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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of fludrocortisone on the outcomes of subarachnoid hemorrhage patients: A retrospective analysis. J Stroke Cerebrovasc Dis 2024; 33:107643. [PMID: 38387759 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107643] [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: 08/31/2023] [Revised: 02/05/2024] [Accepted: 02/18/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. The primary outcome was adjusted for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were neurologic and cardiopulmonary dysfunction events. RESULTS Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64 % were female, and 41 (53 %) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95 % CI, 0.14-0.80; P = 0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22 % vs. 39 %, P = 0.16); cardiac dysfunction (0 % vs. 11 %; P = 0.10); and pulmonary edema (15 % vs. 8 %; P = 0.59). CONCLUSIONS The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Haripottawekul A, Persad-Paisley EM, Paracha S, Haque D, Shamshad A, Furie KL, Reznik ME, Mahta A. Comparison of the Effects of Blood Pressure Parameters on Rebleeding and Outcomes in Unsecured Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 185:e582-e590. [PMID: 38382760 DOI: 10.1016/j.wneu.2024.02.078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/12/2024] [Accepted: 02/13/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) has been linked to preprocedural rebleeding risk and poor outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study seeks to compare the effects of SBP and mean arterial pressure (MAP) on rebleeding and functional outcomes in aSAH patients. METHODS We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic center in 2016-2023. Binary regression analysis was used to determine the association between BP parameters and outcomes including rebleeding and poor outcome defined as modified Rankin Scale 4-6 at 3 months postdischarge. RESULTS The cohort included 324 patients (mean age 57 years [standard deviation 13.4], 61% female). Symptomatic rebleeding occurred in 34 patients (11%). Higher BP measurements were recorded in patients with rebleeding and poor outcome, however, only MAP met statistical significance for rebleeding (odds ratio {OR} 1.02 for 1 mmHg increase in MAP, 95% confidence interval {CI}: 1.001-1.03, P = 0.043; OR 1 per 1 mmHg increase in SBP, 95% CI 0.99-1.01; P = 0.06)) and for poor outcome (OR 1.01 for 1 mmHg increase in MAP, 95% CI: 1.002-1.025, P = 0.025; OR 1 for 1 mmHg increase in SBP, 95% CI: 0.99-1.02, P = 0.23) independent of other predictors. CONCLUSIONS MAP may appear to be slightly better correlated with rebleeding and poor outcomes in unsecured aSAH compared to SBP. Larger prospective studies are needed to identify and mitigate risk factors for rebleeding and poor outcome in aSAH patients.
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Affiliation(s)
- Ariyaporn Haripottawekul
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Elijah M Persad-Paisley
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Saba Paracha
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Deena Haque
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alizeh Shamshad
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Karen L Furie
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Michael E Reznik
- Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ali Mahta
- Department of Neurology, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Section of Medical Education, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.
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Wu R, Hu F, Liu C, Liang J. The value of modified hijdra score in patients with aneurysmal subarachnoid hemorrhage. Heliyon 2024; 10:e28550. [PMID: 38590907 PMCID: PMC10999927 DOI: 10.1016/j.heliyon.2024.e28550] [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: 07/18/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background The complexity of calculating the Hijdra score has limited its clinical utility in aiding the diagnosis of intracranial ruptured aneurysms. Objective This study aimed to investigate the diagnostic and prognostic value of the modified Hijdra score in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Data from 773 patients with subarachnoid hemorrhage (SAH) at the First People's Hospital of Lianyungang from January 2018 to June 2023 were collected. The modified Hijdra scoring method simplifies the assessment of 10 basal cisterns/cisterns fissures compared to the traditional scoring method, with scores ranging from 0 to 2 for each item, and assigns specific scores to hematomas larger than 1 cm in diameter. The data were divided into an evaluation group (n = 641) and a validation group (n = 132). In the evaluation group, the performance of the modified Hijdra score in diagnosis and prognostic prediction was assessed, while the diagnostic and prognostic prediction efficacy of the modified Hijdra method was evaluated using the validation set. Results Among the 641 patients in the evaluation group,550 (85. 8%) were diagnosed with intracranial aneurysms. The modified Hijdra score demonstrated an AUC of 0. 894 for aneurysm diagnosis, with a sensitivity of 98. 0% and a specificity of 64. 8% at a CutOff value of 7. 5. The diagnostic efficacy of the modified Hijdra score was 93. 24%, with a negative predictive value of 84. 29%, while the Hijdra score 's diagnostic efficacy was 85. 34% with a negative predictive value of 48. 89%. The AUC of the modified Hijdra score for predicting prognosis in patients with aneurysms was 0. 824, with a sensitivity of 84. 3% and a specificity of 70. 0% at a CutOff value of 16. 5. In CTA-negative patients, the modified Hijdra score was significantly higher (P < 0. 0001) in patients with aneurysmal SAH (15. 48 ± 3. 93) compared to those with non-aneurysmal SAH (6. 31 ± 4. 52). Conclusions The modified Hijdra score is a valuable tool for assisting in the diagnosis and prognosis prediction of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Rongjie Wu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Fangbo Hu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Changtao Liu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
| | - Jingshan Liang
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
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Yang C, Jiang Z, Gao X, Yang H, Su J, Weng R, Ni W, Gu Y. Taurine ameliorates sensorimotor function by inhibiting apoptosis and activating A2 astrocytes in mice after subarachnoid hemorrhage. Amino Acids 2024; 56:31. [PMID: 38616233 PMCID: PMC11016520 DOI: 10.1007/s00726-024-03387-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/27/2024] [Indexed: 04/16/2024]
Abstract
Subarachnoid hemorrhage (SAH) is a form of severe acute stroke with very high mortality and disability rates. Early brain injury (EBI) and delayed cerebral ischemia (DCI) contribute to the poor prognosis of patients with SAH. Currently, some researchers have started to focus on changes in amino acid metabolism that occur in brain tissues after SAH. Taurine is a sulfur-containing amino acid that is semi-essential in animals, and it plays important roles in various processes, such as neurodevelopment, osmotic pressure regulation, and membrane stabilization. In acute stroke, such as cerebral hemorrhage, taurine plays a neuroprotective role. However, the role of taurine after subarachnoid hemorrhage has rarely been reported. In the present study, we established a mouse model of SAH. We found that taurine administration effectively improved the sensorimotor function of these mice. In addition, taurine treatment alleviated sensorimotor neuron damage and reduced the proportion of apoptotic cells. Furthermore, taurine treatment enhanced the polarization of astrocytes toward the neuroprotective phenotype while inhibiting their polarization toward the neurotoxic phenotype. This study is the first to reveal the relationship between taurine and astrocyte polarization and may provide a new strategy for SAH research and clinical treatment.
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Affiliation(s)
- Chunlei Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Zhiwen Jiang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Xinjie Gao
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Heng Yang
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Jiabin Su
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Ruiyuan Weng
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China
- National Center for Neurological Disorders, Shanghai, 201107, China
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China
| | - Wei Ni
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 201107, China.
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China.
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China.
| | - Yuxiang Gu
- Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, 200040, China.
- National Center for Neurological Disorders, Shanghai, 201107, China.
- Neurosurgical Institute of Fudan University, Shanghai, 201107, China.
- Shanghai Key Laboratory of Brain Function and Restoration and Neural Regeneration, Shanghai, 200052, China.
- Institute of Science and Technology for Brain-Inspired Intelligence, Fudan University, Shanghai, 200433, China.
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Germans MR, Tjerkstra MA, Post R, Brenner A, Vergouwen MDI, Rinkel GJ, Roos YB, van den Berg R, Coert BA, Vandertop WP, Verbaan D. Impact of time to start of tranexamic acid treatment on rebleed risk and outcome in aneurysmal subarachnoid hemorrhage. Eur Stroke J 2024:23969873241246591. [PMID: 38606724 DOI: 10.1177/23969873241246591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION The ULTRA-trial investigated effectiveness of ultra-early administration of tranexamic acid (TXA) in subarachnoid hemorrhage (SAH) and showed that TXA reduces the risk of rebleeding without concurrent improvement in clinical outcome. Previous trials in bleeding conditions, distinct from SAH, have shown that time to start of antifibrinolytic treatment influences outcome. This post-hoc analysis of the ULTRA-trial investigates whether the interval between hemorrhage and start of TXA impacts the effect of TXA on rebleeding and functional outcome following aneurysmal SAH. PATIENTS AND METHODS A post-hoc comparative analysis was conducted between aneurysmal SAH patients of the ULTRA-trial, receiving TXA and usual care to those receiving usual care only. We assessed confounders, hazard ratio (HR) of rebleeding and odds ratio (OR) of good outcome (modified Rankin Scale 0-3) at 6 months, and investigated the impact of time between hemorrhage and start of TXA on the treatment effect, stratified into time categories (0-3, 3-6 and >6 h). RESULTS Sixty-four of 394 patients (16.2%) in the TXA group experienced a rebleeding, compared to 83 of 413 patients (19.9%) with usual care only (HR 0.86, 95% confidence interval (CI): 0.62-1.19). Time to start of TXA modifies the effect of TXA on rebleeding rate (p < 0.001), with a clinically non-relevant reduction observed only when TXA was initiated after 6 h (absolute rate reduction 1.4%). Tranexamic acid treatment showed no effect on good outcome (OR 0.96, 95% CI: 0.72-1.27) with no evidence of effect modification on the time to start of TXA (p = 0.53). DISCUSSION AND CONCLUSIONS This study suggests that the effect of TXA on rebleeding is modified by time to treatment, providing a protective, albeit clinically non-relevant, effect only when started after 6 h. No difference in functional outcome was seen. Routine TXA treatment in the aneurysmal SAH population, even within a specified time frame, is not recommended to improve functional outcome.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriël Je Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, The Netherlands
| | - René van den Berg
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
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Panni P, Simionato F, Cao R, Pedicelli A, Marchese E, Caricato A, Alexandre A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Aspide R, Lanterna AL, Ambrosi A, Mortini P, Azzolini ML, Calvi MR, Falini A. Hemorrhage Volume Drives Early Brain Injury and Outcome in Poor-Grade Aneurysmal SAH. AJNR Am J Neuroradiol 2024; 45:393-399. [PMID: 38453415 DOI: 10.3174/ajnr.a8135] [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: 07/17/2023] [Accepted: 12/06/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND AND PURPOSE Early brain injury is a major determinant of clinical outcome in poor-grade (World Federation of Neurosurgical Societies [WFNS] IV-V) aneurysmal SAH and is radiologically defined by global cerebral edema. Little is known, though, about the effect of global intracranial hemorrhage volume on early brain injury development and clinical outcome. MATERIALS AND METHODS Data from the multicentric prospective Poor-Grade Aneurysmal Subarachnoid Hemorrhage (POGASH) Registry of consecutive patients with poor-grade aneurysmal SAH admitted from January 1, 2015, to August 31, 2022, was retrospectively evaluated. Poor grade was defined according to the worst-pretreatment WFNS grade. Global intracranial hemorrhage volume as well as the volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH were calculated by means of analytic software in a semiautomated setting. Outcomes included severe global cerebral edema (defined by Subarachnoid Hemorrhage Early Brain Edema Score grades 3-4), in-hospital mortality (mRS 6), and functional independence (mRS 0-2) at follow-up. RESULTS Among 400 patients (median global intracranial hemorrhage volume of 91 mL; interquartile range, 59-128), severe global cerebral edema was detected in 218/400 (54.5%) patients. One hundred twenty-three (30.8%) patients died during the acute phase of hospitalization. One hundred fifty-five (38.8%) patients achieved mRS 0-2 at a median of 13 (interquartile range, 3-26) months of follow-up. Multivariable analyses showed global intracranial hemorrhage volume as independently associated with severe global cerebral edema (adjusted OR, 1.009; 95% CI, 1.004-1.014; P < .001), mortality (adjusted OR, 1.006; 95% CI, 1.001-1.01; P = .018) and worse clinical outcome (adjusted OR, 0.992; 95% CI, 0.98-0.996; P < .010). The effect of global intracranial hemorrhage volume on clinical-radiologic outcomes changed significantly according to different age groups (younger than 50, 50-70, older than 70 year of age). Volumes of intracerebral hemorrhage, intraventricular hemorrhage, and SAH affected the 3 predefined outcomes differently. Intracerebral hemorrhage volume independently predicted global cerebral edema and long-term outcome, intraventricular hemorrhage volume predicted mortality and long-term outcome, and SAH volume predicted long-term clinical outcome. CONCLUSIONS Global intracranial hemorrhage volume plays a pivotal role in global cerebral edema development and emerged as an independent predictor of both mortality and long-term clinical outcome. Aging emerged as a reducing predictor in the relationship between global intracranial hemorrhage volume and global cerebral edema.
