasm. HANDBOOK OF CLINICAL NEUROLOGY 2021; 176:135-169. [PMID: 33272393 DOI: 10.1016/b978-0-444-64034-5.00009-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The worldwide incidence of spontaneous subarachnoid hemorrhage is about 6.1 per 100,000 cases per year (Etminan et al., 2019). Eighty-five percent of cases are due to intracranial aneurysms. The mean age of those affected is 55 years, and two-thirds of the patients are female. The prognosis is related mainly to the neurologic condition after the subarachnoid hemorrhage and the age of the patient. Overall, 15% of patients die before reaching the hospital, another 20% die within 30 days, and overall 75% are dead or remain disabled. Case fatality has declined by 17% over the last 3 decades. Despite the improvement in outcome probably due to improved diagnosis, early aneurysm repair, administration of nimodipine, and advanced intensive care support, the outcome is not very good. Even among survivors, 75% have permanent cognitive deficits, mood disorders, fatigue, inability to return to work, and executive dysfunction and are often unable to return to their premorbid level of functioning. The key diagnostic test is computed tomography, and the treatments that are most strongly supported by scientific evidence are to undertake aneurysm repair in a timely fashion by endovascular coiling rather than neurosurgical clipping when feasible and to administer enteral nimodipine. The most common complications are aneurysm rebleeding, hydrocephalus, delayed cerebral ischemia, and medical complications (fever, anemia, and hyperglycemia). Management also probably is optimized by neurologic intensive care units and multidisciplinary teams.
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Affiliation(s)
- Nima Etminan
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - R Loch Macdonald
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, United States.
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22
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Gerner ST, Hülsbrink R, Reichl J, Mrochen A, Eyüpoglu IY, Brandner S, Dörfler A, Engelhorn T, Kuramatsu JB, Schwab S, Huttner HB. Parenchymatous hematoma in patients with atraumatic subarachnoid hemorrhage: Characteristics, treatment, and clinical outcomes. Int J Stroke 2020; 16:648-659. [PMID: 33210962 DOI: 10.1177/1747493020971878] [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: 11/15/2022]
Abstract
BACKGROUND Data regarding the influence of concomitant parenchymatous hematoma (PH) on long-term outcomes in patients with atraumatic subarachnoid hemorrhage (SAH) are scarce. Further, it is not established if these patients benefit from surgical intervention. AIM The aim of this study was to determine the influence of concomitant PH in SAH patients on functional long-term outcome, and whether these patients may benefit from surgical hematoma evacuation. METHODS Over a 5-year period, all consecutive patients with SAH treated at the Departments of Neurology, Neuroradiology, and Neurosurgery, at the University Hospital Erlangen (Germany) were recorded. In addition to the clinical and imaging characteristics of SAH, we documented the presence, location, and volume of PH as well as treatment parameters. Outcome assessment at 12 months included functional outcome (modified Rankin scale (mRS), favorable = 0-2), health-related quality of life, and long-term complications. For outcome analysis, a propensity score matching (ratio 1:1, caliper 0.1) was performed to compare SAH patients with and without PH. Sub-analyses were performed regarding PH treatment (surgical evacuation vs. conservative). RESULTS A total of 494 patients with atraumatic SAH were available. Eighty-five (17.2%) had PH on initial imaging. SAH patients with PH had a worse clinical condition on admission and had a greater extent of subarachnoid/intraventricular hemorrhage. Median PH volume was 11.0 ml (5.4-31.8) with largest volumes observed in patients with ruptured middle cerebral artery (MCA)-aneurysm (31.7 ml (16.3-43.2)). After propensity-score matching (PSM), patients with PH had worse functional outcomes at 12 months (modified Rankin scale (mRS) 0-2: PH 31.8% vs. ØPH57.7% p < 0.001), and a lower rate of self-reported health compared to patients without PH (EQ-5D VAS: PH 50(30-70) vs. ØPH 80(65-95); p < 0.001). In PH patients, surgical evacuation was associated with a higher rate of favorable outcome at 12 months compared to those treated conservatively (surgery 14/28 (50.0%) vs. conservative 14/57 (24.6%); adjusted odds-ratio (OR; 95%CI): 1.34 (1.08-1.66); p = 0.001), irrespective of aneurysm location. Subgroup-analysis revealed positive associations of surgical hematoma evacuation with outcome in subgroups with larger PH volumes (>10 ml; OR (95%CI): 1.39 (1.09-1.79)), frontal PH location (OR 1.59 (1.14-2.23)), and early surgery (within 600 min after onset; OR 1.42 (1.03-1.94)). CONCLUSIONS Concomitant PH occurs frequently in patients with SAH and is associated with functional impairment after 1 year. Surgical evacuation of PH may improve outcomes in these patients, irrespective of aneurysm-location.
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Affiliation(s)
- Stefan T Gerner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Robert Hülsbrink
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jonathan Reichl
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Anne Mrochen
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Ilker Y Eyüpoglu
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Sebastian Brandner
- Department of Neurosurgery, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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23
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Gracia Arnillas MP, Alvarez-Lerma F, Masclans JR, Roquer J, Soriano C, Manzano D, Zapatero A, Diaz Y, Duran X, Castellví A, Cuadrado E, Ois A. Impact of adrenomedullin levels on clinical risk stratification and outcome in subarachnoid haemorrhage. Eur J Clin Invest 2020; 50:e13318. [PMID: 32535893 DOI: 10.1111/eci.13318] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 06/03/2020] [Accepted: 06/04/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE To use classification tree analysis to identify risk factors for nonsurvival in a neurological patients with subarachnoid haemorrhage (SAH) and to propose a clinical model for predicting of mortality. METHODS Prospective study of SAH admitted to a Critical Care Department and Stroke Unit over a 2-year period. Middle region of pro-ADM plasma levels (MR-proADM) was measured in EDTA plasma within the first 24 hours of hospital admission using the automatic immunofluorescence test. A regression tree was made to identify prognostic models for the development of mortality at 90 days. RESULTS Ninety patients were included. The mean MR-proADM plasma value in the samples analysed was 0.78 ± 0.41 nmol/L. MR-proADM plasma levels were significantly associated with mortality at 90 days (1.05 ± 0.51 nmol/L vs 0.64 ± 0.25 nmol/L; P < .001). Regression tree analysis provided an algorithm based on the combined use of clinical variables and one biomarker allowing accurate mortality discrimination of three distinct subgroups with high risk of 90-day mortality ranged from 75% to 100% (AUC 0.9; 95% CI 0.83-0.98). CONCLUSIONS The study established a model (APACHE II, MR-proADM and Hunt&Hess) to predict fatal outcomes in patients with SAH. The proposed decision-making algorithm may help identify patients with a high risk of mortality.
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Affiliation(s)
- Maria Pilar Gracia Arnillas
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Francisco Alvarez-Lerma
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Jose-Ramón Masclans
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Jaume Roquer
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
| | - Carolina Soriano
- IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Demian Manzano
- Neurosurgery Department, Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - Ans Zapatero
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Yolanda Diaz
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain.,IMIM (Medical Research Mar Institute), IMIM- Hospital del Mar, Barcelona, Spain
| | - Xavi Duran
- AMIB Methodological and Biostatistical Advice IMIM, IMIM- Hospital del Mar, Barcelona, Spain
| | - Andrea Castellví
- Critical Care Department, IMIM- Hospital del Mar, Barcelona, Spain
| | - Elisa Cuadrado
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
| | - Angel Ois
- Department of Neurology, Neurovascular Research Group, IMIM- Hospital del Mar, Barcelona, Spain
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24
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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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25
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Flores-Sanchez JD, Saal G, Zumaeta J, Palacios F, Rodriguez R, Molina C. Comparación del tratamiento quirúrgico y endovascular de aneurismas del segmento comunicante posterior. Surg Neurol Int 2020. [DOI: 10.25259/sni_255_2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Antecedentes:
Los aneurismas del segmento comunicante posterior representan aproximadamente 25% de todos los aneurismas intracraneales, y el 50% de los aneurismas de la arteria carótida interna. El objetivo fue evaluar la eficacia del tratamiento quirúrgico y endovascular en el manejo de aneurismas de esta localización.
