Subarachnoid hemorrhage: who dies, and why?

Blood DNA Methylation Analysis Reveals a Distinctive Epigenetic Signature of Vasospasm in Aneurysmal Subarachnoid Hemorrhage

Vasospasm is a potentially preventable cause of poor prognosis in patients with aneurysmal subarachnoid hemorrhage (aSAH). Epigenetics might provide insight on its molecular mechanisms. We aimed to analyze the association between differential DNA methylation (DNAm) and development of vasospasm. We conducted an epigenome-wide association study in 282 patients with aSAH admitted to our hospital. DNAm was assessed with the EPIC Illumina chip (> 850 K CpG sites) in whole-blood samples collected at hospital admission. We identified differentially methylated positions (DMPs) at the CpG level using Cox regression models adjusted for potential confounders, and then we used the DMP results to find differentially methylated regions (DMRs) and enriched biological pathways. A total of 145 patients (51%) experienced vasospasm. In the DMP analysis, we identified 31 CpGs associated with vasospasm at p-value < 10-5. One of them (cg26189827) was significant at the genome-wide level (p-value < 10-8), being hypermethylated in patients with vasospasm and annotated to SUGCT gene, mainly expressed in arteries. Region analysis revealed 13 DMRs, some of them annotated to interesting genes such as POU5F1, HLA-DPA1, RUFY1, and CYP1A1. Functional enrichment analysis showed the involvement of biological processes related to immunity, inflammatory response, oxidative stress, endothelial nitric oxide, and apoptosis. Our findings show, for the first time, a distinctive epigenetic signature of vasospasm in aSAH, establishing novel links with essential biological pathways, including inflammation, immune responses, and oxidative stress. Although further validation is required, our results provide a foundation for future research into the complex pathophysiology of vasospasm.

Development of a 3D Brain Model to Study Sex-Specific Neuroinflammation After Hemorrhagic Stroke

Subarachnoid hemorrhage (SAH) accounts for 5% of stroke, with women having a decreased inflammatory response compared to men; however, this mechanism has yet to be identified. One hurdle in SAH research is the lack of human brain models. Studies in murine models are helpful, but human models should be used in conjunction for improved translatability. These observations lead us to develop a 3D system to study the sex-specific microglial and neuroglial function in a novel in vitro human SAH model and compare it to our validated in vivo SAH model. Our lab has developed a 3D, membrane-based in vitro cell culture system with human astrocytes, microglia, and neurons from both sexes. The 3D cultures were incubated with male and female cerebrospinal fluid from SAH patients in the Neuro-ICU. Furthermore, microglial morphology, erythrophagocytosis, microglial inflammatory cytokine production, and neuronal apoptosis were studied and compared with our murine SAH models. The human 3D system demonstrated intercellular interactions and proportions of the three cell types similar to the adult human brain. In vitro and in vivo models of SAH showed concordance in male microglia being more inflammatory than females via morphology and flow cytometry. On the contrary, both in vitro and in vivo models revealed that female microglia were more phagocytic and less prone to damaging neurons than males. One possible explanation for the increased phagocytic ability of female microglia was the increased expression of CD206 and MerTK. Our in vitro, human, 3D cell culture SAH model showed similar results to our in vivo murine SAH model with respect to microglial morphology, inflammation, and phagocytosis when comparing the sexes. A human 3D brain model of SAH may be a useful adjunct to murine models to improve translation to SAH patients.

Multi-centric AI Model for Unruptured Intracranial Aneurysm Detection and Volumetric Segmentation in 3D TOF-MRI

The aim of this study was to develop an open-source nnU-Net-based AI model for combined detection and segmentation of unruptured intracranial aneurysms (UICA) in 3D TOF-MRI and compare models trained on datasets with aneurysm-like differential diagnoses. This retrospective study (2020–2023) included 385 anonymized 3D TOF-MRI images from 345 patients (mean age 59 years, 60% female) at multiple centers plus 113 subjects from the ADAM challenge. Images featured untreated or possible UICA and differential diagnoses. Four distinct training datasets were created, and the nnU-Net framework was used for model development. Performance was assessed on a separate test set using sensitivity and false positive (FP)/case rate for detection and DICE score and NSD (normalized surface distance, 0.5 mm threshold) for segmentation. Segmentation performance on the test set was also compared to a second human reader. The four models achieved overall sensitivity between 82 and 85% and an FP/case rate of 0.20 to 0.31, with no significant differences (p = 0.90 and p = 0.16) between them. The primary model showed 85% sensitivity and 0.23 FP/case rate, outperforming the ADAM-challenge winner (61%) and a nnU-Net trained on ADAM data (51%) in sensitivity (p < 0.05). Mean DICE (0.73) and NSD (0.84 for 0.5 mm threshold) for correctly detected UICA did not significantly differ from human reader performance. Our open-source, nnU-Net-based AI model (available at https://zenodo.org/records/13386859) demonstrates high sensitivity, low FP rates, and consistent segmentation accuracy for UICA detection and segmentation in 3D TOF-MRI, suggesting its potential to improve clinical diagnosis and monitoring of UICA.