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Affiliation(s)
- Pietro Panni
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery (P.P., P.M.), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Franco Simionato
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences (A.P., A. Alexandre). Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery (E.M.), Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine (A.C.), Fondazione Policlinico Universitario A. Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Andrea Alexandre
- Institute of Radiological Sciences (A.P., A. Alexandre). Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery (A. Feletti, M.T), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery (A. Feletti, M.T), Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A (P.Z.), Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency (N.G., S.P.), Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency (N.G., S.P.), Spedali Civili University Hospital, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology (D.M.), Spedali Civili University Hospital, Brescia, Italy
| | - Vittorio Semeraro
- Department of Radiology (V.S.), SS Annunziata Hospital, Taranto, Italy
| | - Giordano Nardin
- Department of Critical Care (G.N.), SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology (E.L.), Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care (G.P.), Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care (E.P., V.M., M.P), Parma University Hospital, Parma, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery (C.B., A.S.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery (C.B., A.S.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology (L.C.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | - Raffaele Aspide
- Department of Neurointensive Care (R.A.), IRCCS Institute of Neurological Sciences "Bellaria," Bologna, Italy
| | | | - Alessandro Ambrosi
- Biostatistics, School of Medicine (A. Ambrosi), Vita-Salute San Raffaele University, Milan, Italy
| | - Pietro Mortini
- Department of Neurosurgery (P.P., P.M.), IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Maria Luisa Azzolini
- Deparment of Neurocritical Care (M.L.A., M.R.C.), San Raffaele University Hospital, Milan, Italy
| | - Maria Rosa Calvi
- Deparment of Neurocritical Care (M.L.A., M.R.C.), San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- From the Department of Neuroradiology (P.P., F.S., R.C., A. Falini), Division of Interventional Neuroradiology, IRCCS San Raffaele Scientific Institute, Vita-Salute San Raffaele University, Milan, Italy
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7
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Wang G, Huang K, Tian Q, Guo Y, Liu C, Li Z, Yu Z, Zhang Z, Li M. S100A9 aggravates early brain injury after subarachnoid hemorrhage via inducing neuroinflammation and inflammasome activation. iScience 2024; 27:109165. [PMID: 38420589 PMCID: PMC10901081 DOI: 10.1016/j.isci.2024.109165] [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: 09/26/2023] [Revised: 12/03/2023] [Accepted: 02/05/2024] [Indexed: 03/02/2024] Open
Abstract
Subarachnoid hemorrhage (SAH) is a stroke subtype with high mortality, and its severity is closely related to the short-term prognosis of SAH patients. S100 calcium-binding protein A9 (S100A9) has been shown to be associated with some neurological diseases. In this study, the concentration of S100A9 in clinical cerebrospinal fluid samples was detected by enzyme-linked immunosorbent assay (ELISA), and the relationship between S100A9 and the prognosis of patients was explored. In addition, WT mice and S100A9 knockout mice were used to establish an in vivo SAH model. Neurological scores, brain water content, and histopathological staining were performed after a specified time. A co-culture model of BV2 and HT22 cells was treated with heme chloride to establish an in vitro SAH model. Our study confirmed that the expression of S100A9 protein in the CSF of SAH patients is increased, and it is related to the short-term prognosis of SAH patients. S100A9 protein is highly expressed in microglia in the central nervous system. S100A9 gene knockout significantly improved neurological function scores and reduced neuronal apoptosis. S100A9 protein can activate TLR4 receptor, promote nuclear transcription of NF-κB, increase the activation of inflammatory body, and ultimately aggravate nerve injury.
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Affiliation(s)
- Guijun Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Kesheng Huang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Qi Tian
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Yujia Guo
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Chengli Liu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Zhijie Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Zhui Yu
- Department of Critical Care Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Zhan Zhang
- Department of Rehabilitation Medicine, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, China
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Caylor MM, Macdonald RL. Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:159-169. [PMID: 37740138 DOI: 10.1007/s12028-023-01847-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 08/23/2023] [Indexed: 09/24/2023]
Abstract
BACKGROUND Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries. METHODS Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan. RESULTS The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad. CONCLUSIONS We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.
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Affiliation(s)
- Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - R Loch Macdonald
- Community Neurosciences Institute, Community Health Partners, 7257 North Fresno Street, Fresno, CA, 93720, USA.
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9
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Zhou Z, Dai A, Yan Y, Jin Y, Zou D, Xu X, Xiang L, Guo L, Xiang L, Jiang F, Zhao Z, Zou J. Accurately predicting the risk of unfavorable outcomes after endovascular coil therapy in patients with aneurysmal subarachnoid hemorrhage: an interpretable machine learning model. Neurol Sci 2024; 45:679-691. [PMID: 37624541 DOI: 10.1007/s10072-023-07003-4] [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: 06/06/2023] [Accepted: 08/02/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Despite endovascular coiling as a valid modality in treatment of aneurysmal subarachnoid hemorrhage (aSAH), there is a risk of poor prognosis. However, the clinical utility of previously proposed early prediction tools remains limited. We aimed to develop a clinically generalizable machine learning (ML) models for accurately predicting unfavorable outcomes in aSAH patients after endovascular coiling. METHODS Functional outcomes at 6 months after endovascular coiling were assessed via the modified Rankin Scale (mRS) and unfavorable outcomes were defined as mRS 3-6. Five ML algorithms (logistic regression, random forest, support vector machine, deep neural network, and extreme gradient boosting) were used for model development. The area under precision-recall curve (AUPRC) and receiver operating characteristic curve (AUROC) was used as main indices of model evaluation. SHapley Additive exPlanations (SHAP) method was applied to interpret the best-performing ML model. RESULTS A total of 371 patients were eventually included into this study, and 85.4% of them had favorable outcomes. Among the five models, the DNN model had a better performance with AUPRC of 0.645 (AUROC of 0.905). Postoperative GCS score, size of aneurysm, and age were the top three powerful predictors. The further analysis of five random cases presented the good interpretability of the DNN model. CONCLUSION Interpretable clinical prediction models based on different ML algorithms have been successfully constructed and validated, which would serve as reliable tools in optimizing the treatment decision-making of aSAH. Our DNN model had better performance to predict the unfavorable outcomes at 6 months in aSAH patients compared with Yan's nomogram model.
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Affiliation(s)
- Zhou Zhou
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Anran Dai
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yuqing Yan
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yuzhan Jin
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - DaiZun Zou
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - XiaoWen Xu
- Office of Clinical Trials, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - LeHeng Guo
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - FuPing Jiang
- Department of Geriatrics, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - ZhiHong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China.
| | - JianJun Zou
- Department of Pharmacy, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
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Mei Q, Shen H, Liu J. A nomogram for the prediction of short-term mortality in patients with aneurysmal subarachnoid hemorrhage requiring mechanical ventilation: a post-hoc analysis. Front Neurol 2024; 14:1280047. [PMID: 38259653 PMCID: PMC10800534 DOI: 10.3389/fneur.2023.1280047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 12/15/2023] [Indexed: 01/24/2024] Open
Abstract
Background Aneurysmal subarachnoid hemorrhage (aSAH) is a devastating stroke subtype with high morbidity and mortality. Although several studies have developed a prediction model in aSAH to predict individual outcomes, few have addressed short-term mortality in patients requiring mechanical ventilation. The study aimed to construct a user-friendly nomogram to provide a simple, precise, and personalized prediction of 30-day mortality in patients with aSAH requiring mechanical ventilation. Methods We conducted a post-hoc analysis based on a retrospective study in a French university hospital intensive care unit (ICU). All patients with aSAH requiring mechanical ventilation from January 2010 to December 2015 were included. Demographic and clinical variables were collected to develop a nomogram for predicting 30-day mortality. The least absolute shrinkage and selection operator (LASSO) regression method was performed to identify predictors, and multivariate logistic regression was used to establish a nomogram. The discriminative ability, calibration, and clinical practicability of the nomogram to predict short-term mortality were tested using the area under the curve (AUC), calibration plot, and decision curve analysis (DCA). Results Admission GCS, SAPS II, rebleeding, early brain injury (EBI), and external ventricular drain (EVD) were significantly associated with 30-day mortality in patients with aSAH requiring mechanical ventilation. Model A incorporated four clinical factors available in the early stages of the aSAH: GCS, SAPS II, rebleeding, and EBI. Then, the prediction model B with the five predictors was developed and presented in a nomogram. The predictive nomogram yielded an AUC of 0.795 [95% CI, 0.731-0.858], and in the internal validation with bootstrapping, the AUC was 0.780. The predictive model was well-calibrated, and decision curve analysis further confirmed the clinical usefulness of the nomogram. Conclusion We have developed two models and constructed a nomogram that included five clinical characteristics to predict 30-day mortality in patients with aSAH requiring mechanical ventilation, which may aid clinical decision-making.
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Affiliation(s)
- Qing Mei
- Department of Neurology, Beijing Pinggu Hospital, Beijing, China
| | - Hui Shen
- Department of Interventional Neuroradiology, Sanbo Brain Hospital, Capital Medical University, Beijing, China
| | - Jian Liu
- Department of Functional Neurosurgery, Zhujiang Hospital, Southern Medical University, The National Key Clinical Specialty, The Engineering Technology Research Centre of Education Ministry of China, Guangdong Provincial Key Laboratory on Brain Function Repair and Regeneration, Guangzhou, China
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11
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States. J Stroke Cerebrovasc Dis 2024; 33:107449. [PMID: 37995500 PMCID: PMC10841607 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. METHODS We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. RESULTS Although mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. CONCLUSIONS The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY 40202, USA.
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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García-García S, Cepeda S, Müller D, Mosteiro A, Torné R, Agudo S, de la Torre N, Arrese I, Sarabia R. Mortality Prediction of Patients with Subarachnoid Hemorrhage Using a Deep Learning Model Based on an Initial Brain CT Scan. Brain Sci 2023; 14:10. [PMID: 38248225 PMCID: PMC10812955 DOI: 10.3390/brainsci14010010] [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: 11/05/2023] [Revised: 12/10/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) entails high morbidity and mortality rates. Convolutional neural networks (CNN) are capable of generating highly accurate predictions from imaging data. Our objective was to predict mortality in SAH patients by processing initial CT scans using a CNN-based algorithm. METHODS We conducted a retrospective multicentric study of a consecutive cohort of patients with SAH. Demographic, clinical and radiological variables were analyzed. Preprocessed baseline CT scan images were used as the input for training using the AUCMEDI framework. Our model's architecture leveraged a DenseNet121 structure, employing transfer learning principles. The output variable was mortality in the first three months. RESULTS Images from 219 patients were processed; 175 for training and validation and 44 for the model's evaluation. Of the patients, 52% (115/219) were female and the median age was 58 (SD = 13.06) years. In total, 18.5% (39/219) had idiopathic SAH. The mortality rate was 28.5% (63/219). The model showed good accuracy at predicting mortality in SAH patients when exclusively using the images of the initial CT scan (accuracy = 74%, F1 = 75% and AUC = 82%). CONCLUSION Modern image processing techniques based on AI and CNN make it possible to predict mortality in SAH patients with high accuracy using CT scan images as the only input. These models might be optimized by including more data and patients, resulting in better training, development and performance on tasks that are beyond the skills of conventional clinical knowledge.
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Affiliation(s)
- Sergio García-García
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Santiago Cepeda
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Dominik Müller
- IT-Infrastructure for Translational Medical Research, University of Augsburg, 86159 Augsburg, Germany;
| | - Alejandra Mosteiro
- Neurosurgery Department, Hospital Clinic de Barcelona, 08036 Barcelona, Spain; (A.M.); (R.T.)
| | - Ramón Torné
- Neurosurgery Department, Hospital Clinic de Barcelona, 08036 Barcelona, Spain; (A.M.); (R.T.)
| | - Silvia Agudo
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Natalia de la Torre
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Ignacio Arrese
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
| | - Rosario Sarabia
- Neurosurgery Department, Rio Hortega University Hospital, 47012 Valladolid, Spain; (S.C.); (S.A.); (N.d.l.T.); (I.A.); (R.S.)
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13
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Wang H, Bothe TL, Deng C, Lv S, Khedkar PH, Kovacs R, Patzak A, Wu L. Comparison of Prognostic Models for Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning. World Neurosurg 2023; 180:e686-e699. [PMID: 37821029 DOI: 10.1016/j.wneu.2023.10.008] [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: 09/26/2023] [Accepted: 10/03/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Controversy exists regarding the superiority of the performance of prognostic tools based on advanced machine learning (ML) algorithms for patients with aneurysmal subarachnoid hemorrhage (aSAH). However, it is unclear whether ML prognostic models will benefit patients due to the lack of a comprehensive assessment. We aimed to develop and evaluate ML models for predicting unfavorable functional outcomes for aSAH patients and identify the model with the greatest performance. METHODS In this retrospective study, a dataset of 955 patients with aSAH was used to construct and validate prognostic models for functional outcomes assessed using the modified Rankin scale during a follow-up period of 3-6 months. Clinical scores and clinical and radiological features on admission and secondary complications were used to construct models based on 5 ML algorithms (i.e., logistic regression [LR], k-nearest neighbor, extreme gradient boosting, random forest, and artificial neural network). For evaluation among the models, the area under the receiver operating characteristic curve, area under the precision-recall curve, calibration curve, and decision curve analysis were used. RESULTS Composite models had significantly higher area under the receiver operating characteristic curves than did simple models in predicting unfavorable functional outcomes. Compared with other composite models (random forest and extreme gradient boosting) with good calibration, LR had the highest area under the precision-recall score and showed the greatest benefit in decision curve analysis. CONCLUSIONS Of the 5 studied ML models, the conventional LR model outperformed the advanced algorithms in predicting the prognosis and could be a useful tool for health care professionals.
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Affiliation(s)
- Han Wang
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany; Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China
| | - Tomas L Bothe
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Chulei Deng
- Department of Neurosurgery, Jinling Hospital, Nanjing, China
| | - Shengyin Lv
- Department of Neurology, Second Hospital of Nanjing, Nanjing University of Chinese Medicine, Nanjing, China
| | - Pratik H Khedkar
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Richard Kovacs
- Institute of Neurophysiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Andreas Patzak
- Institute of Translational Physiology, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu, Berlin, Germany
| | - Lingyun Wu
- Department of Neurosurgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, China.