Métodos:
Estudio comparativo retrospectivo. Se revisó las historias clínicas de pacientes con aneurisma del segmento comunicante posterior que ingresaron al departamento de Neurocirugía del Hospital Nacional Guillermo Almenara durante el periodo 2010–2017. Se comparó estancia hospitalaria, complicaciones, mortalidad y estado funcional a los 12 meses, en relación al tratamiento recibido, microquirúrgico o endovascular.
Resultados:
Se evaluaron 256 pacientes, 111 (43.36%) recibieron tratamiento quirúrgico, y 145 (56.64%) endovascular. En el caso de aneurismas rotos, el estado de independencia funcional fue alcanzado por 68 (66.7%) y 69 (70.4%) pacientes que recibieron tratamiento quirúrgico y endovascular, respectivamente (OR: 0.84, IC 95%: 0.46–1.53; P = 0.505). Se presentaron complicaciones neurológicas en 37 (36,3%) y 34 (34.7%) pacientes sometidos a tratamiento microquirúrgico y endovascular, respectivamente (OR: 1.07, IC 95%: 0.60–1.91; P = 0.912). La estancia hospitalaria promedio fue 19.55 ± 13.85 y 14.06 ± 14.97 días, para pacientes con tratamiento quirúrgico y endovascular, respectivamente (P < 0.008). La mortalidad fue 11.8% y 11.2%, con ligera predominancia en el grupo tratado quirúrgicamente (OR: 1.05, IC 95%: 0.44–2.52; P = 0.904).
Conclusión:
No existe diferencia significativa respecto al resultado funcional a los 12 meses, complicaciones y mortalidad entre ambos tipos de tratamiento en el caso de aneurismas rotos. Los pacientes sometidos a terapia endovascular tuvieron de forma significativa menor estancia hospitalaria.
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Ariyada K, Ohida T, Shibahashi K, Hoda H, Hanakawa K, Murao M. Long-term Functional Outcomes for World Federation of Neurosurgical Societies Grade V Aneurysmal Subarachnoid Hemorrhage after Active Treatment. Neurol Med Chir (Tokyo) 2020; 60:390-396. [PMID: 32669527 PMCID: PMC7431870 DOI: 10.2176/nmc.oa.2020-0052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
This study investigated the long-term outcomes of patients with World Federation of Neurosurgical Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (SAH) who underwent early aneurysm repair. We evaluated consecutive patients with WFNS grade V aneurysmal SAH from April 2010 to March 2015 who underwent aneurysm repair within 72 h after onset. We assessed the functional outcomes at discharge and 3 years after onset using the modified Rankin Scale (mRS). The primary outcome was defined as a favorable functional outcome (mRS ≤2). We identified 145 patients with grade V SAH during the study period. Of these, 44 patients (19 males and 25 females; median age, 64 years; range, 24–79 years) met the inclusion criteria. For aneurysm repair, surgical clipping and coiling were performed in 40 (90.9%) and 4 (9.1%) patients, respectively. Although no patient had a favorable functional outcome at discharge, 11 (25.0%) patients had a favorable functional outcome at the end of follow-up. The number of patients with a favorable outcome significantly increased during the first year (P = 0.012) and during the follow-up period (P <0.001). Patients who underwent active rehabilitation had significant improvement. Our study showed that one-fourth of the patients who underwent early aneurysm repair with WFNS grade V SAH achieved a mRS score of ≤2 over a 3-year period. It might be important to consider age and rehabilitation for better clinical outcomes. Larger studies are required to adequately assess the long-term functional outcomes and other multi-faceted prognoses.
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Affiliation(s)
- Kenichi Ariyada
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Tomoya Ohida
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Keita Shibahashi
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Hidenori Hoda
- Tertiary Emergency Medical Center, Tokyo Metropolitan Bokutoh Hospital
| | - Kazuo Hanakawa
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
| | - Masahiko Murao
- Department of Neurosurgery, Tokyo Metropolitan Bokutoh Hospital
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Ojha M, Finnis ME, Heckelmann M, Raith EP, Moodie S, Chapman MJ, Reddi B, Maiden MJ. Outcomes following grade V subarachnoid haemorrhage: A single-centre retrospective study. Anaesth Intensive Care 2020; 48:289-296. [PMID: 32659113 DOI: 10.1177/0310057x20927033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SummaryGrade V subarachnoid haemorrhage is associated with high mortality and morbidity, yet there are few contemporary reports on the treatment provided and outcomes of these patients. In this single-centre retrospective cohort study, we primarily sought to determine the 12-month mortality of patients admitted to the Royal Adelaide Hospital intensive care unit between 2006 and 2016 with grade V subarachnoid haemorrhage. Secondary objectives were to describe treatments provided, patient destination following hospital discharge, organ donation and hospital financial costs. Over the 11-year study period, there were 139 patients admitted with grade V subarachnoid haemorrhage. The annual number of admissions did not change over time. The median age was 56 (interquartile range 48-70) years, 88 (63%) were female and 77 (55%) had a procedure to isolate an aneurysm. There were 77 (55%) patients who died in the intensive care unit, 87 (63%) died in hospital and 89 (64%) had died at 12 months. Of the 52 patients who survived to hospital discharge, 33 (63%) were transferred to a rehabilitation facility, 17 (33%) to another acute care hospital and two (4%) were discharged. Of the 87 patients who died in hospital, 45 (52%) donated organs. The total hospital cost of managing this cohort was A$8.3 million, with a median cost of A$41,824 (interquartile range A$9,933-A$97,332) per patient. Grade V subarachnoid haemorrhage has a high mortality rate, with one-third of patients alive after one year.
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Affiliation(s)
- Minny Ojha
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael Heckelmann
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Eamon P Raith
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stewart Moodie
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Donate Life SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care Unit, Barwon Health, Geelong, Australia
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28
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Wartenberg KE, Hwang DY, Haeusler KG, Muehlschlegel S, Sakowitz OW, Madžar D, Hamer HM, Rabinstein AA, Greer DM, Hemphill JC, Meixensberger J, Varelas PN. Gap Analysis Regarding Prognostication in Neurocritical Care: A Joint Statement from the German Neurocritical Care Society and the Neurocritical Care Society. Neurocrit Care 2020; 31:231-244. [PMID: 31368059 PMCID: PMC6757096 DOI: 10.1007/s12028-019-00769-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background/Objective Prognostication is a routine part of the delivery of neurocritical care for most patients with acute neurocritical illnesses. Numerous prognostic models exist for many different conditions. However, there are concerns about significant gaps in knowledge regarding optimal methods of prognostication. Methods As part of the Arbeitstagung NeuroIntensivMedizin meeting in February 2018 in Würzburg, Germany, a joint session on prognostication was held between the German NeuroIntensive Care Society and the Neurocritical Care Society. The purpose of this session was to provide presentations and open discussion regarding existing prognostic models for eight common neurocritical care conditions (aneurysmal subarachnoid hemorrhage, intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, traumatic spinal cord injury, status epilepticus, Guillain–Barré Syndrome, and global cerebral ischemia from cardiac arrest). The goal was to develop a qualitative gap analysis regarding prognostication that could help inform a future framework for clinical studies and guidelines. Results Prognostic models exist for all of the conditions presented. However, there are significant gaps in prognostication in each condition. Furthermore, several themes emerged that crossed across several or all diseases presented. Specifically, the self-fulfilling prophecy, lack of accounting for medical comorbidities, and absence of integration of in-hospital care parameters were identified as major gaps in most prognostic models. Conclusions Prognostication in neurocritical care is important, and current prognostic models are limited. This gap analysis provides a summary assessment of issues that could be addressed in future studies and evidence-based guidelines in order to improve the process of prognostication.