Multi-centric AI Model for Unruptured Intracranial Aneurysm Detection and Volumetric Segmentation in 3D TOF-MRI

The aim of this study was to develop an open-source nnU-Net-based AI model for combined detection and segmentation of unruptured intracranial aneurysms (UICA) in 3D TOF-MRI and compare models trained on datasets with aneurysm-like differential diagnoses. This retrospective study (2020-2023) included 385 anonymized 3D TOF-MRI images from 345 patients (mean age 59 years, 60% female) at multiple centers plus 113 subjects from the ADAM challenge. Images featured untreated or possible UICA and differential diagnoses. Four distinct training datasets were created, and the nnU-Net framework was used for model development. Performance was assessed on a separate test set using sensitivity and false positive (FP)/case rate for detection and DICE score and NSD (normalized surface distance, 0.5 mm threshold) for segmentation. Segmentation performance on the test set was also compared to a second human reader. The four models achieved overall sensitivity between 82 and 85% and an FP/case rate of 0.20 to 0.31, with no significant differences (p = 0.90 and p = 0.16) between them. The primary model showed 85% sensitivity and 0.23 FP/case rate, outperforming the ADAM-challenge winner (61%) and a nnU-Net trained on ADAM data (51%) in sensitivity (p < 0.05). Mean DICE (0.73) and NSD (0.84 for 0.5 mm threshold) for correctly detected UICA did not significantly differ from human reader performance. Our open-source, nnU-Net-based AI model (available at https://zenodo.org/records/13386859 ) demonstrates high sensitivity, low FP rates, and consistent segmentation accuracy for UICA detection and segmentation in 3D TOF-MRI, suggesting its potential to improve clinical diagnosis and monitoring of UICA.

Treatment Effect of Early Intravenous Milrinone for Cerebral Vasospasm or Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

This study assessed the effect of intravenous (IV) milrinone as first-line therapy for cerebral vasospasm (CVS) or delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

A retrospective study was performed on consecutive patients with aSAH from 2017 to 2022. We assessed the association of IV milrinone treatment with outcomes graded with modified Rankin Scale score at 6 months. We compared the use of alternative therapies for CVS or DCI between patients who received IV milrinone and those who did not. All statistical analyses were performed using STATA 18.0 (StataCorp, College Station, TX).

RESULTS

Of 336 patients, 130 (39%) developed CVS or DCI. Seventy-three patients received IV milrinone and 57 patients did not. Among symptomatic patients, 59% showed improvement in symptoms after milrinone was started. Twenty percent of patients in the milrinone group required vasopressor therapy, whereas 84% of patients were treated with vasopressors in the nonmilrinone group (p < 0.01). Thirty one percent of patients receiving milrinone and 56% of patients in the non-milrinone group received endovascular therapy (p = 0.02). Univariate analysis showed milrinone was likely associated with good outcome (odds ratio [OR] 2.12 [95% confidence interval [CI] 0.97-4.63]; p = 0.06). Propensity score matching analysis confirmed an association between milrinone and good outcome (coefficient 0.30, standard error 0.13 [95% confidence interval [CI] 0.05-0.55]; p = 0.02).

CONCLUSIONS

Our study showed several potential benefits of early IV milrinone therapy for patients with aSAH with CVS or DCI. Patients who received IV milrinone had better outcome and required vasopressor or endovascular therapy less often. Limitations of the study included several protocol deviations, incomplete documentation of drug effect, and inconsistent assessment of CVS resolution. Early IV milrinone improved outcomes and reduced the use of other therapies to treat CVS and DCI. These results need confirmation in a large clinical trial with stratification of patients by clinical severity, indication, and optimized protocols.