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Germans MR, Rohr J, Globas C, Schubert T, Kaserer A, Brandi G, Studt JD, Greutmann M, Geiling K, Verweij L, Regli L. Challenges in Coagulation Management in Neurosurgical Diseases: A Scoping Review, Development, and Implementation of Coagulation Management Strategies. J Clin Med 2023; 12:6637. [PMID: 37892774 PMCID: PMC10607506 DOI: 10.3390/jcm12206637] [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: 09/18/2023] [Revised: 10/13/2023] [Accepted: 10/17/2023] [Indexed: 10/29/2023] Open
Abstract
Bleeding and thromboembolic (TE) complications in neurosurgical diseases have a detrimental impact on clinical outcomes. The aim of this study is to provide a scoping review of the available literature and address challenges and knowledge gaps in the management of coagulation disorders in neurosurgical diseases. Additionally, we introduce a novel research project that seeks to reduce coagulation disorder-associated complications in neurosurgical patients. The risk of bleeding after elective craniotomy is about 3%, and higher (14-33%) in other indications, such as trauma and intracranial hemorrhage. In spinal surgery, the incidence of postoperative clinically relevant bleeding is approximately 0.5-1.4%. The risk for TE complications in intracranial pathologies ranges from 3 to 20%, whereas in spinal surgery it is around 7%. These findings highlight a relevant problem in neurosurgical diseases and current guidelines do not adequately address individual circumstances. The multidisciplinary COagulation MAnagement in Neurosurgical Diseases (COMAND) project has been developed to tackle this challenge by devising an individualized coagulation management strategy for patients with neurosurgical diseases. Importantly, this project is designed to ensure that these management strategies can be readily implemented into healthcare practices of different types and with sustainable integration.
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Affiliation(s)
- Menno R. Germans
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Jonas Rohr
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
| | - Christoph Globas
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neurology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Tilman Schubert
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
- Department of Neuroradiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland
| | - Alexander Kaserer
- Institute of Anesthesiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Giovanna Brandi
- Neurocritical Care Unit, Institute for Intensive Care Medicine, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Jan-Dirk Studt
- Department of Medical Oncology and Hematology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Matthias Greutmann
- University Heart Center, Department of Cardiology, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Katharina Geiling
- Department of Geriatrics, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland;
| | - Lotte Verweij
- Institute for Implementation Science in Health Care, University of Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland;
- Centre of Clinical Nursing Science, University Hospital Zurich, Universitätstrasse 84, 8006 Zurich, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (J.R.); (L.R.)
- Clinical Neuroscience Center, University Hospital Zurich, Rämistrasse 100 (CAMPUS), 8091 Zurich, Switzerland; (C.G.); (T.S.)
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15
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Yamaguchi S, Izumo T, Sato I, Morofuji Y, Kaminogo M, Anda T, Horie N, Matsuo T. Impact of immediate general anesthesia in the emergency room on prevention of rebleeding after subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:2855-2864. [PMID: 37434015 DOI: 10.1007/s00701-023-05705-4] [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: 03/17/2023] [Accepted: 06/27/2023] [Indexed: 07/13/2023]
Abstract
BACKGROUND Aneurysm rebleeding is fatal in patients with aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether immediate general anesthesia (iGA) management in the emergency room, upon arrival, prevents rebleeding after admission and reduces mortality following aSAH. METHODS The clinical data of 3033 patients with World Federation of Neurosurgical Societies (WFNS) grade 1, 2, or 3 aSAH from the Nagasaki SAH Registry Study between 2001 and 2018 were retrospectively analyzed. iGA was defined as sedation and analgesia using intravenous anesthetics and opioids combined with intubation induction. We calculated crude and adjusted odds ratios to evaluate the associations between iGA and the risk of rebleeding/death using multivariable logistic regression models with fully conditional specification for multiple imputations. In the analysis of the relationship between iGA and death, we excluded patients with aSAH who died within 3 days after the onset of symptoms. RESULTS Of the 3033 patients with aSAH who met the eligibility criteria, 175 patients (5.8%) received iGA (mean age, 62.4 years; 49 were male). Heart disease, WFNS grade, and lack of iGA were independently associated with rebleeding in the multivariable analysis with multiple imputations. Among the 3033 patients, 15 were excluded due to death within 3 days after the onset of symptoms. After excluding these cases, our analysis revealed that age, diabetes mellitus, history of cerebrovascular disease, WFNS grade, Fisher grade, lack of iGA, rebleeding, postoperative rebleeding, no shunt operation, and symptomatic spasm were independently associated with mortality. CONCLUSIONS Management by iGA was associated with a 0.28-fold decrease in the risks of both rebleeding and mortality in patients with aSAH, even after adjusting for the patient's history of diseases, comorbidities, and aSAH status. Thus, iGA can be a treatment for the prevention of rebleeding before aneurysmal obliteration treatment.
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Affiliation(s)
- Susumu Yamaguchi
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan.
| | - Izumi Sato
- Department of Clinical Epidemiology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Makio Kaminogo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Takeo Anda
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Hiroshima University School of Medicine, Hiroshima, Japan
| | - Takayuki Matsuo
- Department of Neurosurgery, Nagasaki University Graduate School of Biomedical Sciences, 1-7-1, Sakamoto, Nagasaki, 852-8501, Japan
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Mistry AM, Naidugari J, Feldman MJ, Magarik JA, Ding D, Abecassis IJ, Semler MW, Rice TW. Impact of Fludrocortisone on the Outcomes of Subarachnoid Hemorrhage Patients: A Retrospective Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296246. [PMID: 37808869 PMCID: PMC10557818 DOI: 10.1101/2023.09.28.23296246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background Whether the use of fludrocortisone affects outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH) and its usage rate in the United States remain unknown. Methods We conducted a retrospective analysis of 78 consecutive patients with a ruptured aSAH at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days. We adjusted the primary outcome for age, hypertension, aSAH grade, and time from aSAH onset to aneurysm treatment. Secondary outcomes were brain and cardiopulmonary dysfunction events. Results Among 78 patients at a single center, the median age was 58 years [IQR, 49 to 64.5]; 64% were female, and 41 (53%) received fludrocortisone. The adjusted common odds ratio, aOR, of a proportional odds regression model of fludrocortisone use with mRS was 0.33 (95% CI, 0.14-0.80; P=0.02), with values <1.0 favoring fludrocortisone. Organ-specific dysfunction events were not statistically different: delayed cerebral ischemia (22% vs. 39%, P=0.16); cardiac dysfunction (0% vs. 11%; P=0.10); and pulmonary edema (15% vs. 8%; P=0.59). Conclusions The risk of disability or death at 90 days was lower with the use of fludrocortisone in aSAH patients.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Dale Ding
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Isaac J. Abecassis
- Department of Neurosurgery, University of Louisville, Louisville, KY, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of Mineralocorticoids and Isotonic Crystalloids in Subarachnoid Hemorrhage Patients in the United States. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.28.23296245. [PMID: 37808838 PMCID: PMC10557832 DOI: 10.1101/2023.09.28.23296245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. Methods We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20% of all acute inpatient care in the United States. Results Although mineralocorticoids are used by 70% of the NINDS StrokeNet sites in aSAH patients, it is used in less than 25% of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41% and 45%, respectively. Conclusions The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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18
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Hofmann BB, Karadag C, Rubbert C, Schieferdecker S, Neyazi M, Abusabha Y, Fischer I, Boogaarts HD, Muhammad S, Beseoglu K, Hänggi D, Turowski B, Kamp MA, Cornelius JF. Novel Insights into Pathophysiology of Delayed Cerebral Ischemia: Effects of Current Rescue Therapy on Microvascular Perfusion Heterogeneity. Biomedicines 2023; 11:2624. [PMID: 37892998 PMCID: PMC10603935 DOI: 10.3390/biomedicines11102624] [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: 08/16/2023] [Revised: 09/11/2023] [Accepted: 09/21/2023] [Indexed: 10/29/2023] Open
Abstract
General microvascular perfusion and its heterogeneity are pathophysiological features of delayed cerebral ischemia (DCI) that are gaining increasing attention. Recently, CT perfusion (CTP) imaging has made it possible to evaluate them radiologically using mean transit time (MTT) and its heterogeneity (measured by cvMTT). This study evaluates the effect of multimodal rescue therapy (intra-arterial nimodipine administration and elevation of blood pressure) on MTT and cvMTT during DCI in aneurysmal subarachnoid haemorrhage (aSAH) patients. A total of seventy-nine aSAH patients who underwent multimodal rescue therapy between May 2012 and December 2019 were retrospectively included in this study. CTP-based perfusion impairment (MTT and cvMTT) on the day of DCI diagnosis was compared with follow-up CTP after initiation of combined multimodal therapy. The mean MTT was significantly reduced in the follow-up CTP compared to the first CTP (3.7 ± 0.7 s vs. 3.3 ± 0.6 s; p < 0.0001). However, no significant reduction of cvMTT was observed (0.16 ± 0.06 vs. 0.15 ± 0.06; p = 0.44). Mean arterial pressure was significantly increased between follow-up and first CTP (98 ± 17 mmHg vs. 104 ± 15 mmHg; p < 0.0001). The combined multimodal rescue therapy was effective in addressing the general microvascular perfusion impairment but did not affect the mechanisms underlying microvascular perfusion heterogeneity. This highlights the need for research into new therapeutic approaches that also target these pathophysiological mechanisms of DCI.
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Affiliation(s)
- Björn B. Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Simon Schieferdecker
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Milad Neyazi
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Yousef Abusabha
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Hieronymus D. Boogaarts
- Department of Neurosurgery, Medical Faculty, Radboud University Nijmegen, 6525 GA Nijmegen, The Netherlands
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Daniel Hänggi
- Department of Neurosurgery, International Neuroscience Institute, 30625 Hannover, Germany
| | - Bernd Turowski
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Marcel A. Kamp
- Centre for Palliative and Neuropalliative Care, Brandenburg Medical School Theodor Fontane, Campus Rüdersdorf, 15562 Rüdersdorf bei Berlin, Germany
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany
| | - Jan F. Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
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Sigmon J, Crowley KL, Groth CM. Therapeutic review: The role of tranexamic acid in management of traumatic brain injury, nontraumatic intracranial hemorrhage, and aneurysmal subarachnoid hemorrhage. Am J Health Syst Pharm 2023; 80:1213-1222. [PMID: 37280158 DOI: 10.1093/ajhp/zxad134] [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: 06/06/2023] [Indexed: 06/08/2023] Open
Abstract
PURPOSE To summarize current literature evaluating tranexamic acid in the management of intracranial bleeding associated with traumatic and nontraumatic brain injuries and implications for clinical practice. SUMMARY Intracranial hemorrhage, regardless of etiology, is associated with high morbidity and mortality. Tranexamic acid is an antifibrinolytic with anti-inflammatory properties shown to reduce mortality in trauma patients with extracranial injuries. In traumatic brain injury, a large randomized trial found no difference in outcomes when tranexamic acid was compared to placebo; however, subgroup analyses suggested that it may reduce head injury-related mortality in the context of mild-to-moderate injury if treatment occurs within 1 hour of symptom onset. More recent out-of-hospital data have disputed these findings and even suggested harm in severely injured patients. In spontaneous, nontraumatic intracranial hemorrhage, treatment with tranexamic acid did not result in a difference in functional status; however, rates of hematoma expansion, even though modest, were significantly reduced. In aneurysmal subarachnoid hemorrhage, tranexamic acid may prevent rebleeding, but has not led to improved outcomes or reduced mortality, and there is concern for increased incidence of delayed cerebral ischemia. Overall, tranexamic acid has not been shown to result in increased risk of thromboembolic complications across these classes of brain injury. CONCLUSION Despite its favorable safety profile overall, tranexamic acid does not seem to improve functional outcomes and cannot be routinely recommended. More data are needed to determine which head injury subpopulations are most likely to benefit from tranexamic acid and which patients are at increased risk for harm.
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Affiliation(s)
| | - Kelli L Crowley
- Department of Pharmacy, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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20
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Zhou Z, Lu W, Zhang C, Xiang L, Xiang L, Chen C, Wang B, Guo L, Shan Y, Li X, Zhao Z, Zou J, Dai X, Zhao Z. A visualized MAC nomogram online predicts the risk of three-month mortality in Chinese elderly aneurysmal subarachnoid hemorrhage patients undergoing endovascular coiling. Neurol Sci 2023; 44:3209-3220. [PMID: 37020068 PMCID: PMC10075504 DOI: 10.1007/s10072-023-06777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Accepted: 03/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) is an aggressive disease with higher mortality rate in the elderly population. Unfortunately, the previous models for predicting clinical prognosis are still not accurate enough. Therefore, we aimed to construct and validate a visualized nomogram model to predict online the 3-month mortality in elderly aSAH patients undergoing endovascular coiling. METHOD We conducted a retrospective analysis of 209 elderly aSAH patients at People's Hospital of Hunan Province, China. A nomogram was developed based on multivariate logistic regression and forward stepwise regression analysis, then validated using the bootstrap validation method (n = 1000). In addition, the performance of the nomogram was evaluated by various indicators to prove its clinical value. RESULT Morbid pupillary reflex, age, and using a breathing machine were independent predictors of 3-month mortality. The AUC of the nomogram was 0.901 (95% CI: 0.853-0.950), and the Hosmer-Lemeshow goodness-of-fit test showed good calibration of the nomogram (p = 0.4328). Besides, the bootstrap validation method internally validated the nomogram with an area under the curve of the receiver operator characteristic (AUROC) of 0.896 (95% CI: 0.846-0.945). Decision curve analysis (DCA) and clinical impact curve (CIC) indicated the nomogram's excellent clinical utility and applicability. CONCLUSION An easily applied visualized nomogram model named MAC (morbid pupillary reflex-age-breathing machine) based on three accessible factors has been successfully developed. The MAC nomogram is an accurate and complementary tool to support individualized decision-making and emphasizes that patients with higher risk of mortality may require closer monitoring. Furthermore, a web-based online version of the risk calculator would greatly contribute to the spread of the model in this field.