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Affiliation(s)
- Katja E Wartenberg
- Neurocritical Care and Stroke Unit, Department of Neurology, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany.
| | - David Y Hwang
- Department of Neurology, Yale School of Medicine, P.O. Box 208018, New Haven, CT, 06520-8018, USA
| | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg, Josef-Schneider-Strasse 11, 97080, Würzburg, Germany
| | - Susanne Muehlschlegel
- Department of Neurology, Anesthesiology and Surgery, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, USA
| | - Oliver W Sakowitz
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Posilipostrasse 4, 71640, Ludwigsburg, Germany
| | - Dominik Madžar
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Department of Neurology, University of Erlangen, Schwabachanlage 6, 91054, Erlangen, Germany
| | | | - David M Greer
- Department of Neurology, Boston University Medical Center, 72 East Concord St, Boston, MA, 02118, USA
| | - J Claude Hemphill
- Department of Neurology, University of California San Francisco, 1001 Potrero Ave, San Francisco, CA, 94110, USA
| | - Juergen Meixensberger
- Department of Neurosurgery, University of Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Panayiotis N Varelas
- Department of Neurology and Neurosurgery, Henry Ford Hospital, 2799 W. Grand Blvd Neurosurgery - K-11, Detroit, MI, 48202, USA
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29
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Maher M, Schweizer TA, Macdonald RL. Treatment of Spontaneous Subarachnoid Hemorrhage: Guidelines and Gaps. Stroke 2020; 51:1326-1332. [PMID: 31964292 DOI: 10.1161/strokeaha.119.025997] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Tom A Schweizer
- Neuroscience Research Program, Li Ka Shing Knowledge Institute, Institute of Medical Science (T.A.S.)
| | - R Loch Macdonald
- Division of Neurosurgery, Departments of Surgery and Physiology, Keenan Research Centre for Biomedical Science, St Michael's Hospital, University of Toronto, Ontario, Canada (R.L.M.)
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Lin CM, Wang AYC, Chen CC, Wu YM, Liu CH, Tsay PK, Chang CH. Warning headache correlates survival rate in aneurysmal subarachnoid hemorrhage. Biomed J 2019; 42:352-357. [PMID: 31783996 PMCID: PMC6889243 DOI: 10.1016/j.bj.2019.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 12/31/2018] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
Background Severe headaches, projectile vomiting, focal neurological deficits and early onset seizure are regarded as early warning symptoms of subarachnoid hemorrhage (SAH). Earlier diagnosis based on such warning symptoms theoretically would improve the clinical prognosis. However, it is still not clear whether the prognosis is correlated with early warning symptoms. Here, we reviewed warning symptoms and other predictive factors in the emergency room (ER) setting and examined their correlations with mortality. Methods Ninety saccular aneurysmal SAH cases were reviewed in a single medical center between January 2011 and December 2013. We examined differences in mortality rate related to warning symptoms, SAH scales, onset-to-ER time, hydrocephalus, and aneurysm size, location, and complexity. Logistic regression analyses were performed to determine the correlations of warning symptoms and other predictive factors with mortality. Receiver operating characteristic (ROC) curve analysis was used to calculate the area the under curve (AUC) of SAH mortality prediction tools. Results Warning headache, projectile vomiting, the Hunt and Hess scale, Fisher scale, World Federation of Neurological Surgeons (WFNS) grading scale, and modified WFNS (m-WFNS) scale, body mass index, aneurysm complexity and hydrocephalus were significantly different between the survivors and the decedents. The warning headache and WFNS grade were strongly correlated with mortality. The rate of prognostic prediction improved from 90.4% to 94.6% when warning headache was additionally evaluated. Conclusions With growing healthcare costs and recognition of the value of palliative care, early identification via warning headache and a detailed clinical history review is necessary for cases of aSAH.
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Affiliation(s)
- Chuan-Min Lin
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yi-Ming Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Hung Liu
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei-Kwei Tsay
- Department of Public Health and Center of Biostatistics, Chang Gung University, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chien-Hung Chang
- Department of Neurology, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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31
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Yu Z, Zheng J, Liu X, Wen D, Guo R, Li M, You C, Li H, Ma L, Yang M. Prognostic factors for adult patients with hemorrhagic moyamoya disease in the acute stage. Clin Neurol Neurosurg 2019; 184:105409. [PMID: 31302379 DOI: 10.1016/j.clineuro.2019.105409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Hemorrhagic moyamoya disease (MMD) is one common subtype in adult patients. However, the study about outcome of hemorrhagic MMD patients in the acute stage is still lacking. This study is aimed to explore the short-term prognostic factors for adult patients with hemorrhagic MMD in the acute stage. PATIENTS AND METHODS Adult hemorrhagic MMD patients in the acute stage awere retrospectively analyzed. Both clinical and imaging data were collected. Unfavorable functional outcome at discharge was considered when modified Rankin Scale score ≥3. Multivariate logistic regression was used to investigate the prognostic factors in patients with hemorrhagic MMD in the acute stage. RESULTS A total of 107 patients were included in this study. Among these patients, 17 died and 59 had unfavorable functional outcome at 9.6 ± 7.8 days. In multivariate logistic regression, admission blood glucose (odds ratio (OR) = 1.457, 95% confidence interval (CI) 1.156-1.836, P = 0.001), midline shift >5 mm (OR = 24.268, 95%CI 4.324-136.191, P < 0.001), and subarachnoid hemorrhage (OR = 13.067, 95%CI 2.020-84.512, P = 0.007) were independently associated with death at discharge. Moreover, admission Glasgow Coma Scale (GCS) score (OR = 0.420, 95%CI 0.296-0.598, P < 0.001), midline shift >5 mm (OR = 6.685, 95%CI 1.226-36.455, P = 0.028), and intraparenchymal hemorrhage (OR = 4.790, 95%CI 1.184-19.381, P = 0.028) were independently associated with unfavorable functional outcome at discharge. CONCLUSION This study shows that admission blood glucose, midline shift >5 mm, and subarachnoid hemorrhage are independent predictors of short-term mortality in hemorrhagic MMD in the acute stage. In addition, admission GCS score, midline shift >5 mm, and intraparenchymal hemorrhage are independent predictors of short-term unfavorable functional outcome in hemorrhagic MMD in the acute stage.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Xuyang Liu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui Guo
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Mou Li
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
| | - Mu Yang
- Radiation Oncology Key Laboratory of Sichuan Province, Sichuan Cancer Hospital & Institute, Sichuan Cancer Center, School of Medicine, University of Electronic Science and Technology of China, Chengdu, China.