Association between triglyceride-glucose index and risk of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage

PURPOSE

This study aimed to investigate the association between the triglyceride-glucose (TyG) index and the risk of acute kidney injury (AKI) in patients with aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

This retrospective cohort study included aSAH patients in West China Hospital. The TyG index was calculated as ln[fasting triglycerides (mg/dL) × fasting glucose (mg/dL)/2]. The primary outcome was AKI within 7 days of admission, and secondary outcomes included hospital, 90-day, and 180-day mortality. Multivariate logistic regression and Cox proportional hazards models were used to adjust for potential confounders. The association between the TyG index and AKI was also assessed with restricted cubic spline analysis. A predictive logistic model for AKI risk was developed and its performance was assessed using the area under the receiver operating characteristic curve, calibration correction curves, and decision curve analysis. Based on the optimal model, an online Shiny R application was developed.

RESULTS

A total of 3271 patients with aneurysmal subarachnoid hemorrhage were included. AKI occurred in 156 patients (4.7%), with the incidence significantly increasing across TyG index quartiles (Q1: 2.7%, Q4: 8.6%; P for trend < 0.001). Each 1-unit increase in TyG index was associated with an 90% higher odds of AKI (OR 1.90, 95% CI 1.48-2.45). Mortality rates also increased with higher TyG quartiles: hospital mortality (HR 1.30, 95% CI 1.05-1.62), 90-day mortality (HR 1.20, 95% CI 1.03-1.39), and 180-day mortality (HR 1.18, 95% CI 1.02-1.37). Kaplan-Meier analysis revealed reduced survival in higher TyG quartiles (Log-rank P < 0.001). Subgroup analyses confirmed consistent associations across demographics characteristics and treatment modalities. Incorporating the TyG index into risk models improves their discriminatory power and calibration. A Shiny application based on this model is freely accessible at ( https://asahaki.shinyapps.io/asahaki/ ).

CONCLUSION

The TyG index is an independent predictor of AKI and mortality in aSAH patients. Its incorporation into clinical assessment facilitates early risk stratification and individualized management.

Impact of Social Determinants of Health on Outcomes of Nontraumatic Subarachnoid Hemorrhage

BACKGROUND

Nontraumatic subarachnoid hemorrhage (SAH) presents a significant health burden, yet the influence of social determinants of health on outcomes remains unclear. This study examines the impact of social determinants of health on outcomes of patients with SAH.

METHODS AND RESULTS

We conducted a retrospective analysis of prospectively collected data from the GWTG (Get With The Guidelines)-Stroke registry, including patients with SAH across the United States from 2012 to 2021. The role of the Social Deprivation Index (SDI) and adjusted gross income, stratified into tertiles, were assessed. Outcomes included in-hospital death, length of stay, and discharge disposition (good: home/rehabilitation; poor: long-term facility/hospice/death). Covariates included demographics, medical history, vascular risk factors, and SAH severity. Multivariable regressions were used to estimate associations, presenting odds ratios (ORs) and relative risks. Our study comprised 108 090 patients with nontraumatic SAH (mean age, 59.76 years; 61.3% women). The average length of stay was 12.04 days, 55.6% had good discharge disposition, and the overall mortality rate was 15.5%. Analyses showed that a high Social Deprivation Index was associated with reduced odds of a good discharge (unadjusted OR, 0.90 [95% CI, 0.87-0.92]; adjusted OR, 0.87 [95% CI, 0.82-0.92]), while higher adjusted gross income correlated with decreased death (unadjusted OR, 0.94 [95% CI, 0.90-0.97]; adjusted OR, 0.90 [95% CI, 0.83-0.96]). A high Social Deprivation Index was significantly associated with longer length of stay (unadjusted relative risk, 1.06 [95% CI, 1.07-1.26]; adjusted relative risk, 1.03 [95% CI, 1.01-1.13]).

CONCLUSIONS

Social determinants of health shape outcomes for patients with SAH, with a clear gradient of impact across socioeconomic levels.

Prognostic factors in aneurysmal subarachnoid hemorrhage with poor initial clinical grade

Introduction

Aneurysmal subarachnoid hemorrhage (aSAH) is a rare cause of stroke that poses significant morbidity and mortality, as it affects patients around the age of 50 years. While advances in early aneurysm intervention have reduced mortality rates, many patients still experience poor outcomes due to early brain injury (EBI) and delayed cerebral ischemia (DCI). This study aims to explore the characteristics of patients with poor neurological outcomes among patients with poor neurological status at admission, using comprehensive clinical and neuroimaging data.