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Affiliation(s)
- Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Wei Lu
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Cheng Zhang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - BiJun Wang
- Clinical Research Institute, Hengyang Medical School, The Affiliated Nanhua Hospital, University of South China, Hengyang, China
| | - LeHeng Guo
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - YaJie Shan
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - XueMei Li
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Zheng Zhao
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China
| | - JianJun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
- Department of Pharmacy, Nanjing First Hospital, China Pharmaceutical University, Nanjing, China.
| | - XiaoMing Dai
- Department of Hepatobiliary Surgery, Hengyang Medical School, The First Affiliated Hospital, University of South China, Hengyang, China.
| | - ZhiHong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China.
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21
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Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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22
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Zhou Z, Wang F, Chen T, Wei Z, Chen C, Xiang L, Xiang L, Zhang Q, Huang K, Jiang F, Zhao Z, Zou J. Pre- and Post-Operative Online Prediction of Outcome in Patients Undergoing Endovascular Coiling after Aneurysmal Subarachnoid Hemorrhage: Visual and Dynamic Nomograms. Brain Sci 2023; 13:1185. [PMID: 37626541 PMCID: PMC10452244 DOI: 10.3390/brainsci13081185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/05/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) causes long-term functional dependence and death. Early prediction of functional outcomes in aSAH patients with appropriate intervention strategies could lower the risk of poor prognosis. Therefore, we aimed to develop pre- and post-operative dynamic visualization nomograms to predict the 1-year functional outcomes of aSAH patients undergoing coil embolization. METHODS Data were obtained from 400 aSAH patients undergoing endovascular coiling admitted to the People's Hospital of Hunan Province in China (2015-2019). The key indicator was the modified Rankin Score (mRS), with 3-6 representing poor functional outcomes. Multivariate logistic regression (MLR)-based visual nomograms were developed to analyze baseline characteristics and post-operative complications. The evaluation of nomogram performance included discrimination (measured by C statistic), calibration (measured by the Hosmer-Lemeshow test and calibration curves), and clinical usefulness (measured by decision curve analysis). RESULTS Fifty-nine aSAH patients (14.8%) had poor outcomes. Both nomograms showed good discrimination, and the post-operative nomogram demonstrated superior discrimination to the pre-operative nomogram with a C statistic of 0.895 (95% CI: 0.844-0.945) vs. 0.801 (95% CI: 0.733-0.870). Each was well calibrated with a Hosmer-Lemeshow p-value of 0.498 vs. 0.276. Moreover, decision curve analysis showed that both nomograms were clinically useful, and the post-operative nomogram generated more net benefit than the pre-operative nomogram. Web-based online calculators have been developed to greatly improve the efficiency of clinical applications. CONCLUSIONS Pre- and post-operative dynamic nomograms could support pre-operative treatment decisions and post-operative management in aSAH patients, respectively. Moreover, this study indicates that integrating post-operative variables into the nomogram enhanced prediction accuracy for the poor outcome of aSAH patients.
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Affiliation(s)
- Zhou Zhou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Fusang Wang
- Department of Pharmacy, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou 510275, China
| | - Tingting Chen
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China
| | - Ziqiao Wei
- The Second Clinical Medicine School of Nanjing Medical University, Nanjing 211166, China
| | - Chen Chen
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Lan Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Liang Xiang
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Qian Zhang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Kaizong Huang
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Fuping Jiang
- Department of Geriatrics, Nanjing First Hospital, Nanjing Medical University, Nanjing 210000, China
| | - Zhihong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha 410081, China
| | - Jianjun Zou
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing 210009, China
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23
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Betteridge T, Finnis M, Cohen J, Delaney A, Young P, Udy A. Blood Pressure Management Goals in Critically Ill Aneurysmal Subarachnoid Hemorrhage Patients in Australia and New Zealand. J Neurosurg Anesthesiol 2023:00008506-990000000-00070. [PMID: 37442781 DOI: 10.1097/ana.0000000000000926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/07/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION Blood pressure (BP) management is common in patients with aneurysmal subarachnoid hemorrhage (SAH) admitted to an intensive care unit. However, the practice patterns of BP management (timing, dose, and duration) have not been studied locally. METHODS This post hoc analysis explored BP management goals (defined as the setting of a minimum systolic BP target or application of induced hypertension) in patients enrolled into the PROMOTE-SAH study in eleven neurosurgical centers in Australia and New Zealand. The primary outcome was 'dead or disabled' (modified Rankin Score ≥4) at 6 months, with the hypothesis being that setting BP management goals would be associated with improved outcomes. RESULTS BP management goals were recorded in 266 of 357 (75%) patients, of which 149 were recorded as receiving induced hypertension for delayed cerebral ischemia (DCI) or vasospasm on 738 (19%) study days. In patients with a minimum systolic BP goal recorded (on 2067 d), the indication for the BP management goal was vasospasm or DCI on 651 (32%) days; no indication for BP management goals was documented on 1416 (69%) days. Crude analysis demonstrated an association between setting BP management goals and reduced death or disability (P=0.03), but this association was not significant after adjustment for the presence of DCI or vasospasm and clustered by the site. CONCLUSIONS BP management goals are commonly 'prescribed' to aSAH patients admitted to an intensive care unit in Australia and New Zealand, but BP management goal setting was not associated with improved outcomes in the adjusted analysis.
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Affiliation(s)
| | - Mark Finnis
- Royal Adelaide Hospital, Port Rd, Adelaide, SA
| | - Jeremy Cohen
- Royal Brisbane and Womens Hospital, Butterfield St, Herston, QLD
| | | | - Paul Young
- Royal Adelaide Hospital, Port Rd, Adelaide, SA
| | - Andrew Udy
- The Alfred Hospital, Commercial Rd, Melbourne, VIC, Australia
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Kurisu K, Hokari M, Uchida K, Asaoka K, Ajiki M, Takada T, Itamoto K, Fujimura M. Treatment of aneurysmal subarachnoid hemorrhage in subacute phase; retrospective comparison of treatment in sub- and hyper-acute phases. Clin Neurol Neurosurg 2023; 230:107781. [PMID: 37244196 DOI: 10.1016/j.clineuro.2023.107781] [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: 02/28/2023] [Revised: 05/08/2023] [Accepted: 05/11/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE As soon as possible treatment initiation for aneurysmal subarachnoid hemorrhage (aSAH) is recommended. However, some patients require treatment in "subacute" phase of aSAH, defined in this study as "more than one day after the onset". To establish an optimal treatment strategy for these patients, we retrospectively analyzed the clinical experience of treating ruptured aneurysm with either clipping or coiling in subacute phase. METHODS Patients treated for aSAH between 2015 and 2021were analyzed. Patients were divided into the hyperacute phase (within 24 h) and subacute phase (later than 24 h) groups. The subacute group was analyzed to determine whether the selected procedure and its timing affected postoperative course and clinical outcomes. In addition, we conducted a multivariate logistic regression analysis to determine the independent factors that affect clinical outcomes. RESULTS Of 215 patients, 31 were treated in the subacute phase. While cerebral vasospasm at initial imaging was more frequently observed in subacute group, there was no difference in incidence of postoperative vasospasms. Patients in subacute group seemed to have better clinical outcomes due to the milder severity at the time of treatment initiation. Risk of angiographic vasospasm seemed to be higher in patients treated with clipping than coiling, while no difference was seen in clinical outcomes. Multivariate logistic regression analysis showed that the timing and selected treatment did not significantly affect the clinical outcome or the occurrence of delayed vasospasm. CONCLUSIONS Treatment of aSAH in the subacute phase may also result in favorable clinical outcomes, similar to patients treated in the hyperacute phase with mild presentation. However, further investigations are required to establish the optimal treatment strategies for such patients.
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Affiliation(s)
- Kota Kurisu
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan.
| | - Masaaki Hokari
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Kazuki Uchida
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Katsuyuki Asaoka
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Minoru Ajiki
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Tatsuro Takada
- Department of Cerebrovascular Medicine, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Koji Itamoto
- Department of Neurosurgery, Teine Keijinkai Hospital, Maeda 1-12-1-40, Teine-ku, Sapporo, Hokkaido 006-8111, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Kita 15, Nishi 7, Kita-ku, Sapporo, Hokkaido 060-8638, Japan
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Bögli SY, Beham S, Hirsbrunner L, Nellessen F, Casagrande F, Keller E, Brandi G. Sex-specific extracerebral complications in patients with aneurysmal subarachnoid hemorrhage. Front Neurol 2023; 14:1098300. [PMID: 37234781 PMCID: PMC10206055 DOI: 10.3389/fneur.2023.1098300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 04/10/2023] [Indexed: 05/28/2023] Open
Abstract
Background Extracerebral complications in patients with aneurysmal subarachnoid hemorrhage (aSAH) often occur during their stay at the neurocritical care unit (NCCU). Their influence on outcomes is poorly studied. The identification of sex-specific extracerebral complications in patients with aSAH and their impact on outcomes might aid more personalized monitoring and therapy strategies, aiming to improve outcomes. Methods Consecutive patients with aSAH admitted to the NCCU over a 6-year period were evaluated for the occurrence of extracerebral complications (according to prespecified criteria). Outcomes were assessed with the Glasgow Outcome Scale Extended (GOSE) at 3 months and dichotomized as favorable (GOSE 5-8) and unfavorable (GOSE 1-4). Sex-specific extracerebral complications and their impact on outcomes were investigated. Based on the results of the univariate analysis, a multivariate analysis with unfavorable outcomes or the occurrence of certain complications as dependent variables was performed. Results Overall, 343 patients were included. Most of them were women (63.6%), and they were older than men. Demographics, presence of comorbidities, radiological findings, severity of bleeding, and aneurysm-securing strategies were compared among the sexes. More women than men suffered from cardiac complications (p = 0.013) and infection (p = 0.048). Patients with unfavorable outcomes were more likely to suffer from cardiac (p < 0.001), respiratory (p < 0.001), hepatic/gastrointestinal (p = 0.023), and hematological (p = 0.021) complications. In the multivariable analysis, known factors including age, female sex, increasing number of comorbidities, increasing World Federation of Neurosurgical Societies (WFNS), and Fisher grading were expectedly associated with unfavorable outcomes. When adding complications to these models, these factors remained significant. However, when considering the complications, only pulmonary and cardiac complications remained independently associated with unfavorable outcomes. Conclusion Extracerebral complications after aSAH are frequent. Cardiac and pulmonary complications are independent predictors of unfavorable outcomes. Sex-specific extracerebral complications in patients with aSAH exist. Women suffered more frequently from cardiac and infectious complications potentially explaining the worse outcomes.
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Affiliation(s)
- Stefan Y. Bögli
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Sabrina Beham
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Laura Hirsbrunner
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Friederike Nellessen
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Francesca Casagrande
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
| | - Emanuela Keller
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Giovanna Brandi
- Neurocritical Care Unit, Department of Neurosurgery, Institute for Intensive Care Medicine, University Hospital Zurich, Zurich, Switzerland
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Li R, Lin F, Chen Y, Lu J, Han H, Ma L, Zhao Y, Yan D, Li R, Yang J, He S, Li Z, Zhang H, Yuan K, Wang K, Hao Q, Ye X, Wang H, Li H, Zhang L, Shi G, Zhou J, Zhao Y, Zhang Y, Li Y, Wang S, Chen X, Zhao Y. A 90-Day Prognostic Model Based on the Early Brain Injury Indicators after Aneurysmal Subarachnoid Hemorrhage: the TAPS Score. Transl Stroke Res 2023; 14:200-210. [PMID: 35567655 DOI: 10.1007/s12975-022-01033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 04/17/2022] [Accepted: 05/06/2022] [Indexed: 12/11/2022]
Abstract
This study aimed to establish a new scoring model based on the early brain injury (EBI) indicators to predict the 90-day functional outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively enrolled 825 patients and prospectively enrolled 108 patients with aSAH who underwent surgical clipping or endovascular coiling (derivation cohort = 640; validation cohort = 185; prospective cohort = 108) in our institute. We established a logistic regression model based on independent risk factors associated with 90-day unfavorable outcomes. The discrimination of the prognostic model was assessed by the area under the curve in a receiver operating characteristic curve analysis. The Hosmer-Lemeshow goodness-of-fit test and a calibration plot were used to evaluate the calibration of the prediction model. The developed scoring model named "TAPS" (total score, 0-7 points) included the following admission variables: age > 55 years old, WFNS grade of 4-5, mFS grade of 3-4, Graeb score of 5-12, white blood cell count > 11.28 × 109/L, and surgical clipping. The model showed good discrimination with the area under the curve in the derivation, validation, and prospective cohorts which were 0.816 (p < 0.001, 95%CI = 0.77-0.86), 0.810 (p < 0.001, 95%CI = 0.73-0.90), and 0.803 (p < 0.001, 95%CI = 0.70-0.91), respectively. The model also demonstrated good calibration (Hosmer-Lemeshow goodness-of-fit test: X2 = 1.75, df = 8, p = 0.988). Compared with other predictive models, TAPS is an easy handle tool for predicting the 90-day unfavorable outcomes of aSAH patients, which can help clinicians better understand the concept of EBI and quickly identify those patients at risk of poor prognosis, providing more positive treatment strategies. Trial registration: NCT04785976. Registered 5 March 2021-retrospectively registered, http://www.clinicaltrials.gov .