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Paľa A, Schick J, Klein M, Mayer B, Schmitz B, Wirtz CR, König R, Kapapa T. The influence of nimodipine and vasopressors on outcome in patients with delayed cerebral ischemia after spontaneous subarachnoid hemorrhage. J Neurosurg 2019; 132:1096-1104. [PMID: 30849754 DOI: 10.3171/2018.11.jns182891] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 11/27/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a major factor contributing to the inferior outcome of patients with spontaneous subarachnoid hemorrhage (SAH). Nimodipine and induced hypertension using vasopressors are an integral part of standard therapy. Consequences of the opposite effect of nimodipine and vasopressors on blood pressure on patient outcome remain unclear. The authors report the detailed general characteristics and influence of nimodipine and vasopressors on outcome in patients with SAH. METHODS The authors performed a 2-center, retrospective, clinical database analysis of 732 SAH patients treated between 2008 and 2016. Demographic and clinical data such as age, sex, World Federation of Neurosurgical Societies (WFNS) grade, BMI, Fisher grade, history of arterial hypertension and smoking, aneurysm location, C-reactive protein (CRP) level, and detailed dosage of vasopressors and nimodipine during the treatment period were evaluated. Clinical outcome was analyzed using the modified Rankin Scale (mRS) 6 months after treatment. Univariate and multivariate regression analyses were performed. Additionally, mean arterial pressure (MAP), age, nimodipine, and vasopressor dose cutoff were evaluated with regard to outcome. The level of significance was set at ≤ 0.05. RESULTS Follow-up was assessed for 397 patients, 260 (65.5%) of whom achieved a good outcome (defined as an mRS score of 0-3). Univariate and multivariate analyses confirmed that nimodipine (p = 0.049), age (p = 0.049), and CRP level (p = 0.002) are independent predictors of good outcome. WFNS grade, Fisher score, hypertension, initial hydrocephalus, and total vasopressor dose showed significant influence on outcome in univariate analysis, and patient sex, smoking status, BMI, and MAP showed no significant association with outcome. A subgroup analysis of patients with milder initial SAH (WFNS grades I-III) revealed that initial hydrocephalus (p = 0.003) and CRP levels (p = 0.001) had significant influence on further outcome. When evaluating only patients with WFNS grade IV or V, age, CRP level (p = 0.011), vasopressor dose (p = 0.030), and nimodipine dose (p = 0.049) were independent predictors of patient outcome. Patients with an MAP < 93 mm Hg, a nimodipine cutoff dose of 241.8 mg, and cutoff total vasopressor dose of 523 mg had better outcomes. CONCLUSIONS According to the authors' results, higher doses of vasopressors can safely provide a situation in which the maximum dose of nimodipine could be administered. Cutoff values of the total vasopressor dose were more than 3 times higher in patients with severe SAH (WFNS grade IV or V), while the nimodipine cutoff remained similar in patients with mild and severe SAH. Hence, it seems encouraging that a maximum nimodipine dosage can be achieved despite the need for a higher vasopressor dose in patients with SAH.
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Affiliation(s)
- Andrej Paľa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | | | - Moritz Klein
- 2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Benjamin Mayer
- 3Institute of Epidemiology and Medical Biometry, University of Ulm; and
| | - Bernd Schmitz
- 4Section of Neuroradiology, University of Ulm, Günzburg, Germany
| | - Christian Rainer Wirtz
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Ralph König
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
| | - Thomas Kapapa
- 1Department of Neurosurgery, University of Ulm.,2Department of Neurosurgery, Bezirkskrankenhaus Günzburg, University of Ulm, Günzburg
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Tack RW, Vergouwen MDI, van der Schaaf I, van der Zwan A, Rinkel GJ, Lindgren AE. Preventable poor outcome from rebleeding by emergency aneurysm occlusion in patients with aneurysmal subarachnoid haemorrhage. Eur Stroke J 2019; 4:240-246. [PMID: 31984231 DOI: 10.1177/2396987319828160] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 01/11/2019] [Indexed: 11/17/2022] Open
Abstract
Introduction The risk of rebleeding is highest during the initial hours after aneurysmal subarachnoid haemorrhage (aSAH), but the aneurysm is not occluded in all patients immediately after admission.Our aim was to determine the proportion of aSAH patients with poor outcome from early in-hospital rebleeding that can be prevented by three emergency aneurysm occlusion regimes. Patients and methods From our prospectively collected database, we retrieved from all aSAH patients admitted between July 2007 and July 2017 data on clinical condition on admission, time of rebleeding, and outcome at 3 months. Results Of 1391 consecutive aSAH patients, 923 were in good clinical condition and had an aneurysm on initial imaging that was amenable for treatment. Poor outcome from rebleeding could have been avoided by treatment <4 h during day time shifts in 4 (0.4% [95% CI: 0.2-1.1]) patients (number needed to treat [NNT]: 250), by treatment and <1 h during daytime shift in 9 (1.0% [95% CI: 0.5-1.8]; NNT: 111), and treatment <1 h at 24/7 basis in 16 (1.7% [95% CI: 1.1-2.8%]; NNT: 59). Discussion Emergency aneurysm occlusion can reduce poor outcome due to rebleeding, but only in small proportions of patients. Whether such strategies lead to improved outcome for all patients and are cost-effective is highly uncertain. Conclusion We do not recommend instalment of a treatment regimen where occlusion of ruptured aneurysm is performed within 1 h on a 24/7 basis.
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Affiliation(s)
- Reinier Wp Tack
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Mervyn DI Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Albert van der Zwan
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel Je Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti E Lindgren
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.,Neurosurgery of NeuroCenter, Kuopio University Hospital, Kuopio, Finland
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34
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Zijlmans JL, Coert BA, van den Berg R, Sprengers ME, Majoie CB, Vandertop WP, Verbaan D. Unfavorable Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage WFNS Grade I. World Neurosurg 2018; 118:e217-e222. [DOI: 10.1016/j.wneu.2018.06.157] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Revised: 06/18/2018] [Accepted: 06/19/2018] [Indexed: 10/28/2022]
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35
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Cho WS, Kim JE, Park SQ, Ko JK, Kim DW, Park JC, Yeon JY, Chung SY, Chung J, Joo SP, Hwang G, Kim DY, Chang WH, Choi KS, Lee SH, Sheen SH, Kang HS, Kim BM, Bae HJ, Oh CW, Park HS. Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage. J Korean Neurosurg Soc 2018. [PMID: 29526058 PMCID: PMC5853198 DOI: 10.3340/jkns.2017.0404.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.
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Affiliation(s)
- Won-Sang Cho
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jeong Eun Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sukh Que Park
- Department of Neurosurgery, Soonchunhyang University School of Medicine, Seoul, Korea
| | - Jun Kyeung Ko
- Departments of Neurosurgery, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Dae-Won Kim
- Department of Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University School of Medicine, Iksan, Korea
| | - Jung Cheol Park
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Je Young Yeon
- Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seung Young Chung
- Department of Neurosurgery, Eulji University Hospital, Daejeon, Korea
| | - Joonho Chung
- Department of Neurosurgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sung-Pil Joo
- Department of Neurosurgery, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Gyojun Hwang
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Deog Young Kim
- Department of Rehabilitation Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won Hyuk Chang
- Department of Physical and Rehabilitation Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Kyu-Sun Choi
- Department of Neurosurgery, Hanyang University Medical Center, Seoul, Korea
| | - Sung Ho Lee
- Department of Neurosurgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hun Sheen
- Department of Neurosurgery, Bundang Jesaeng General Hospital, Seongnam, Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Chang Wan Oh
- Department of Neurosurgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Hyeon Seon Park
- Department of Neurosurgery, Inha University School of Medicine, Incheon, Korea
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Zumofen DW, Roethlisberger M, Achermann R, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Ferrari A, Corniola MV, Schoeni D, Goldberg J, Valsecchi D, Robert T, Maduri R, Seule M, Burkhardt JK, Marbacher S, Bijlenga P, Blackham KA, Bucher HC, Mariani L, Guzman R. Factors associated with clinical and radiological status on admission in patients with aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2018; 41:1059-1069. [PMID: 29428981 DOI: 10.1007/s10143-018-0952-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/25/2018] [Accepted: 01/28/2018] [Indexed: 01/12/2023]
Abstract
Grading scales yield objective measure of the severity of aneurysmal subarachnoid hemorrhage and serve as to guide treatment decisions and for prognostication. The purpose of this cohort study was to determine what factors govern a patient's disease-specific admission scores in a representative Central European cohort. The Swiss Study of Subarachnoid Hemorrhage includes anonymized data from all tertiary referral centers serving subarachnoid hemorrhage patients in Switzerland. The 2009-2014 dataset was used to evaluate the impact of patient and aneurysm characteristics on the patients' status at admission using descriptive and multivariate regression analysis. The primary/co-primary endpoints were the GCS and the WFNS grade. The secondary endpoints were the Fisher grade, the presence of a thick cisternal or ventricular clot, the presence of a new focal neurological deficit or cranial nerve palsy, and the patient's intubation status. In our cohort of 1787 consecutive patients, increasing patient age by 10 years and low pre-ictal functional status (mRS 3-5) were inversely correlated with "high" GCS score (GCS ≥ 13) (OR 0.91, 95% CI 0.84-0.97 and OR 0.67, 95% CI 0.31-1.46), "low" WFNS grade (grade VI-V) (OR 1.21, 95% CI 1.04-1.20 and OR 1.47, 95% CI 0.66-3.27), and high Fisher grade (grade III-IV) (OR 1.08, 95% CI 1.00-1.17 and OR 1.54, 95% CI 0.55-4.32). Other independent predictors for the patients' clinical and radiological condition at admission were the ruptured aneurysms' location and its size. In sum, chronological age and pre-ictal functional status, as well as the ruptured aneurysm's location and size, determine the patients' clinical and radiological condition at admission to the tertiary referral hospital.