Methods

We analyzed 377 aSAH patients (WFNS 4-5) admitted between 2013 and 2020, focusing on demographics, clinical assessments, imaging, treatments, and outcomes at discharge and 3 months later.

Results

Among the cohort, which predominantly consisted of females, the mortality rate was 49%. Our findings indicate that older patients had poorer functional outcomes; notably, 59% of patients aged 75 and older had limitations on therapeutic efforts, leading to a 100% mortality rate in that subgroup. There was no difference in outcomes between endovascular and surgical treatments. However, patients undergoing multimodal monitoring had better functional outcomes at discharge. Angiographic vasospasm was found in 31% of patients and was linked to poorer outcomes at discharge (p = 0.016). Though DCI did not directly correlate with functional outcomes, it correlated strongly with new cerebral infarcts (90% incidence).

Conclusion

The prognosis of patients with aSAH and poor neurological status on admission is generally poor. Multimodal monitoring and tailored treatment appear to be beneficial in achieving favorable results in these patients. Despite the initial severity, up to 20% of patients achieve a good functional result on discharge and up to 35% do so at 3 months. These should be considered in the initial prognostic assessment with the families of these patients.

Which Intravenous Isotonic Fluid Offers Better Outcomes for Patients with a Brain Injury?

Administering intravenous fluids is a common therapy for critically ill patients. Isotonic crystalloid solutions, such as saline or balanced solutions, are frequently used for intravenous fluid therapy. The choice between saline or a balanced crystalloid has been a significant question in critical care medicine. Recent large randomized controlled trials (RCTs) have investigated whether balanced crystalloids yield better outcomes in general or specific critical care populations, and many of them have confirmed this hypothesis. Although the broad eligibility criteria of these RCTs suggest applicability to neurocritical care patients, it is important to discuss whether using balanced crystalloids, as opposed to saline, would benefit patients who primarily have neurological disorders or diseases. This review considers the relevance of this question, weighs the pros and cons of the two fluid types, examines available data, and anticipates results from ongoing RCTs to guide clinicians in selecting the optimal fluid for patients with brain injury.

SAHRANG: Subarachnoid Hemorrhage Recovery and Galantamine - A pilot multicenter randomized placebo-controlled trial

Background Subarachnoid hemorrhage (SAH) causes life-long neurologic dysfunctions. Peripheral inflammatory processes as a reaction to brain injury has been shown to worsen outcomes after SAH. Galantamine has been shown to reduce proinflammatory microglial activities and improve synaptic connections. We hypothesize that galantamine treatment after SAH mitigates inflammation-mediated neuronal injury and improve outcomes. We conducted a pilot clinical trial to examine the tolerability and safety of galantamine in SAH patients. Methods This prospective, multicenter, double-blind, randomized, placebo-controlled study contiguously screened and enrolled adult patients presenting with aneurysmal subarachnoid hemorrhage of the Fisher grade 3 within 72 hours of symptom onset. A total of 60 patients were enrolled with a 1:1 ratio to two treatment arms. The first 30 patients were randomized to galantamine 8mg every 12 hours or a placebo, and the other 30 patients to either galantamine 12mg every 12 hours or a placebo. All medications were started within 36 hours after securing the aneurysm and continued for 90 days. Primary outcomes-tolerability as assessed by the number of patients who stop study medication due to adverse events associated with the study drug and mortality due to the study drug-were assessed at 90 days. Results There were no differences in tolerability and safety between the two groups. Bradycardia was the most common adverse event (37%), followed by clinical seizure (3%) and skin rash (3%). One subject in the galantamine group discontinued medication due to a skin rash, and another subject from the placebo group discontinued due to nausea (p=0.92). Mortality did not differ between the two groups. At 90 days, one subject from the galantamine group and four subjects from the placebo group died (p=0.34). Conclusions Galantamine and placebo did not differ in their side effects and safety profiles when administered to SAH patients during the early and subacute stages of the disease.