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Affiliation(s)
- Runting Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Fa Lin
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Yu Chen
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Junlin Lu
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Heze Han
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Li Ma
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Yahui Zhao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Debin Yan
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Ruinan Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Jun Yang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Shihao He
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Zhipeng Li
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Haibin Zhang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Kexin Yuan
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Ke Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Qiang Hao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Xun Ye
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Hao Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China
| | - Hongliang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yang Zhao
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Yukun Zhang
- Department of Neurosurgery, Peking University International Hospital, Beijing, China
| | - Youxiang Li
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China. .,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China. .,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China.
| | - Yuanli Zhao
- Department of Neurosurgery, Fengtai District, Beijing Tiantan Hospital, Capital Medical University, No. 119 South Fourth Ring West Road, Beijing, 100070, China.,Department of Neurosurgery, Peking University International Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Stroke Center, Beijing Institute for Brain Disorders, Beijing, China.,Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
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Volatile Sedation With Isoflurane in Neurocritical Care Patients After Poor-grade Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2023; 173:e194-e206. [PMID: 36780983 DOI: 10.1016/j.wneu.2023.02.032] [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: 12/01/2022] [Revised: 02/04/2023] [Accepted: 02/06/2023] [Indexed: 02/13/2023]
Abstract
OBJECTIVE Volatile sedation after aneurysmal subarachnoid hemorrhage (aSAH) promises several advantages, but there are still concerns regarding intracranial hypertension due to vasodilatory effects. We prospectively analyzed cerebral parameters during the switch from intravenous to volatile sedation with isoflurane in patients with poor-grade (World Federation of Neurosurgical Societies grade 4-5) aSAH. METHODS Eleven patients were included in this prospective observational study. Between day 3 and 5 after admission, intravenous sedation was switched to isoflurane using the Sedaconda Anesthetic Conserving Device (Sedana Medical, Danderyd, Sweden). Intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PBrO2), cerebral mean flow velocities (MFVs; transcranial Doppler ultrasound) and regional cerebral oxygen saturation (rSO2, near-infrared spectroscopy monitoring), as well as cardiopulmonary parameters were assessed before and after the sedation switch (-12 to +12 hours). Additionally, perfusion computed tomography data during intravenous and volatile sedation were analyzed retrospectively for changes in cerebral blood flow. RESULTS There were no significant changes in mean ICP, CPP, and PBrO2 after the sedation switch to isoflurane. Mean rSO2 showed a non-significant trend towards higher values, and mean MFV in the middle cerebral arteries increased significantly after the initiation of volatile sedation. Isoflurane sedation resulted in a significantly increased norepinephrine administration. Despite an increase in mean inspiratory pressure, we observed a significant increase in mean partial arterial pressure of carbon dioxide. CONCLUSIONS Isoflurane sedation does not compromise ICP or cerebral oxygenation in poor-grade aSAH patients, but the significant depression of CPP could limit the use of volatiles in case of hemodynamic instability or high vasopressor demand.
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Roethlisberger M, Aghlmandi S, Rychen J, Chiappini A, Zumofen DW, Bawarjan S, Stienen MN, Fung C, D'Alonzo D, Maldaner N, Steinsiepe VK, Corniola MV, Goldberg J, Cianfoni A, Robert T, Maduri R, Saliou G, Starnoni D, Weber J, Seule MA, Gralla J, Bervini D, Kulcsar Z, Burkhardt JK, Bozinov O, Remonda L, Marbacher S, Lövblad KO, Psychogios M, Bucher HC, Mariani L, Bijlenga P, Blackham KA, Guzman R. Impact of Very Small Aneurysm Size and Anterior Communicating Segment Location on Outcome after Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2023; 92:370-381. [PMID: 36469672 DOI: 10.1227/neu.0000000000002212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 08/31/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Very small anterior communicating artery aneurysms (vsACoA) of <5 mm in size are detected in a considerable number of patients with aneurysmal subarachnoid hemorrhage (aSAH). Single-center studies report that vsACoA harbor particular risks when treated. OBJECTIVE To assess the clinical and radiological outcome(s) of patients with aSAH diagnosed with vsACoA after aneurysm treatment and at discharge. METHODS Information on n = 1868 patients was collected in the Swiss Subarachnoid Hemorrhage Outcome Study registry between 2009 and 2014. The presence of a new focal neurological deficit at discharge, functional status (modified Rankin scale), mortality rates, and procedural complications (in-hospital rebleeding and presence of a new stroke on computed tomography) was assessed for vsACoA and compared with the results observed for aneurysms in other locations and with diameters of 5 to 25 mm. RESULTS This study analyzed n = 1258 patients with aSAH, n = 439 of which had a documented ruptured ACoA. ACoA location was found in 38% (n = 144/384) of all very small ruptured aneurysms. A higher in-hospital bleeding rate was found in vsACoA compared with non-ACoA locations (2.8 vs 2.1%), especially when endovascularly treated (2.1% vs 0.5%). In multivariate analysis, aneurysm size of 5 to 25 mm, and not ACoA location, was an independent risk factor for a new focal neurological deficit and a higher modified Rankin scale at discharge. Neither very small aneurysm size nor ACoA location was associated with higher mortality rates at discharge or the occurrence of a peri-interventional stroke. CONCLUSION Very small ruptured ACoA have a higher in-hospital rebleeding rate but are not associated with worse morbidity or mortality.
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Affiliation(s)
- Michel Roethlisberger
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Soheila Aghlmandi
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jonathan Rychen
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Alessio Chiappini
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurological Surgery, Maimonides Medical Center, New York, USA
| | - Schatlo Bawarjan
- Department of Neurosurgery, University Hospital of Göttingen, Göttingen, Germany
| | - Martin N Stienen
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Christian Fung
- Department of Neurosurgery, University Hospital of Freiburg, Freiburg Germany.,Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Donato D'Alonzo
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Nicolai Maldaner
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Valentin K Steinsiepe
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marco V Corniola
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Johannes Goldberg
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Alessandro Cianfoni
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Thomas Robert
- Departments of Neurosurgery and Neuroradiology, Neurocenter of Southern Switzerland, Ospedale regionale, Lugano, Switzerland
| | - Rodolfo Maduri
- Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Guillaume Saliou
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Daniele Starnoni
- Departments of Neurosurgery and Neuroradiology, University Hospital of Lausanne, Switzerland
| | - Johannes Weber
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Martin A Seule
- Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Jan Gralla
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - David Bervini
- Departments of Neurosurgery and Neuroradiology, University Hospital of Bern, Bern Switzerland
| | - Zsolt Kulcsar
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Oliver Bozinov
- Department of Neurosurgery and Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Departments of Neurosurgery and Neuroradiology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Remonda
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Departments of Neurosurgery and Neuroradiology, Kantonsspital Aarau, Aarau, Switzerland
| | - Karl-Olof Lövblad
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Marios Psychogios
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Heiner C Bucher
- Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Luigi Mariani
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Philippe Bijlenga
- Departments of Neurosurgery and Neuroradiology, University Hospital of Geneva, Geneva Switzerland
| | - Kristine A Blackham
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Raphael Guzman
- Departments of Neurosurgery and Interventional Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
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Koester SW, Catapano JS, Rhodenhiser EG, Rudy RF, Winkler EA, Benner D, Cole TS, Baranoski JF, Srinivasan VM, Graffeo CS, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Propensity-adjusted analysis of ultra-early aneurysmal subarachnoid hemorrhage treatment and patient outcomes. Acta Neurochir (Wien) 2023; 165:993-1000. [PMID: 36702969 DOI: 10.1007/s00701-023-05497-7] [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: 08/29/2022] [Accepted: 01/05/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Optimal definitive treatment timing for patients with aneurysmal subarachnoid hemorrhage (aSAH) remains controversial. We compared outcomes for aSAH patients with ultra-early treatment versus later treatment at a single large center. METHOD Patients who received definitive open surgical or endovascular treatment for aSAH between January 1, 2014, and July 31, 2019, were included. Ultra-early treatment was defined as occurring within 24 h from aneurysm rupture. The primary outcome was poor neurologic outcome (modified Rankin Scale score > 2). Propensity adjustment was performed for age, sex, Charlson Comorbidity Index, Hunt and Hess grade, Fisher grade, aneurysm treatment type, aneurysm type, size, and anterior location. RESULTS Of the 1013 patients (mean [SD] age, 56 [14] years; 702 [69%] women, 311 [31%] men) included, 94 (9%) had ultra-early treatment. Compared with the non-ultra-early cohort, the ultra-early treatment cohort had a significantly lower percentage of saccular aneurysms (53 of 94 [56%] vs 746 of 919 [81%], P <0 .001), greater frequency of open surgical treatment (72 of 94 [77%] vs 523 of 919 [57%], P <0 .001), and greater percentage of men (38 of 94 [40%] vs 273 of 919 [30%], P = .04). After adjustment, ultra-early treatment was not associated with neurologic outcome in those with at least 180-day follow-up (OR = 0.86), the occurrence of delayed cerebral ischemia (OR = 0.87), or length of stay (exp(β), 0.13) (P ≥ 0.60). CONCLUSIONS In a large, single-center cohort of aSAH patients, ultra-early treatment was not associated with better neurologic outcome, fewer cases of delayed cerebral ischemia, or shorter length of stay.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Emmajane G Rhodenhiser
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Robert F Rudy
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Dimitri Benner
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Tyler S Cole
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA
| | - Michael T Lawton
- Department of Neurosurgery, Neuroscience Publications, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W. Thomas Rd, Phoenix, AZ, 85013, USA.
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Wang J, Li R, Li S, Ma T, Zhang X, Ren Y, Chen X, Peng Y. Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study. Front Neurosci 2023; 17:1064987. [PMID: 36875639 PMCID: PMC9982002 DOI: 10.3389/fnins.2023.1064987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Background Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive. Methods All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups. Results Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI. Conclusions The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.
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Affiliation(s)
- Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Tjerkstra MA, Post R, Germans MR, Vergouwen MDI, Jellema K, Koot RW, Kruyt ND, Willems PWA, Wolfs JFC, de Beer FC, Kieft H, Nanda D, van der Pol B, Roks G, de Beer F, Halkes PHA, Reichman LJA, Brouwers PJAM, Van den Berg-Vos RM, Kwa VIH, van der Ree TC, Bronner I, Bienfait HP, Boogaarts H, Klijn CJM, van den Berg R, Coert BA, Horn J, Majoie CBLM, Rinkel GJE, Roos YBWM, Vandertop WP, Verbaan D. Tranexamic Acid After Aneurysmal Subarachnoid Hemorrhage: Post Hoc Analysis of the ULTRA Trial. Neurology 2022; 99:e2605-e2614. [PMID: 36266046 DOI: 10.1212/wnl.0000000000201160] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 07/11/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The ULTRA trial showed that ultra-early and short-term tranexamic acid treatment after subarachnoid hemorrhage did not improve clinical outcome at 6 months. An expected proportion of the included patients experienced nonaneurysmal subarachnoid hemorrhage. In this post hoc study, we will investigate whether ultra-early and short-term tranexamic acid treatment in patients with aneurysmal subarachnoid hemorrhage improves clinical outcome at 6 months. METHODS The ULTRA trial is a multicenter, prospective, randomized, controlled, open-label trial with blinded outcome assessment, conducted between July 24, 2013, and January 20, 2020. After confirmation of subarachnoid hemorrhage on noncontrast CT, patients were allocated to either ultra-early and short-term tranexamic acid treatment with usual care or usual care only. In this post hoc analysis, we included all ULTRA participants with a confirmed aneurysm on CT angiography and/or digital subtraction angiography. The primary endpoint was clinical outcome at 6 months, assessed by the modified Rankin scale (mRS), dichotomized into good (0-3) and poor (4-6) outcomes. RESULTS Of the 813 ULTRA trial patients who experienced an aneurysmal subarachnoid hemorrhage, 409 (50%) were assigned to the tranexamic acid group and 404 (50%) to the control group. In the intention-to-treat analysis, 233 of 405 (58%) patients in the tranexamic acid group and 238 of 399 (60%) patients in the control group had a good clinical outcome (adjusted odds ratio [aOR] 0.92; 95% CI 0.69-1.24). None of the secondary outcomes showed significant differences between the treatment groups: excellent clinical outcome (mRS 0-2) (aOR 0.76; 95% CI 0.57-1.03), all-cause mortality at 30 days (aOR 0.91; 95% CI 0.65-1.28), and all-cause mortality at 6 months (aOR 1.10; 95% CI 0.80-1.52). DISCUSSION Ultra-early and short-term tranexamic acid treatment did not improve clinical outcomes at 6 months in patients with aneurysmal subarachnoid hemorrhage and therefore cannot be recommended. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov (NCT02684812; submission date February 18, 2016, first patient enrollment on July 24, 2013). CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tranexamic acid does not improve outcomes in patients presenting with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Maud A Tjerkstra
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands.