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Affiliation(s)
- Daniel W Zumofen
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland. .,Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland.
| | - Michel Roethlisberger
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Rita Achermann
- Department Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031, Basel, Switzerland
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital Göttingen, Robert Koch Strasse 40, 37075, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Christian Fung
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100, CH-8091, Zurich, Switzerland
| | - Andrea Ferrari
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St.Gallen, Switzerland
| | - Marco V Corniola
- Department of Neurosurgery, Hopitaux Universitaires Genève, Rue Gabrielle-Perret-Gentil 4, CH-1205, Geneva, Switzerland
| | - Daniel Schoeni
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, Inselspital, University of Bern, Freiburgstrasse 16, CH-3010, Bern, Switzerland
| | - Daniele Valsecchi
- Department of Neurosurgery, Ospedale Civico di Lugano, Via Tesserete 46, CH-6900, Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Ospedale Civico di Lugano, Via Tesserete 46, CH-6900, Lugano, Switzerland
| | - Rodolfo Maduri
- Service of Neurosurgery, Department of Clinical Neurosciences, University Hospital of Lausanne, Rue du Bugnon 46, CH-1011, Lausanne, Switzerland
| | - Martin Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, Rorschacher Strasse 95, CH-9007, St.Gallen, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA, 94143-0112, USA
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Tellstrasse 25, CH-5001, Aarau, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, Hopitaux Universitaires Genève, Rue Gabrielle-Perret-Gentil 4, CH-1205, Geneva, Switzerland
| | - Kristine A Blackham
- Department of Radiology, Division of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Petersgraben 4, CH-4031, Basel, Switzerland
| | - Heiner C Bucher
- Department Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12, CH-4031, Basel, Switzerland
| | - Luigi Mariani
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital Basel, Spitalstrasse 21, CH-4031, Basel, Switzerland
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Saito G, Zapata R, Rivera R, Zambrano H, Rojas D, Acevedo H, Ravera F, Mosquera J, Vásquez JE, Mura J. Long-chain omega-3 fatty acids in aneurysmal subarachnoid hemorrhage: A randomized pilot trial of pharmaconutrition. Surg Neurol Int 2017; 8:304. [PMID: 29404191 PMCID: PMC5764917 DOI: 10.4103/sni.sni_266_17] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/18/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Functional recovery after aneurysmal subarachnoid hemorrhage (SAH) remains a significant problem. We tested a novel therapeutic approach with long-chain omega-3 polyunsaturated fatty acids (n-3 PUFAs) to assess the safety and feasibility of an effectiveness trial. METHODS We conducted a multicentre, parallel, randomized, open-label pilot trial. Patients admitted within 72 hours after SAH with modified Fisher scale scores of 3 or 4 who were selected for scheduled aneurysm clipping were allocated to receive either n-3 PUFA treatment (parenteral perioperative: 5 days; oral: 8 weeks) plus usual care or usual care alone. Exploratory outcome measures included major postoperative intracranial bleeding complications (PIBCs), cerebral infarction caused by delayed cerebral ischemia, shunt-dependent hydrocephalus, and consent rate. The computed tomography evaluator was blinded to the group assignment. RESULTS Forty-one patients were randomized, but one patient had to be excluded after allocation. Twenty patients remained for intention to treat analysis in each trial arm. No PIBs (95% confidence interval [CI]: 0.00 to 0.16) or other unexpected harm were observed in the intervention group (IG). No patient suspended the intervention due to side effects. There was a trend towards improvements in all benefit-related outcomes in the IG. The overall consent rate was 0.91 (95% CI: 0.78 to 0.96), and there was no consent withdrawal. CONCLUSIONS Although the balance between the benefit and harm of the intervention appears highly favourable, further testing on SAH patients is required. We recommend proceeding with amendments in a dose-finding trial to determine the optimal duration of parenteral treatment.
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Affiliation(s)
- Geisi Saito
- Department of Anaesthesiology, Instituto de Neurocirugía Asenjo, Providencia, Santiago, Chile
| | - Rodrigo Zapata
- Neurosurgery Service, Hospital Regional Libertador Bernardo O’Higgins, Rancagua, Santiago, Chile
| | - Rodrigo Rivera
- Chief of Neuroradiology Service, Instituto de Neurocirugía Asenjo, Providencia, Santiago, Chile
| | - Héctor Zambrano
- Neurology Service, Hospital Regional Libertador Bernardo O’Higgins, Rancagua, Santiago, Chile
| | - David Rojas
- Department of Neurological Sciences, Universidad de Chile, Santiago, Chile
- Neurosurgery Service, Instituto de Neurocirugía Asenjo, Providencia, Santiago, Chile
| | - Hernán Acevedo
- Neurosurgery Service, Instituto de Neurocirugía Asenjo, Providencia, Santiago, Chile
| | - Franco Ravera
- Chief of Neurosurgery Service, Hospital Regional Libertador Bernardo O’Higgins, Rancagua, and Department of Neurosurgery, Universidad de Chile, Santiago, Chile
| | - John Mosquera
- Neurosurgery Service, Hospital Regional Libertador Bernardo O’Higgins, Rancagua, Santiago, Chile
| | - Juan E. Vásquez
- Neurosurgery Service, Hospital Regional Libertador Bernardo O’Higgins, Rancagua, Santiago, Chile
| | - Jorge Mura
- Department of Neurological Sciences, Universidad de Chile, Santiago, Chile
- Chief of Cerebrovascular and Skull Base Surgery, Instituto de Neurocirugía Asenjo, Providencia, Santiago, Chile
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Mark DG, Kene MV, Vinson DR, Ballard DW. Outcomes Following Possible Undiagnosed Aneurysmal Subarachnoid Hemorrhage: A Contemporary Analysis. Acad Emerg Med 2017; 24:1451-1463. [PMID: 28675519 DOI: 10.1111/acem.13252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 06/18/2017] [Accepted: 06/23/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES Existing literature suggests that patients with aneurysmal subarachnoid hemorrhage (aSAH) and "sentinel" aSAH symptoms prompting healthcare evaluations prior to aSAH diagnosis are at increased risk of unfavorable neurologic outcomes and death. Accordingly, these encounters have been presumed to be unrecognized opportunities to diagnose aSAH and the worse outcomes representative of the added risks of delayed diagnoses. We sought to reinvestigate this paradigm among a contemporary cohort of patients with aSAH. METHODS A case-control cohort was retrospectively assembled among patients diagnosed with aSAH between January 1, 2007 and June 30, 2013 within an integrated healthcare delivery system. Patients with a discrete clinical evaluation for headache or neck pain within 14 days prior to formal aSAH diagnosis were identified as cases, and the remaining patients served as controls. Modified Rankin Scale scores at 90 days and 1 year were determined by structured chart review. Multivariable logistic regression controlling for age, sex, ethnicity, presence of intracerebral or intraventricular hemorrhage at diagnosis, and aneurysm size was used to compare adjusted outcomes. Sensitivity analyses were performed using varying definitions of favorable neurologic outcomes, a restricted control subgroup of patients with normal mental status at hospital admission, inclusion of additional cases that were diagnosed outside of the integrated health system, and exclusion of patients without evidence of subarachnoid blood on initial noncontrast cranial computed tomography (CT) at the diagnostic encounter (i.e. "CT-negative" SAH). RESULTS A total of 450 patients with aSAH were identified, 46 (10%) of whom had clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis (cases). In contrast to prior reports, no differences were observed among cases compared to control patients in adjusted odds of death or unfavorable neurologic status at 90 days (0.35, 95% confidence interval [CI] = 0.11-1.15; 0.59, 95% CI = 0.22-1.60, respectively) or at 1 year (0.58, 95% CI = 0.19-1.73; 0.52, 95% CI = 0.18-1.51, respectively). Likewise, neither restricting the analysis to a control subgroup of patients with normal mental status at hospital admission, varying the dichotomous definition of unfavorable neurologic outcome, inclusion of cases diagnosed outside the integrated health system, or exclusion of patients with CT-negative SAH resulted in significant adjusted outcome differences. CONCLUSION In a contemporary cohort of patients with aSAH, we observed no statistically significant increase in the adjusted odds of death or unfavorable neurologic outcomes among patients with clinical evaluations for possible aSAH-related symptoms in the 14 days preceding formal diagnosis of aSAH. While these findings cannot exclude a smaller risk difference than previously reported, they can help refine decision analyses and testing threshold determinations for patients with possible aSAH.