The utility of the 5-Item frailty index in assessing the risk of complications and mortality following surgical management of non-traumatic subarachnoid hemorrhage

The modified 5-item frailty index (mFI-5), an index of reduced physiological reserve, has risen as a predictor of complications following surgical procedures. We examined the association of mFI-5 and surgical outcomes following the management of nontraumatic subarachnoid hemorrhage (nSAH). We queried the American College of Surgeons National Surgical Quality Improvement Program database for patients who received surgical management of nSAH between 2006 and 2021. We computed the mFI-5 by granting a point for each of 1) congestive heart failure, 2) hypertension requiring medications, 3) diabetes, 4) chronic obstructive pulmonary disease or pneumonia within 30 days before surgery, and 5) dependent functional status. Our 30-day endpoints were minor complications (Clavien-Dindo: 1 & 2), major complications (Clavien-Dindo: 3 & 4), and mortality. Using the Chi-squared test, we compared baseline patient demographics and comorbidities between patients with a mFI-5 ≥ 2, patients with a mFI-5 = 1, and non-frail patients. Then, we fitted a multivariable logistic regression adjusting for patient demographics, comorbidities, operative time, and frailty status. The cohort included 1,139 patients, of which 33.7 % were men and 2.9 % had a bleeding diathesis. After adjusting for covariates, mFI-5 ≥ 2 was independently associated with minor complications (1.93, 95 %CI: 1.31-2.84, p = 0.001), major complications (aOR: 1.62, 95 %CI: 1.10-2.37, p = 0.015), and mortality (aOR: 2.90, 95 %CI: 1.66-5.08, p = 0.003). The mFI-5 can be independently used by surgeons for risk stratification and postoperative planning.

Efficacy and safety of corticosteroids for stroke and traumatic brain injury: a systematic review and meta-analysis

BACKGROUND

Corticosteroids are frequently used in practice to treat patients with neurological disorders. However, its effect for stroke and traumatic brain injury (TBI) remains controversial. This study aimed to systematically review and evaluate efficacy and safety of corticosteroids for the treatment of stroke and TBI.

METHODS

We searched Ovid-Medline and Ovid-Embase databases for randomised controlled trials (RCTs) and cohort studies evaluating the efficacy and safety of corticosteroids in patients with ischaemic stroke, intracerebral haemorrhage (ICH), subarachnoid haemorrhage (SAH) or TBI. The treatment intervention was corticosteroid, and the control was placebo or routine care. Outcome measures were death, functional outcomes and adverse events. We calculated odds ratio (OR) and 95% confidence interval (CI) for the effect size, pooled the results using random-effects modelling, and assessed heterogeneity by I2 statistic.

RESULTS

We identified 47 studies (41 RCTs and 6 cohort studies). Nine studies enrolled patients with ischaemic stroke (n = 2806), 6 studies for ICH (n = 1229), 1 study recruited both ischaemic stroke (n = 13) and ICH (n = 27), 10 studies for SAH (n = 1318) and 21 studies for TBI (n = 12,414). Dexamethasone was the most used corticosteroid (28 studies). Corticosteroids reduced risk of death at 3 months after ischaemic stroke (n = 1791; 31% vs. 26%, OR 0.77, 95% CI 0.62-0.95; df = 1, I2 = 0%) and after ICH (1 study; n = 850; 44% vs. 27%, OR 0.48, 95% CI 0.35-0.64), had no effect on death at 1 month after SAH (1 study; n = 140; 22% vs. 32%, OR 1.73, 95% CI 0.81-3.68), and increased risk of death at 6 months after TBI (n = 10,755; 23% vs. 27%, OR 1.20, 95% CI 1.10-1.32; df = 6, I2 = 0%). The pooled analyses found no significant effect of corticosteroids on functional outcome after ischaemic stroke, ICH, SAH or TBI, respectively.

CONCLUSION

Corticosteroids reduced the risk of death and in selected patients with stroke, such as those with large artery occlusion after thrombectomy, but increased the risk of death after TBI, had no effect on functional outcomes. Further trials are needed to identify individual stroke patients who may benefit from corticosteroids.

SYSTEMATIC REVIEW REGISTRATION

International Prospective Register of Systematic Reviews (CRD42023474473).