| | - René Post
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Menno R Germans
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Mervyn D I Vergouwen
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Korné Jellema
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Radboud W Koot
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Nyika D Kruyt
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Peter W A Willems
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Jasper F C Wolfs
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Frits C de Beer
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Hans Kieft
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Dharmin Nanda
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Bram van der Pol
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Gerwin Roks
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Frank de Beer
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Patricia H A Halkes
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Loes J A Reichman
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Paul J A M Brouwers
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Renske M Van den Berg-Vos
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Vincent I H Kwa
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Taco C van der Ree
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Irene Bronner
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Henri P Bienfait
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Hieronymus Boogaarts
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Catharina J M Klijn
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - René van den Berg
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Bert A Coert
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Janneke Horn
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Charles B L M Majoie
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Gabriël J E Rinkel
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Yvo B W M Roos
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - W Peter Vandertop
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
| | - Dagmar Verbaan
- From the Department of Neurosurgery (M.A.T., R.P., B.A.C., W.V., D.V.), Amsterdam Neuroscience Research Institute, Amsterdam University Medical Centres, the Netherlands; Department of Neurosurgery (M.R.G.), Clinical Neuroscience Centre, University Hospital Zurich, Switzerland; Department of Neurology and Neurosurgery (M.D.I.V., P.W.A.W., G.J.E.R.), UMC Utrecht Brain Centre, University Medical Centre Utrecht, Utrecht University; Department of Neurology (K.J.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (R.W.K.), Leids University Medical Centre; Department of Neurology (N.D.K.), Leids University Medical Centre; Department of Neurosurgery (J.F.C.W.), Haaglanden Medical Centre, the Hague; Department of Neurosurgery (F.C.B., D.N.), Isala Hospital, Zwolle; Department of Intensive Care (H.K.), Isala Hospital, Zwolle; Department of Neurosurgery (B.P.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (G.R.), Elisabeth Tweesteden Ziekenhuis, Tilburg; Department of Neurology (F.B.), Spaarne Gasthuis, Haarlem; Department of Neurology (P.H.A.H.), Noordwest Ziekenhuisgroep, Alkmaar; Department of Neurology (L.J.A.R.), Ziekenhuisgroep Twente, Almelo; Department of Neurology (P.J.A.M.B.), Medisch Spectrum Twente, Enschede; Department of Neurology (R.M.V.B.-V., V.I.H.K.), OLVG, Amsterdam; Department of Neurology (R.M.V.B.-V., Y.B.W.M.R.), Amsterdam University Medical Centres, Llocation AMC; Department of Neurology (T.C.R.), Dijklander Hospital, Hoorn; Department of Neurology (I.B.), Flevo Hospital, Almere; Department of Neurology (H.P.B.), Gelre Hospital, Apeldoorn; Department of Neurosurgery (H.B.), Radboud University Medical Centre, Nijmegen; Department of Neurology (C.J.M.K.), Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen; Department of Radiology and Nuclear Medicine (R.B., C.B.L.M.M.), Amsterdam University Medical Centres, Location AMC; and Department of Intensive Care (J.H.), Amsterdam University Medical Centres, Location AMC, the Netherlands
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Picetti E, Barbanera A, Bernucci C, Bertuccio A, Bilotta F, Boccardi EP, Cafiero T, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Lanterna L, Menozzi R, Munari M, Panni P, Rossi S, Stocchetti N, Sturiale C, Zoerle T, Zona G, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)–Part 1. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2022; 2:13. [PMCID: PMC10245531 DOI: 10.1186/s44158-022-00042-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 03/21/2022] [Indexed: 06/16/2023]
Abstract
Abstract
Background
Issues remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI). In this manuscript, we aim to provide a list of experts’ recommendations regarding the early management of SAH patients from hospital admission, in a center with neurosurgical/neuro-endovascular facilities, until securing of the bleeding aneurysm.
Methods
A multidisciplinary consensus panel composed of 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different background (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted.
Results
Among 19 statements discussed. The consensus was reached on 18 strong recommendations. In one case, consensus could not be agreed upon and no recommendation was provided.
Conclusions
This consensus provides practical recommendations for the management of SAH patients in hospitals with neurosurgical/neuroendovascular facilities until aneurysm securing. It is intended to support clinician’s decision-making and not to mandate a standard of practice.
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Maldaner N, Visser V, Hostettler IC, Bijlenga P, Haemmerli J, Roethlisberger M, Guzman R, Daniel RT, Giammattei L, Stienen MN, Regli L, Verbaan D, Post R, Germans MR. External Validation of the HATCH (Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus) Score for Prediction of Functional Outcome After Subarachnoid Hemorrhage. Neurosurgery 2022; 91:906-912. [PMID: 36069543 DOI: 10.1227/neu.0000000000002128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The Hemorrhage, Age, Treatment, Clinical State, Hydrocephalus (HATCH) Score has previously shown to predict functional outcome in aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To validate the HATCH score. METHODS This is a pooled cohort study including prospective collected data on 761 patients with aSAH from 4 different hospitals. The HATCH score for prediction of functional outcome was validated using calibration and discrimination analysis (area under the curve). HATCH score model performance was compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score. RESULTS At the follow-up of at least 6 months, favorable (Glasgow Outcome Score 4-5) and unfavorable functional outcomes (Glasgow Outcome Score 1-3) were observed in 512 (73%) and 189 (27%) patients, respectively. A higher HATCH score was associated with an increased risk of unfavorable outcome with a score of 1 showing a risk of 1.3% and a score of 12 yielding a risk of 67%. External validation showed a calibration intercept of -0.07 and slope of 0.60 with a Brier score of 0.157 indicating good model calibration and accuracy. With an area under the curve of 0.81 (95% CI 0.77-0.84), the HATCH score demonstrated superior discriminative ability to detect favorable outcome at follow-up compared with the World Federation of Neurosurgical Societies and Barrow Neurological Institute score with 0.72 (95% CI 0.67-0.75) and 0.63 (95% CI 0.59-0.68), respectively. CONCLUSION This multicenter external validation analysis confirms the HATCH score to be a strong independent predictor for functional outcome. Its incorporation into daily practice may be of benefit for goal-directed patient care in aSAH.
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Affiliation(s)
- Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Victoria Visser
- Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | | | - Philippe Bijlenga
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | - Julien Haemmerli
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | | | - Raphael Guzman
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Lorenzo Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - René Post
- Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, The Netherlands
| | - Menno Robbert Germans
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Labán-Seminario LM, Carrillo-Larco RM, Bernabé-Ortiz A. Stroke-related length of hospitalization trends and in-hospital mortality in Peru. PeerJ 2022; 10:e14467. [PMID: 36452071 PMCID: PMC9703986 DOI: 10.7717/peerj.14467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
Background Peru faces challenges to provide adequate care to stroke patients. Length of hospitalization and in-hospital mortality are two well-known indicators of stroke care. We aimed to describe the length of stay (LOS) of stroke in Peru, and to assess in-hospital mortality risk due to stroke, and subtypes. Methods This retrospective cohort study used hospitalization registries coding with ICD-10 from 2002 to 2017 (N = 98,605) provided by the Ministry of Health; in-hospital mortality was available for 2016-2017 (N = 6,566). Stroke cases aged ≥35 years were divided into subarachnoid hemorrhage (I60), intracerebral hemorrhage (I61), cerebral infarction (I63), and stroke not specified as hemorrhage or infarction (I64). Data included stroke LOS and in-hospital mortality; socio-demographic and clinical variables. We fitted a region- and hospital level-stratified Weibull proportional hazard model to assess the in-hospital mortality. Results The median LOS was 7 days (IQR: 4-13). Hemorrhagic strokes had median LOS longer than ischemic strokes and stroke not specified as hemorrhage or infarction (P = <0.001). The case fatality rate (CFR) of patients with stroke was 11.5% (95% CI [10-12%]). Subarachnoid hemorrhage (HR = 2.45; 95% CI [1.91-3.14]), intracerebral hemorrhage (HR = 1.95; 95% CI [1.55-2.46]), and stroke not specified as hemorrhage or infarction (HR = 1.45; 95% CI [1.16-1.81]) were associated with higher in-hospital mortality risk in comparison to ischemic strokes. Discussion Between 2002 and 2017, LOS due to stroke has not changed in Peru in stroke patients discharged alive. Hemorrhagic cases had the longest LOS and highest in-hospital mortality risk during 2016 and 2017. The findings of our study seem to be consistent with a previous study carried out in Peru and similar to that of HIC and LMIC, also there is an increased median LOS in stroke cases managed in specialized centers. Likewise, LOS seems to depend on the type of stroke, where ischemic stroke cases have the lowest LOS. Peru needs to improve access to stroke care.
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Affiliation(s)
- L. Max Labán-Seminario
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Rodrigo M. Carrillo-Larco
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru,Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, United Kingdom
| | - Antonio Bernabé-Ortiz
- CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru,Universidad Científica del Sur, Lima, Peru
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Germans MR, Dronkers WJ, Baharoglu MI, Post R, Verbaan D, Rinkel GJ, Roos YB. Antifibrinolytic therapy for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2022; 11:CD001245. [PMID: 36350005 PMCID: PMC9644641 DOI: 10.1002/14651858.cd001245.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Rebleeding is an important cause of death and disability in people with aneurysmal subarachnoid haemorrhage. Rebleeding is probably related to the dissolution of the blood clot at the site of the aneurysm rupture by natural fibrinolytic activity. This review is an update of previously published Cochrane Reviews. OBJECTIVES To assess the effects of antifibrinolytic treatment in people with aneurysmal subarachnoid haemorrhage. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (May 2022), CENTRAL (in the Cochrane Library 2021, Issue 1), MEDLINE (December 2012 to May 2022), and Embase (December 2012 to May 2022). In an effort to identify further published, unpublished, and ongoing studies, we searched reference lists and trial registers, performed forward tracking of relevant references, and contacted drug companies (the latter in previous versions of this review). SELECTION CRITERIA Randomised trials comparing oral or intravenous antifibrinolytic drugs (tranexamic acid, epsilon amino-caproic acid, or an equivalent) with control in people with subarachnoid haemorrhage of suspected or proven aneurysmal cause. DATA COLLECTION AND ANALYSIS Two review authors (MRG & WJD) independently selected trials for inclusion, and extracted the data for the current update. In total, three review authors (MIB & MRG in the previous update; MRG & WJD in the current update) assessed risk of bias. For the primary outcome, we dichotomised the outcome scales into good and poor outcome, with poor outcome defined as death, vegetative state, or (moderate) severe disability, assessed with either the Glasgow Outcome Scale or the Modified Rankin Scale. We assessed death from any cause, rates of rebleeding, delayed cerebral ischaemia, and hydrocephalus per treatment group. We expressed effects as risk ratios (RR) with 95% confidence intervals (CI). We used random-effects models for all analyses. We assessed the quality of the evidence with GRADE. MAIN RESULTS We included one new trial in this update, for a total of 11 included trials involving 2717 participants. The risk of bias was low in six studies. Five studies were open label, and we rated them at high risk of performance bias. We also rated one of these studies at high risk for attrition and reporting bias. Five trials reported on poor outcome (death, vegetative state, or (moderate) severe disability), with a pooled risk ratio (RR) of 1.03 (95% confidence interval (CI) 0.94 to 1.13; P = 0.53; 5 trials, 2359 participants; high-quality evidence), which showed no difference between groups. All trials reported on death from all causes, which showed no difference between groups, with a pooled RR of 1.02 (95% CI 0.90 to 1.16; P = 0.77; 11 trials, 2717 participants; high-quality evidence). In trials that combined short-term antifibrinolytic treatment (< 72 hours) with preventative measures for delayed cerebral ischaemia, the RR for poor outcome was 0.98 (95% CI 0.81 to 1.18; P = 0.83; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment reduced the risk of rebleeding, reported at the end of follow-up (RR 0.65, 95% CI 0.47 to 0.91; P = 0.01; 11 trials, 2717 participants; absolute risk reduction 7%, 95% CI 3 to 12%; moderate-quality evidence), but there was heterogeneity (I² = 59%) between the trials. The pooled RR for delayed cerebral ischaemia was 1.27 (95% CI 1.00 to 1.62; P = 0.05; 7 trials, 2484 participants; moderate-quality evidence). However, this effect was less extreme after the implementation of ischaemia preventative measures and < 72 hours of treatment (RR 1.10, 95% CI 0.83 to 1.46; P = 0.49; 2 trials, 1318 participants; high-quality evidence). Antifibrinolytic treatment showed no effect on the reported rate of hydrocephalus (RR 1.09, 95% CI 0.99 to 1.20; P = 0.09; 6 trials, 1992 participants; high-quality evidence). AUTHORS' CONCLUSIONS The current evidence does not support the routine use of antifibrinolytic drugs in the treatment of people with aneurysmal subarachnoid haemorrhage. More specifically, early administration with concomitant treatment strategies to prevent delayed cerebral ischaemia does not improve clinical outcome. There is sufficient evidence from multiple randomised controlled trials to incorporate this conclusion in treatment guidelines.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
- Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Wouter J Dronkers
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Merih I Baharoglu
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
| | - Gabriel Je Rinkel
- Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, Netherlands
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
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Koester SW, Catapano JS, Rumalla K, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Baranoski JF, Srinivasan VM, Graffeo CS, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Health Care Expenditures Associated with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis. World Neurosurg 2022; 167:e600-e606. [PMID: 35995358 DOI: 10.1016/j.wneu.2022.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The additional hospital costs associated with delayed cerebral ischemia (DCI) have not been well investigated in prior literature. In this study, the total hospital cost of DCI in aneurysmal subarachnoid hemmorhage (aSAH) patients treated at a single quaternary center was analyzed. METHODS All patients in the Post-Barrow Ruptured Aneurysm Trial treated for an aSAH between January 1, 2014, and July 31, 2019, were retrospectively analyzed. DCI was defined as cerebral infarction identified on computed tomography, magnetic resonance imaging, or autopsy after exclusion of procedure-related infarctions. The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Propensity score covariate-adjusted linear regression analysis included age, sex, open versus endovascular treatment, Hunt and Hess score, and Charlson Comorbidity Index score. RESULTS Of the 391 patients included, 144 (37%) had DCI. Patients with DCI had a significantly greater cost compared to patients without DCI (mean standard deviation $112,081 [$54,022] vs. $86,159 [$38,817]; P < 0.001) and a significantly greater length of stay (21 days [11] vs. 18 days [8], P = 0.003, respectively). In propensity-adjusted linear regression analysis, both DCI (odds ratio, $13,871; 95% confidence interval, $7558-$20,185; P < 0.001) and length of stay (odds ratio, $3815 per day; 95% confidence interval, $3480-$4149 per day; P < 0.001) were found to significantly increase the cost. CONCLUSIONS The significantly higher costs associated with DCI further support the evidence that adverse effects associated with DCI in aSAH pose a significant burden to the health care system.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Wu B, Huang Z, Liu H, He J, Ju Y, Chen Z, Zhang T, Yi F. Ultra-early endovascular treatment improves prognosis in High grade aneurysmal subarachnoid hemorrhage: A single-center retrospective study. Front Neurol 2022; 13:963624. [PMID: 36034293 PMCID: PMC9413045 DOI: 10.3389/fneur.2022.963624] [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: 06/07/2022] [Accepted: 07/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The long-term survival prognosis of patients with high-grade (Hunt-Hess grade IV–V or World Federation of Neurosurgical Societies grade IV–V) aneurysmal subarachnoid hemorrhage (aSAH) is generally poor, and the association between endovascular treatment timing and the prognosis of high-grade aSAH has not been explored in depth. This retrospective cohort study aimed to determine whether endovascular treatment within 24 h of high-grade aSAH is associated with a better prognosis. Methods We retrospectively analyzed the clinical data of patients with high-grade aSAH who were admitted to our institution between January 2018 and January 2021. The Modified Rankin Scale score was used to assess the 6-month prognosis of patients. Univariate and multivariate logistic regression analyses were used to identify the factors associated with prognosis. The area under the receiver operating characteristic (ROC) curve was used to assess the model's discriminatory ability. Results Eighty-six patients were included in the study. In the multivariate analysis, the timing of endovascular treatment (odds ratio = 7.003 [1.800–27.242], P = 0.005) was an independent risk factor for prognosis. The ROC curve showed that the predictive power of the timing of endovascular treatment was 0.744, the best cut-off value was 12.5 h, and the corresponding sensitivity and specificity were 71.4 and 70.5%, respectively. Hydrocephalus (P = 0.005) and pulmonary infection (P = 0.029) were also associated with prognosis. In addition, cerebrospinal fluid drainage immediately after endovascular treatment had a significant effect on reducing hydrocephalus formation. Conclusions Endovascular therapy within 24 h is feasible and improves the prognosis of patients with high-grade aSAH.