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Affiliation(s)
- Dustin G. Mark
- Departments of Emergency Medicine and Critical Care; Kaiser Permanente; Oakland CA
- Division of Research; Kaiser Permanente; Oakland CA
| | - Mamata V. Kene
- Department of Emergency Medicine; Kaiser Permanente; San Leandro CA
| | - David R. Vinson
- Department of Emergency Medicine; Kaiser Permanente; Roseville CA
- Division of Research; Kaiser Permanente; Oakland CA
| | - Dustin W. Ballard
- Department of Emergency Medicine; Kaiser Permanente; San Rafael CA
- Division of Research; Kaiser Permanente; Oakland CA
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Hsieh PC, Wu YM, Wang AYC, Chen CC, Chang CH, Chin SC, Wu TWE, Wu CT, Lee ST. The venous delay phenomenon in computed tomography angiography: a novel imaging outcome predictor for poor cerebral perfusion after severe aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 129:876-882. [PMID: 29171807 DOI: 10.3171/2017.5.jns17794] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Diverse treatment results are observed in patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Significant initial perfusion compromise is thought to predict a worse treatment outcome, but this has scant support in the literature. In this cohort study, the authors correlate the treatment outcomes with a novel poor-outcome imaging predictor representing impaired cerebral perfusion on initial CT angiography (CTA). METHODS The authors reviewed the treatment results of 148 patients with poor-grade aSAH treated at a single tertiary referral center between 2007 and 2016. Patients with the "venous delay" phenomenon on initial CTA were identified. The outcome assessments used the modified Rankin Scale (mRS) at the 3rd month after aSAH. Factors that may have had an impact on outcome were retrospectively analyzed. RESULTS Compared with previously identified outcome predictors, the venous delay phenomenon on initial CTA was found to have the strongest correlation with posttreatment outcomes on both univariable (p < 0.0001) and multivariable analysis (OR 4.480, 95% CI 1.565-12.826; p = 0.0052). Older age and a higher Hunt and Hess grade at presentation were other factors that were associated with poor outcome, defined as an mRS score of 3 to 6. CONCLUSIONS The venous delay phenomenon on initial CTA can serve as an imaging predictor for worse functional outcome and may aid in decision making when treating patients with poor-grade aSAH.
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Affiliation(s)
| | | | | | | | - Chien-Hung Chang
- 3Neurology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Kweishan, Taoyuan, Taiwan
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Fragata I, Alves M, Papoila AL, Nunes AP, Ferreira P, Canto-Moreira N, Canhão P. Early Prediction of Delayed Ischemia and Functional Outcome in Acute Subarachnoid Hemorrhage: Role of Diffusion Tensor Imaging. Stroke 2017; 48:2091-2097. [PMID: 28667021 DOI: 10.1161/strokeaha.117.016811] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/09/2017] [Accepted: 05/26/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Diffusion tensor imaging (DTI) parameters are markers of cerebral lesion in some diseases. In patients with acute subarachnoid hemorrhage (SAH), we investigated whether DTI parameters measured at <72 hours might be associated with delayed cerebral ischemia (DCI) and with poor functional outcome at 3 months (modified Rankin Scale score ≥3). METHODS DTI was performed in a prospective cohort of 60 patients with nontraumatic SAH at <72 hours. Association of fractional anisotropy and apparent diffusion coefficient values at <72 hours with the occurrence of DCI and outcome at 3 months was evaluated with logistic regression models, adjusting for known predictors of prognosis. RESULTS At <72 hours after SAH, fractional anisotropy values at the cerebellum were associated with DCI occurrence (78% less odds of DCI for each 0.1 increase in fractional anisotropy; P=0.019). Early apparent diffusion coefficient values were not associated with DCI. After adjusting for confounding variables, an increase of 10 U in apparent diffusion coefficient at the frontal centrum semiovale corresponded to 15% increased odds of poor outcome (P=0.061). CONCLUSIONS DTI parameters at <72 hours post-SAH are independently associated with the occurrence of DCI and functional outcome. These preliminary results suggest the role of DTI parameters as surrogate markers of prognosis in nontraumatic SAH.
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Affiliation(s)
- Isabel Fragata
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.).
| | - Marta Alves
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
| | - Ana Luísa Papoila
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
| | - Ana Paiva Nunes
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
| | - Patrícia Ferreira
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
| | - Nuno Canto-Moreira
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
| | - Patrícia Canhão
- From the Neuroradiology Department, Centro Hospitalar Lisboa Central, Portugal (I.F.); Centro de Investigação (M.A., A.L.P.), and Unidade Cérebro-Vascular (A.P.N., P.F.), Centro Hospitalar Lisboa Central, Portugal; NOVA Medical School/Faculdade de Ciências Médicas, Lisbon, Portugal (A.L.P.); Radiology Department, Uppsala Universitet Medicinska Fakulteten, Sweden (N.C.M.); and Neurology Department, Centro Hospitalar Lisboa Norte, Portugal and Universidade de Lisboa, Faculdade de Medicina, Instituto de Medicina Molecular, Portugal (P.C.)
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Abstract
Subarachnoid haemorrhage is an uncommon and severe subtype of stroke affecting patients at a mean age of 55 years, leading to loss of many years of productive life. The rupture of an intracranial aneurysm is the underlining cause in 85% of cases. Survival from aneurysmal subarachnoid haemorrhage has increased by 17% in the past few decades, probably because of better diagnosis, early aneurysm repair, prescription of nimodipine, and advanced intensive care support. Nevertheless, survivors commonly have cognitive impairments, which in turn affect patients' daily functionality, working capacity, and quality of life. Additionally, those deficits are frequently accompanied by mood disorders, fatigue, and sleep disturbances. Management requires specialised neurological intensive care units and multidisciplinary clinical expertise, which is better provided in high-volume centres. Many clinical trials have been done, but only two interventions are shown to improve outcome. Challenges that remain relate to prevention of subarachnoid haemorrhage by improved screening and development of lower-risk methods to repair or stabilise aneurysms that have not yet ruptured. Multicentre cooperative efforts might increase the knowledge that can be gained from clinical trials, which is often limited by small studies with differing criteria and endpoints that are done in single centres. Outcome assessments that incorporate finer assessment of neurocognitive function and validated surrogate imaging or biomarkers for outcome could also help to advance the specialty.