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Affiliation(s)
- Botao Wu
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Zhe Huang
- Department of Radiology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Huan Liu
- Department of General Surgery, Zhongshan Hospital of Traditional Chinese Medicine, Guangzhou University of Traditional Chinese Medicine, Zhongshan, China
| | - Jiayao He
- Department of Orthopedics, Affiliated Hospital of Chengdu University, Chengdu, China
| | - Yan Ju
- Department of Endocrinology, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Ziwei Chen
- Department of Neurosurgery, The Third Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Taiwei Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
| | - Fuxin Yi
- Department of Neurosurgery, The First Affiliated Hospital of Jinzhou Medical University, Jinzhou, China
- *Correspondence: Fuxin Yi
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Campos YA, Rana P, Reyes RG, Mazhar K, Stutzman SE, Atem F, Olson DM, Aiyagari V. Relationship Between Automated Pupillometry Measurements and Ventricular Volume in Patients With Aneurysmal Subarachnoid Hemorrhage. J Neurosci Nurs 2022; 54:166-170. [PMID: 35776519 DOI: 10.1097/jnn.0000000000000657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT INTRODUCTION: Pupillometry allows for a standardized assessment of the pupillary light reflex. Acute hydrocephalus (HCP) is a common complication in patients with aneurysmal subarachnoid hemorrhage (aSAH). HCP may affect the pupillary light reflex because of increased intracranial pressure or dilation of the rostral aqueduct. The association between the pupillary light reflex and HCP in aSAH patients has not been clearly established. The objective of this study is to analyze the correlation between the Neurological Pupil index (NPi) and the degree of HCP in aSAH patients. METHODS: The Establishing Normative Data for Pupillometer Assessments in Neuroscience Intensive Care Registry is a prospectively collected database of pupillometry readings in patients admitted to 4 different neurological intensive care units. Patients in the registry with aSAH who had pupillometry assessments within 6 hours of a brain computed tomography were studied. The degree of HCP was quantified using the HCP score, and the relationship between the NPi and HCP was analyzed after controlling for confounders. RESULTS: A total of 43 patients were analyzed (mean age, 54 ± 15 years; 53.2% male; mean HCP score, 5.3 ± 3.8). Thirty-eight patients had HCP. Mean NPi for the right eye was 4.02 (±1.2), and that for the left eye was 3.7 (±1.5). After adjusting for age, sex, race, and sedation, there was no significant correlation between HCP and NPi (right eye: r = 0.12, P = .44; left eye: r = 0.04, P = .8). CONCLUSION: In patients with aSAH, NPi was not correlated with HCP score. A small sample size could be a limitation of this study. Additional studies are needed to characterize the clinical significance of pupillometry in the evaluation of patients with aSAH and HCP.
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Mistry AM, Magarik JA, Feldman MJ, Wang L, Lindsell CJ, Fusco MR, Chitale RV, Bernard GR, Self WH, Rice TW, Hughes CG, Mistry EA, Semler MW. Saline versus Balanced Crystalloids for Adults with Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial. STROKE (HOBOKEN, N.J.) 2022; 2:e000128. [PMID: 36186896 PMCID: PMC9518828 DOI: 10.1161/svin.121.000128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with lower risk of disability and death in aSAH patients compared to balanced crystalloids. METHODS We conducted a post hoc subgroup analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), a pragmatic, unblinded, cluster-randomized, multiple-crossover clinical trial that enrolled 15,802 adults between June 2015 and April 2017. We compared intravenous administration of saline to balanced crystalloids in consecutively enrolled aSAH patients aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between-group differences adjusted for age, hypertension, aSAH grade, and procedure type. RESULTS Of the 79 aSAH patients procedurally treated during the SMART study period, 78 were enrolled (median age, 58 years; IQR, 49 to 64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma-Lyte was the primary balanced crystalloid used. Among 72 patients with 90-day mRS assessment, the adjusted common odds ratio, aOR, for mRS was 0.68 (95% CI, 0.28-1.63; P=0.39), with values less than 1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced-crystalloids group had died (aOR, 0.06; 95% CI, 0.00-0.50; P=0.02). CONCLUSIONS Among procedurally treated aSAH patients, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids.
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Affiliation(s)
| | - Jordan A. Magarik
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Michael J. Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Matthew R. Fusco
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rohan V. Chitale
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gordon R. Bernard
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Eva A. Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W. Semler
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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Jiang W, Zuo Q, Xue G, Zhang X, Tang H, Duan G, Lv N, Zhang L, Feng Z, Wu Y, Yu Y, Liu P, Zhao R, Li Q, Fang Y, Yang P, Zhao K, Dai D, Hong B, Xu Y, Huang Q, Liu J. Low profile visualized intraluminal support stent-assisted Hydrocoil embolization for acutely ruptured wide-necked intracranial aneurysms: a propensity score-matched cohort study. Clin Neurol Neurosurg 2022; 218:107302. [DOI: 10.1016/j.clineuro.2022.107302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 05/03/2022] [Accepted: 05/15/2022] [Indexed: 11/16/2022]
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Dodd WS, Laurent D, Lucke-Wold B, Busl KM, Williams E, Hoh BL. Sensorineural hearing loss due to delayed cerebral ischemia in bilateral auditory cortices following aneurysmal subarachnoid hemorrhage: illustrative case. JOURNAL OF NEUROSURGERY. CASE LESSONS 2022; 3:CASE21700. [PMID: 35712049 PMCID: PMC9199112 DOI: 10.3171/case21700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022]
Abstract
BACKGROUND Recognizing rare signs of delayed cerebral ischemia (DCI) is crucial to caring for patients with subarachnoid hemorrhage. The authors presented a case of central hearing loss that occurred during the clinical course of a patient treated for aneurysmal subarachnoid hemorrhage. OBSERVATIONS The patient had a ruptured right posterior communicating artery aneurysm successfully treated with coil embolization but later developed severe vasospasm and DCI. She developed bilateral hearing loss, and imaging revealed DCI to the left temporal lobe and the right auditory cortex. Computed tomography angiography and digital subtraction angiography demonstrated severe vasospasm of bilateral internal carotid arteries, bilateral middle cerebral arteries, and bilateral anterior cerebral arteries. One month after hospitalization, the patient had recovered fully neurologically intact except for persistent hearing loss. LESSONS This case serves to teach important neuroanatomical features and discuss the unique pathophysiology of DCI affecting the auditory cortex.
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Affiliation(s)
| | | | | | - Katharina M. Busl
- Neurology, College of Medicine, University of Florida, Gainesville, Florida
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Affiliation(s)
- Nikolaus Plesnila
- Institute for Stroke and Dementia Research, University of Munich, Germany
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Stienen MN, Germans MR, Zindel-Geisseler O, Dannecker N, Rothacher Y, Schlosser L, Velz J, Sebök M, Eggenberger N, May A, Haemmerli J, Bijlenga P, Schaller K, Guerra-Lopez U, Maduri R, Beaud V, Al-Taha K, Daniel RT, Chiappini A, Rossi S, Robert T, Bonasia S, Goldberg J, Fung C, Bervini D, Maradan-Gachet ME, Gutbrod K, Maldaner N, Neidert MC, Früh S, Schwind M, Bozinov O, Brugger P, Keller E, Marr A, Roux S, Regli L. Longitudinal neuropsychological assessment after aneurysmal subarachnoid hemorrhage and its relationship with delayed cerebral ischemia: a prospective Swiss multicenter study. J Neurosurg 2022; 137:1742-1750. [PMID: 35535839 DOI: 10.3171/2022.2.jns212595] [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: 11/10/2021] [Accepted: 02/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While prior retrospective studies have suggested that delayed cerebral ischemia (DCI) is a predictor of neuropsychological deficits after aneurysmal subarachnoid hemorrhage (aSAH), all studies to date have shown a high risk of bias. This study was designed to determine the impact of DCI on the longitudinal neuropsychological outcome after aSAH, and importantly, it includes a baseline examination after aSAH but before DCI onset to reduce the risk of bias. METHODS In a prospective, multicenter study (8 Swiss centers), 112 consecutive alert patients underwent serial neuropsychological assessments (Montreal Cognitive Assessment [MoCA]) before and after the DCI period (first assessment, < 72 hours after aSAH; second, 14 days after aSAH; third, 3 months after aSAH). The authors compared standardized MoCA scores and determined the likelihood for a clinically meaningful decline of ≥ 2 points from baseline in patients with DCI versus those without. RESULTS The authors screened 519 patients, enrolled 128, and obtained complete data in 112 (87.5%; mean [± SD] age 53.9 ± 13.9 years; 66.1% female; 73% World Federation of Neurosurgical Societies [WFNS] grade I, 17% WFNS grade II, 10% WFNS grades III-V), of whom 30 (26.8%) developed DCI. MoCA z-scores were worse in the DCI group at baseline (-2.6 vs -1.4, p = 0.013) and 14 days (-3.4 vs -0.9, p < 0.001), and 3 months (-0.8 vs 0.0, p = 0.037) after aSAH. Patients with DCI were more likely to experience a decline of ≥ 2 points in MoCA score at 14 days after aSAH (adjusted OR [aOR] 3.02, 95% CI 1.07-8.54; p = 0.037), but the likelihood was similar to that in patients without DCI at 3 months after aSAH (aOR 1.58, 95% CI 0.28-8.89; p = 0.606). CONCLUSIONS Aneurysmal SAH patients experiencing DCI have worse neuropsychological function before and until 3 months after the DCI period. DCI itself is responsible for a temporary and clinically meaningful decline in neuropsychological function, but its effect on the MoCA score could not be measured at the time of the 3-month follow-up in patients with low-grade aSAH with little or no impairment of consciousness. Whether these findings can be extrapolated to patients with high-grade aSAH remains unclear. Clinical trial registration no.: NCT03032471 (ClinicalTrials.gov).