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Affiliation(s)
- R Loch Macdonald
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada.
| | - Tom A Schweizer
- Division of Neurosurgery, St Michael's Hospital, Toronto, ON, Canada; Labatt Family Centre of Excellence in Brain Injury and Trauma Research, St Michael's Hospital, Toronto, ON, Canada; Department of Surgery, University of Toronto, Toronto, ON, Canada
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Brawanski N, Platz J, Bruder M, Senft C, Berkefeld J, Seifert V, Konczalla J. Outcome and prognostic factors after delayed second subarachnoid haemorrhage. Acta Neurochir (Wien) 2017; 159:307-315. [PMID: 27943077 DOI: 10.1007/s00701-016-3045-4] [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] [Received: 07/29/2016] [Accepted: 11/28/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Data of patients suffering from delayed second subarachnoid haemorrhage (SAH) after aneurysm treatment are still missing. Patients become clearly older than before. Thus, the risk suffering from a second delayed SAH rises. The aim of this study was to analyse clinical outcome and prognostic factors in patients after delayed second SAH. METHOD From 1999 to 2013, 18 of 1,493 patients (1.2%) suffered from a second SAH. Clinical and radiological characteristics were entered into a prospective conducted database. Outcome was assessed according to modified Rankin Scale 6 months after second SAH. P < 0.05 was considered statistically significant. RESULTS Eighteen patients were admitted to our department with a second SAH. The second SAH occurred at a mean interval of 144 months after surgical treatment and 78 months after endovascular treatment (P < 0.05), with an overall mean interval of 125 months. The earliest event of second SAH was after 35 months. In 11 (61%) patients, a de novo aneurysm was detected; in one patient (6%), no cause of second SAH was detected. In six (33%) cases, re-rupture of the formerly secured aneurysm was found. Half of the rebleedings occurred from a basilar aneurysm, 33% from an aneurysm of anterior communicating artery and in one patient from a median cerebral artery aneurysm. At second SAH, 8 of 18 patients presented WFNS grade I-III at time of admission (44%). Overall, favourable outcome was achieved in seven patients (39%). Four patients died (22%), one of them before treatment. Favourable outcome seems to be associated with younger age. In our patients, 39% achieved a favourable outcome after second SAH. CONCLUSIONS A delayed second SAH is a rare entity. After delayed second SAH, age seems to be a prognostic factor for patients' outcome and patients seem to have a worse prognosis. Nonetheless, up to 40% of patients can achieve a favourable outcome.
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Affiliation(s)
- Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany.
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital Frankfurt, Schleusenweg 2-16, 60528, Frankfurt, Germany
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43
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Subjective hearing impairment after subarachnoid haemorrhage: Prevalence and risk factors. J Neurol Sci 2017; 372:184-186. [DOI: 10.1016/j.jns.2016.11.062] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Revised: 10/28/2016] [Accepted: 11/23/2016] [Indexed: 11/18/2022]
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Etminan N, Macdonald R. Management of aneurysmal subarachnoid hemorrhage. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:195-228. [DOI: 10.1016/b978-0-444-63600-3.00012-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rhie SH, Choi JW, Jeon SJ, Kang SD, Joo MC, Kim MS. Characteristics of Patients With Aneurysmal Subarachnoid Hemorrhage and Risk Factors Related to Dysphagia. Ann Rehabil Med 2016; 40:1024-1032. [PMID: 28119832 PMCID: PMC5256314 DOI: 10.5535/arm.2016.40.6.1024] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 09/13/2016] [Indexed: 11/12/2022] Open
Abstract
Objective To investigate the characteristics and risk factors of dysphagia with the Videofluoroscopic Dysphagia Scale (VDS) using a videofluoroscopic swallowing study (VFSS) in patients with ruptured aneurysmal subarachnoid hemorrhage (aSAH). Methods Data of 64 patients presenting with first-ever ruptured aSAH were analyzed. Characteristics of dysphagia were evaluated using VFSS and all subjects were divided into a high (>47) and low risk group (≤47) by the VDS score. Clinical and functional parameters were assessed by medical records including demographics, hypertension and diabetes mellitus (DM), the Glasgow Coma Scale (GCS), the Hunt and Hess scale, endotracheal intubation, acute management modalities, as well as Korean version of the Mini-Mental Status Examination (K-MMSE) and Korean version of Modified Barthel Index (K-MBI). Radiologic factors identified the amount of hemorrhage, ventricular rupture, and aneurysmal location. Results About a half of the subjects showed oral phase abnormalities and the oral transit time was delayed in 46.8% of the patients. The pharyngeal transit time was also prolonged in 39.0% of the subjects and the proportion of penetration and aspiration observed was 46.8%. The parameters-GCS score (p=0.048), hemorrhagic volume (p=0.028), presence of intraventricular hemorrhage (p=0.038), and K-MMSE (p=0.007)-were predisposing factors for dysphagia in patients with aSAH. Conclusion Abnormalities in the oral phase were more prominent in patients with aSAH than in those with other types of stroke. The risk factors associated with dysphagia persisting over 6 months after stroke onset were the initial GCS, hemorrhage volume, presence of intraventricular hemorrhage, and cognitive status as measured by the K-MMSE.
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Affiliation(s)
- Seung Hwa Rhie
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine & Hospital, Iksan, Korea
| | - Ji Won Choi
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine & Hospital, Iksan, Korea
| | - Se Jeong Jeon
- Department of Radiology, Wonkwang University School of Medicine, Iksan, Korea
| | - Sung Don Kang
- Department of Neurosurgery, Wonkwang University School of Medicine, Iksan, Korea
| | - Min Cheol Joo
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine & Hospital, Iksan, Korea
| | - Min Su Kim
- Department of Rehabilitation Medicine, Wonkwang University School of Medicine & Hospital, Iksan, Korea
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Sano H, Inamasu J, Kato Y, Satoh A, Murayama Y. Modified world federation of neurosurgical societies subarachnoid hemorrhage grading system. Surg Neurol Int 2016; 7:S502-3. [PMID: 27583174 PMCID: PMC4982344 DOI: 10.4103/2152-7806.187491] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/18/2016] [Indexed: 11/21/2022] Open
Affiliation(s)
- Hirotoshi Sano
- WFNS Cerebrovascular Diseases and Therapy Committee, Tokyo, Toyoake, Japan; Japan Neurosurgical Society, Tokyo, Toyoake, Japan
| | - Joji Inamasu
- Department of Neurosurgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Yoko Kato
- WFNS Cerebrovascular Diseases and Therapy Committee, Tokyo, Toyoake, Japan; Japan Neurosurgical Society, Tokyo, Toyoake, Japan; Department of Neurosurgery, Fujita Health University School of Medicine, Toyoake, Japan
| | - Akira Satoh
- WFNS Cerebrovascular Diseases and Therapy Committee, Tokyo, Toyoake, Japan; Japan Neurosurgical Society, Tokyo, Toyoake, Japan
| | - Yuichi Murayama
- WFNS Cerebrovascular Diseases and Therapy Committee, Tokyo, Toyoake, Japan; Japan Neurosurgical Society, Tokyo, Toyoake, Japan
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Inamasu J, Nakae S, Ohmi T, Kogame H, Kawazoe Y, Kumai T, Tanaka R, Wakako A, Kuwahara K, Ganaha T, Hirose Y. The outcomes of early aneurysm repair in World Federation of Neurosurgical Societies grade V subarachnoid haemorrhage patients with emphasis on those presenting with a Glasgow Coma Scale score of 3. J Clin Neurosci 2016; 33:142-147. [PMID: 27450281 DOI: 10.1016/j.jocn.2016.03.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2015] [Revised: 02/27/2016] [Accepted: 03/08/2016] [Indexed: 12/26/2022]
Abstract
Grade V subarachnoid haemorrhage (SAH) patients may be dichotomised into those with temporary deterioration and those with irreversible injury, and only the former have a chance of favourable outcomes by aneurysm obliteration. One method of differentiating the two conditions is to wait and observe potential recovery for 12-48hours. However, early rebleeding and non-convulsive seizures may occur during this period. In our institution, grade V SAH patients receive immediate treatment (general anaesthesia induction and aneurysm obliteration within 24hours of onset) to minimise those risks. We focused on therapeutic outcomes in SAH patients presenting with a Glasgow Coma Scale score of 3 (GCS-3). Between January 2006 and December 2013, 82 GCS-3 SAH patients were admitted, among whom 51 (62%) underwent immediate aneurysm obliteration. Their outcomes 90days after onset were evaluated with the Glasgow Outcome Scale, with either good recovery or moderate disability regarded as favourable outcomes. Multivariate logistic regression analysis was performed to identify variables correlated with favourable outcomes. Among the 51 patients, 11 (22%) had favourable 90-day outcomes. Age (odds ratio [OR], 0.838; 95% confidence interval [CI], 0.733-0.959; p=0.010) and intact pupillary light reflex (OR, 21.939; 95% CI, 1.465-328.576; p=0.025) were correlated with favourable outcomes. By contrast, neither intact respiratory pattern nor isocoric pupils was correlated with favourable outcomes. The current results indicate that vigorous intervention may be worth attempting in young GCS-3 SAH patients with intact pupillary light reflex. It remains unclear, however, whether the seemingly high frequency of favourable outcomes was truly due to reduction in early rebleeding or seizures.