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Affiliation(s)
- Martin N Stienen
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich.,13Neuropsychology Unit, Department of Neurology, University Hospital Berne
| | - Menno R Germans
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | | | - Noemi Dannecker
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Yannick Rothacher
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Ladina Schlosser
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Julia Velz
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Martina Sebök
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Noemi Eggenberger
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich
| | - Adrien May
- 4Department of Neurosurgery, University Hospital Geneva
| | | | | | - Karl Schaller
- 4Department of Neurosurgery, University Hospital Geneva
| | | | - Rodolfo Maduri
- 6Avaton Surgical Group, Clinique de Genolier, Swiss Medical Network, Genolier
| | - Valérie Beaud
- 7Neuropsychology Unit, Department of Neurology, University Hospital Lausanne
| | - Khalid Al-Taha
- 8Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne
| | - Roy Thomas Daniel
- 8Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne
| | | | - Stefania Rossi
- 10Neuropsychology Unit, Department of Neurology, Cantonal Hospital Lugano
| | - Thomas Robert
- 9Department of Neurosurgery, Cantonal Hospital Lugano
| | - Sara Bonasia
- 9Department of Neurosurgery, Cantonal Hospital Lugano
| | - Johannes Goldberg
- 11Department of Neurosurgery, University Hospital Berne, Switzerland
| | - Christian Fung
- 11Department of Neurosurgery, University Hospital Berne, Switzerland.,12Department of Neurosurgery, University Hospital Freiburg, Germany
| | - David Bervini
- 11Department of Neurosurgery, University Hospital Berne, Switzerland
| | | | - Klemens Gutbrod
- 13Neuropsychology Unit, Department of Neurology, University Hospital Berne
| | | | | | - Severin Früh
- 15Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen
| | - Marc Schwind
- 15Neuropsychology Unit, Department of Neurology, Cantonal Hospital St. Gallen
| | - Oliver Bozinov
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich.,14Department of Neurosurgery, Cantonal Hospital St. Gallen
| | - Peter Brugger
- 3Neuropsychology Unit, Department of Neurology, University Hospital Zurich.,16Neuropsychology Unit, Rehabilitation Clinic Valens; and
| | - Emanuela Keller
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
| | - Angelina Marr
- 17Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Sébastien Roux
- 17Global Clinical Development, Idorsia Pharmaceuticals Ltd., Allschwil, Switzerland
| | - Luca Regli
- 1Department of Neurosurgery, University Hospital Zurich.,2Clinical Neuroscience Center, University of Zurich
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Admission rate-pressure product as an early predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 45:2811-2822. [PMID: 35488072 DOI: 10.1007/s10143-022-01795-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 03/18/2022] [Accepted: 04/19/2022] [Indexed: 10/18/2022]
Abstract
Early prediction of in-hospital mortality in aneurysmal subarachnoid hemorrhage (aSAH) is essential for the optimal management of these patients. Recently, a retrospective cohort observation has reported that the rate-pressure product (RPP, the product of systolic blood pressure and heart rate), an objective and easily calculated bedside index of cardiac hemodynamics, was predictively associated with in-hospital mortality following traumatic brain injury. We thus wondered whether this finding could also be generalized to aSAH patients. The current study aimed to examine the association of RPP at the time of emergency room (ER) admission with in-hospital mortality and its predictive performance among aSAH patients. We retrospectively included 515 aSAH patients who had been admitted to our ER between 2016 and 2020. Their baseline heart rate and systolic blood pressure at ER presentation were extracted for the calculation of the admission RPP. Meanwhile, we collected relevant clinical, laboratory, and neuroimaging data. Then, these data including the admission RPP were examined by univariate and multivariate analyses to identify independent predictors of hospital mortality. Eventually, continuous and ordinal variables were selected from those independent predictors, and the performance of these selected predictors was further evaluated and compared based on receiver operating characteristic (ROC) curve analyzes. We identified both low (< 10,000; adjusted odds ratio (OR) 3.49, 95% CI 1.93-6.29, p < 0.001) and high (> 15,000; adjusted OR 8.42, 95% CI 4.16-17.06, p < 0.001) RPP on ER admission to be independently associated with in-hospital mortality after aSAH. Furthermore, after centering the admission RPP by its median, the area under its ROC curve (0.761, 95% CI 0.722-0.798, p < 0.001) was found to be statistically superior to any of the other independent predictors included in the ROC analyzes (all p < 0.01). In light of the predictive superiority of the admission RPP, as well as its objectivity and easy accessibility, it is indeed a potentially more applicable predictor for in-hospital death in aSAH patients.
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Economic and Humanistic Burden of Cerebral Vasospasm and Its Related Complications after Aneurysmal Subarachnoid Hemorrhage: A Systematic Literature Review. Neurol Ther 2022; 11:597-620. [PMID: 35441974 PMCID: PMC9095797 DOI: 10.1007/s40120-022-00348-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 03/23/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction Cerebral vasospasm (VSP) is the leading risk factor of neurological deterioration (i.e., delayed cerebral ischemia [DCI] and cerebral infarction) after aneurysmal subarachnoid hemorrhage (aSAH) and a cause of morbidity and mortality. The objective of this systematic literature review is to summarize the economic and humanistic burden of VSP and its related complications after aSAH. Methods A predefined protocol was designed, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Systematic searches were conducted in MEDLINE, Embase, and Cochrane (in January 2021) to identify studies reporting economic and/or humanistic (i.e., health-related quality of life [HRQoL]) outcomes for patients with asymptomatic and symptomatic VSP after aSAH. Related conferences and additional sources were searched manually. Dual screening, data extraction, and qualitative analysis were conducted. Results Of 3818 abstracts identified for review, 43 full-text articles representing 42 single studies met the inclusion criteria and were included. Most studies (33) were observational; nine were randomized clinical trials (RCTs). Economic outcomes were reported in 31 studies, and alongside HRQoL outcomes in 4 studies; 7 studies reported HRQoL outcomes only. Forty studies were conducted in single countries, while only 2 RCTs were conducted in multiple countries. Patients diagnosed with VSP or DCI spent between 2.1 and 7.4 days longer in intensive care and between 4.7 and 17 days longer in hospital (total) compared with patients without VSP or DCI. A significantly higher cost burden of US$33,945 (2021 £26,712) was identified for patients with VSP and £9370 (2021 £13,733) for patients with DCI compared with patients without. Patients with DCI were also disadvantaged by being employed for 62 fewer days (during 24-month follow-up), with an estimated mean cost of £3821 (2021 £5600) for days off work. Poor HRQoL was associated with ≥ 1 days with VSP symptoms (odds ratio [OR]: 2.8, 95% confidence interval [CI]: 1.4–5.3), symptomatic VSP (OR: 1.9, 95% CI: 1.0–3.6), and DCI (OR: 2.3, 95% CI: 1.3–4.2), although this was not consistent across all studies. Symptomatic VSP and DCI were identified as significant risk factors for depressed mood (OR: 2.2, 95% CI: 1.0–4.9) and global cognitive impairment (OR: 2.3) at 12 months, respectively. The severity of VSP was a critical predictor of post-aSAH economic and humanistic burden. Similar trends in economic and humanistic burden were identified in the general aSAH patient population. Study design and patient heterogeneity precluded direct metaanalysis of the results. Conclusion A substantial direct and indirect economic burden is linked to VSP and its related complications after aSAH. Although limited evidence was identified for humanistic burden, these patients seem to suffer from poor HRQoL with long-lasting burden. Overall, there is an urgent need to understand better the concept of “burden of illness” of VSP and its related complications after aSAH. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00348-6. Aneurysmal subarachnoid hemorrhage is a sudden, life-threatening emergency caused by bleeding in the subarachnoid space between the brain and skull. Vasospasm of the arteries surrounding the hemorrhage occurs in most patients and may lead to permanent brain damage. This study summarizes the published literature to describe the burden that patients may experience due to vasospasm and its related complications after aneurysmal subarachnoid hemorrhage, focusing on financial and life quality aspects. We show that the burden of vasospasm, and its related complications, is huge. Patients often experience reduced quality of life due to their poor health and are more likely to suffer from depression and intellectual impairment. There is also a substantial financial burden linked to vasospasm and its related complications, driven by the need for more intensive care, hospitalization, and higher investigative costs associated with the treatment and management of these patients. In addition, days off work and unemployment can cause a substantial indirect financial burden. Our study highlights the need for additional research to understand further the “burden of illness” of vasospasm and its related complications after aneurysmal subarachnoid hemorrhage.
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Tjerkstra MA, Verbaan D, Coert BA, Post R, van den Berg R, Coutinho JM, Horn J, Vandertop WP. Large practice variations in diagnosis and treatment of delayed cerebral ischemia after subarachnoid hemorrhage. World Neurosurg 2022; 160:e412-e420. [PMID: 35033694 DOI: 10.1016/j.wneu.2022.01.033] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 01/07/2022] [Accepted: 01/08/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) contributes to poor outcomes after subarachnoid hemorrhage (SAH). The pathophysiology of DCI is not fully understood, which has hindered the adoption of a uniform definition. Furthermore, a reliable diagnostic test and an effective evidence-based treatment are lacking. This could lead to variations in care. METHODS A web-based survey on the variations in the definition, diagnosis, and treatment of DCI was designed and sent to 314 intensivists, neurologists, and neurosurgeons of all 9 hospitals in the Netherlands who care for patients with SAH. The responders were categorized into physicians responsible for the coordination of SAH care and those who were not. For questions on the definition and diagnosis, only the responses from the coordinating physicians were evaluated. For the treatment questions, all the responses were evaluated. RESULTS The response rate was 34% (106 of 314). All 9 hospitals were represented. Of the responses, 27 did not provide answers for the definition, diagnosis, or treatment questions; 79 responses were used for analysis. Signs of vasospasm were required by 21 of the 47 coordinating physicians (44%) when considering DCI. Of the 47 coordinating physicians, 24 (51%) did not use a diagnostic test results for a positive diagnosis of DCI. When patients were discharged within 21 days, 33 of the 73 responders (45%) did not provide a prescription for nimodipine continuation. Finally, all but one hospital had treated DCI with hypertension induction. CONCLUSIONS We found large variations in the definition, diagnosis, and treatment of DCI in the Netherlands. In the absence of evidence-based treatment, standardization of management seems warranted in an effort to optimize DCI care.
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Affiliation(s)
- Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands.
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Janneke Horn
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam Neurosciences, Amsterdam University Medical Centers, Amsterdam, the Netherlands
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Sirataranon P, Duangthongphon P, Limwattananon P. Preoperative predictors of poor outcomes in Thai patients with aneurysmal subarachnoid hemorrhage. PLoS One 2022; 17:e0264844. [PMID: 35290381 PMCID: PMC8923474 DOI: 10.1371/journal.pone.0264844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 02/17/2022] [Indexed: 12/03/2022] Open
Abstract
Objective A scoring system for aneurysmal subarachnoid hemorrhage (aSAH) is useful for guiding treatment decisions, especially in urgent-care limited settings. This study developed a simple algorithm of clinical conditions and grading to predict outcomes in patients treated by clipping or coiling. Methods Data on patients with aSAH hospitalized in a university’s neurovascular center in Thailand from 2013 to 2018 were obtained for chart review. Factors associated with poor outcomes evaluated at one year were identified using a stepwise logistic regression model. For each patient, the rounded regression coefficients of independent risk factors were linearly combined into a total score, which was assessed for its performance in predicting outcomes using receiver operating characteristic analysis. An appropriate cutoff point of the scores for poor outcomes was based on Youden’s criteria, which maximized the summation between sensitivity or true positive rate and the specificity or true negative rate. Results Patients (n, 121) with poor outcomes (modified Rankin Scale, mRS score, 4–6) had a significantly higher proportion of old age, underlying hypertension, diabetes and chronic kidney disease, high clinical severity grading, preoperative rebleeding, and hydrocephalus than those (n, 336) with good outcomes (mRS score, 0–3). Six variables, including age >70 years, diabetes mellitus, World Federation of Neurosurgical Societies (WFNS) scaling of IV-V, modified Fisher grading of 3–4, rebleeding, and hydrocephalus, were identified as independent risk factors and were assigned a score weight of 2, 1, 2, 1, 3 and 1, respectively. Among the total possible scores ranging from 0–10, the cut point at score 3 yielded the maximum Youden’s index (0.527), which resulted in a sensitivity of 77.7% and specificity of 75.0%. Conclusion A simple 0–10 scoring system on six risk factors for poor outcomes was validated for aSAH and should be advocated for use in limited resource settings.
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Affiliation(s)
- Punnarat Sirataranon
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Pichayen Duangthongphon
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
- * E-mail:
| | - Phumtham Limwattananon
- Neurosurgery Unit, Department of Surgery, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
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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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Yang J, Lu J, Li R, Lin F, Chen Y, Han H, Yan D, Li R, Li Z, Zhang H, Yuan K, Li H, Zhang L, Shi G, Zhou J, Wang S, Zhao Y, Chen X. Application of Intracranial Pressure-Directed Therapy on Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Front Aging Neurosci 2022; 14:831994. [PMID: 35360218 PMCID: PMC8964287 DOI: 10.3389/fnagi.2022.831994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 02/21/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectiveElevated ICP is a well-recognized phenomenon in aneurysmal subarachnoid hemorrhage (aSAH) that has been demonstrated to lead to poor outcomes. Delayed cerebral ischemia (DCI) is the most important reason for a poor clinical outcome after a subarachnoid hemorrhage. DCI is understood as a multifactorial process that evolves over time, largely caused by the sequelae of increased intracranial pressure (ICP). The study aimed to assess how to better define the association between ICP and DCI, and whether rational ICP management can improve the outcome of aSAH patients.MethodsWe prospectively reviewed patients diagnosed with aSAH and received microsurgery clipping at our department from December 2019 to January 2021. Subdural ICP monitoring devices were kept to monitor the ICP. The ICP values were recorded every 1-h epochs. ICP -guided dehydration treatments were routinely performed to control the ICP level of patients after surgery. To evaluate whether the subdural ICP-directed management improved the prognosis of the aSAH patients, we compared the outcome data of the patients in our cohort with those treated at another ward of our hospital at the same period.ResultsIn total, 144 consecutive aSAH patients received microsurgery clipping at our department, 68 of whom underwent ICP monitoring. A total of 11,424 1-h ICP measurements were recorded for the included patients (1.30 years of recordings). Of 68 patients with ICP monitoring, 27 (27/68, 39.7%) patients developed DCI. Univariate analysis showed that higher Hunt-Hess grade (OR 2.138, 95% CI 1.025–4.459, p = 0.043), higher preoperative modified Rankin Scale score (OR 1.534, 95% CI 1.033–2.276, p = 0.034), and the max ICP value of each day value >28.5 mmHg (OR 4.442, 95% CI 1.509–13.082, p = 0.007) were associated with DCI. Also, patients with ICP-directed treatment showed a significantly lower DCI incidence than patients without ICP monitoring.ConclusionOur study suggests that I less than 15 mmHg possibly constitute normal values and that 28.5 mmHg is the ICP threshold most strongly associated with the occurrence of DCI in aSAH patients. Patients who received the ICP-directed treatment presented a lower incidence of DCI. Our findings provide a basis for the recommendation of ICP-directed treatment after aSAH.Trial Registration NumberNCT04785976.
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Affiliation(s)
- Jun Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Debin Yan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ruinan Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhipeng Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Haibin Zhang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Kexin Yuan
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hongliang Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guangzhi Shi
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jianxin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
| | - Yuanli Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- Beijing Translational Engineering Center for 3D Printer in Clinical Neuroscience, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
- Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
- Beijing Key Laboratory of Translational Medicine for Cerebrovascular Disease, Beijing, China
- *Correspondence: Xiaolin Chen,
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