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Affiliation(s)
- Joji Inamasu
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan.
| | - Shunsuke Nakae
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Tatsuo Ohmi
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Hirotaka Kogame
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Yushi Kawazoe
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Tadashi Kumai
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Riki Tanaka
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Akira Wakako
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Kiyonori Kuwahara
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Tsukasa Ganaha
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
| | - Yuichi Hirose
- Department of Neurosurgery, Fujita Health University Hospital, 1-98 Dengakugakubo, Toyoake 470-1192, Japan
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Vergouwen MDI, Jong-Tjien-Fa AV, Algra A, Rinkel GJE. Time trends in causes of death after aneurysmal subarachnoid hemorrhage: A hospital-based study. Neurology 2015; 86:59-63. [PMID: 26590269 DOI: 10.1212/wnl.0000000000002239] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Accepted: 08/31/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare causes of in-hospital death after aneurysmal subarachnoid hemorrhage (aSAH) in 2 time periods within the same institution. METHODS From a prospectively collected institutional database, we retrieved data on 844 consecutive patients with aSAH admitted ≤3 days after ictus in 1999-2002 and 2009-2012. We assessed case-fatality <90 days and causes of in-hospital death and used Poisson regression analyses to calculate adjusted risk ratios (aRR) with corresponding 95% confidence intervals (CI) for change in individual causes of death, with the first time period as the reference group. RESULTS Ninety-day case-fatality declined from 150/381 patients (39%) in 1999-2002 to 140/463 (30%) in 2009-2012 (aRR 0.74 [95% CI 0.62-0.88]). Compared with 1999-2002, the aRR for specific cause of in-hospital death in 2009-2012 was 1.06 (95% CI 0.72-1.56) for death from the initial bleeding, 0.47 (95% CI 0.31-0.71) for death from rebleeding, and 0.91 (95% CI 0.50-1.65) for death from delayed cerebral ischemia. Over time, the proportion of patients with in-hospital rebleeding declined from 90/381 (24%) to 78/463 (17%) (aRR 0.68 [95% CI 0.52-0.90]), median day of rebleeding from day 5 (IQR 1-10) to day 0 (IQR 0-1), and median day of aneurysm treatment from day 4 (IQR 2-13) to day 1 (IQR 1-2). CONCLUSIONS An important contributor to the reduction in in-hospital death is the reduction in death from rebleeding, which probably results from earlier aneurysm treatment. Our results stress the need for early occlusion of the aneurysm and the need for other strategies that improve outcome by reducing the risk of rebleeding.
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Affiliation(s)
- Mervyn D I Vergouwen
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., A.V.J.-T.-F., A.A., G.J.E.R.), and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands.
| | - Amy V Jong-Tjien-Fa
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., A.V.J.-T.-F., A.A., G.J.E.R.), and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Ale Algra
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., A.V.J.-T.-F., A.A., G.J.E.R.), and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
| | - Gabriel J E Rinkel
- From the Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus (M.D.I.V., A.V.J.-T.-F., A.A., G.J.E.R.), and Julius Center for Health Sciences and Primary Care (A.A.), University Medical Center Utrecht, the Netherlands
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de Oliveira Manoel AL, Jaja BN, Germans MR, Yan H, Qian W, Kouzmina E, Marotta TR, Turkel-Parrella D, Schweizer TA, Macdonald RL. The VASOGRADE: A Simple Grading Scale for Prediction of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. Stroke 2015; 46:1826-31. [PMID: 25977276 DOI: 10.1161/strokeaha.115.008728] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 04/07/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients are classically at risk of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage. We validated a grading scale-the VASOGRADE-for prediction of DCI. METHODS We used data of 3 phase II randomized clinical trials and a single hospital series to assess the relationship between the VASOGRADE and DCI. The VASOGRADE derived from previously published risk charts and consists of 3 categories: VASOGRADE-Green (modified Fisher scale 1 or 2 and World Federation of Neurosurgical Societies scale [WFNS] 1 or 2); VASOGRADE-Yellow (modified Fisher 3 or 4 and WFNS 1-3); and VASOGRADE-Red (WFNS 4 or 5, irrespective of modified Fisher grade). The relation between the VASOGRADE and DCI was assessed by logistic regression models. The predictive accuracy of the VASOGRADE was assessed by receiver operating characteristics curve and calibration plots. RESULTS In a cohort of 746 patients, the VASOGRADE significantly predicted DCI (P<0.001). The VASOGRADE-Yellow had a tendency for increased risk for DCI (odds ratio [OR], 1.31; 95% CI, 0.77-2.23) when compared with VASOGRADE-Green; those with VASOGRADE-Red had a 3-fold higher risk of DCI (OR, 3.19; 95% CI, 2.07-4.50). Studies were not a significant confounding factor between the VASOGRADE and DCI. The VASOGRADE had an adequate discrimination for prediction of DCI (area under the receiver operating characteristics curve=0.63) and good calibration. CONCLUSIONS The VASOGRADE results validated previously published risk charts in a large and diverse sample of subarachnoid hemorrhage patients, which allows DCI risk stratification on presentation after subarachnoid hemorrhage. It could help to select patients at high risk of DCI, as well as standardize treatment protocols and research studies.
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Affiliation(s)
- Airton Leonardo de Oliveira Manoel
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.).
| | - Blessing N Jaja
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Menno R Germans
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Han Yan
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Winnie Qian
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Ekaterina Kouzmina
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Tom R Marotta
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - David Turkel-Parrella
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - Tom A Schweizer
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
| | - R Loch Macdonald
- From the Division of Neurosurgery, St Michael's Hospital, Labatt Family Centre of Excellence in Brain Injury and Trauma Research, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St Michael's Hospital and Department of Surgery, University of Toronto, Toronto, Ontario, Canada (B.N.J., T.R.M., D.T.P., T.A.S., R.L.M.); Neuroscience Research Program, Keenan Research Centre of the Li Ka Shing Knowledge Institute of St. Michael's Hospital (A.L.d.O.M, H.Y., W.Q., E.K.); and Department of Neurosurgery, St Elisabeth Ziekenhuis, Tilburg, Netherlands (M.R.G.)
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