Palliative General Anesthesia at Terminal Extubation: "Go Gentle into that Good Night"

Withdrawal of life-sustaining treatments in the intensive care unit most often culminates into the discontinuation of mechanical ventilation and removal of the endotracheal tube or "terminal extubation." Standards of practice call for the appropriate use of analgesia and sedation before, during and after extubation with an explicit goal to relieve suffering but not to hasten death. Patients subjected to this procedure are exposed to variable pharmacologic agents, modes, and doses, without any knowledge or monitoring of what these patients are experiencing. This practice seems to rest on contestable assumptions regarding the reliability of bedside examination, the experiential states of unresponsive patients, and the scope of the doctrine of double effect; instead, I argue for palliative general anesthesia in order to safeguard against potential suffering at the end of life. I employ philosophical notions of harm to justify the normative status of palliative anesthesia, in conjunction with contemporary evidence as it relates to the phenomena of covert consciousness and cognitive-motor dissociation. If this analysis is correct, then it may serve as a valid challenge toward current practice without having engaged into controversial debates over the soundness of the doctrine of double effect, or euthanasia. Primun non nocere offers the strongest justification for general anesthesia when terminal extubation is planned.

The association between systemic immune-inflammation index and the short-term functional outcome of patients with aneurysmal subarachnoid hemorrhage: a meta-analysis

Systemic immune-inflammation index (SII), calculated as platelet count × neutrophil count/lymphocyte count, is a novel biomarker reflecting immune and inflammatory responses. Its prognostic value in patients with subarachnoid hemorrhage (SAH) remains unclear. This meta-analysis aimed to evaluate the association between SII at admission and the short-term functional outcomes of patients with SAH. A systematic search of PubMed, Embase, Web of Science, China National Knowledge Infrastructure, and Wanfang databases identified cohort studies reporting the relationship between SII levels and functional outcomes in SAH. Poor functional outcomes were defined as modified Rankin Scale > 2 or Glasgow Outcome Scale < 4. Heterogeneity was assessed using I² statistic, and data synthesis was performed using a random-effects model by incorporating the influence of heterogeneity. RevMan 5.1 and Stata 17.0 were used for the analyses. Ten cohort studies involving 2,228 patients were included. Meta-analysis revealed that a high SII at admission significantly increased the risk of poor functional outcomes (OR: 3.08, 95% CI: 2.07-4.59, p < 0.001) with moderate heterogeneity (I² = 61%). Subgroup analysis showed a stronger association in studies with SII cutoffs ≥ 1400 compared to < 1400 (p for subgroup difference < 0.001). Meta-regression identified the cutoff value for SII as a significant modifier (p = 0.03) for the association between SII and poor functional outcome. Sensitivity analyses by excluding one dataset at a time showed similar results (p all < 0.05). In conclusion, elevated SII at admission is associated with an increased risk of poor short-term functional outcomes in SAH. These findings highlight SII as a potential prognostic biomarker for early risk stratification in SAH patients.

Factors Influencing the Mortality of Patients with Subarachnoid Haemorrhage in the Intensive Care Unit: A Retrospective Cohort Study

Background: Spontaneous subarachnoid haemorrhage (SAH) represents a significant cerebrovascular disease with considerable morbidity and mortality. The aim of this study was to determine the demographic/clinical characteristics of spontaneous SAH patients admitted in the intensive care unit (ICU) and factors affecting the mortality. Methods: This study was designed as a retrospective cohort study that included patients with a diagnosis of spontaneous SAH hospitalized in the ICU. The clinical and radiological parameters were compared between mortality and survival cohorts. Univariate logistic regression analyses were performed for the effect profiles of the parameters on mortality. Results: ICU mortality was 41% in patients with spontaneous SAH. A number of factors have been identified as being independently associated with mortality in the studied cohort. These factors are hospital admission with loss of consciousness (Glasgow Coma Scale score <8), a high Clinical Comorbidity Index score, stage >2 according to the Hunt and Hess grading system and complication status (meningitis and sepsis/septic shock). Conclusions: Spontaneous SAH is a condition associated with a high mortality in severe cases. Patients exhibiting these risk factors require meticulous monitoring in the ICU.

Dexmedetomidine is Associated with Reduced In-Hospital Mortality Risk of Patients with Subarachnoid Hemorrhage Undergoing Surgery

BACKGROUND

Subarachnoid hemorrhage (SAH) is a severe neurologic event with high mortality. The choice of sedatives in SAH management may influence patient outcomes. This study aimed to investigate the association between sedatives and in-hospital mortality among patients with SAH.

METHODS

This study analyzed data from the MIMIC-IV database, and in-hospital mortality was the primary outcome. Key variables collected included sedatives, demographics, comorbidities, vital signs, laboratory tests, and severity scores. Univariate and multivariate logistic regression analyses were used to assess associations between sedative use and in-hospital mortality, with adjustments for confounding factors. Further stratified analyses explored the effects of dexmedetomidine across different patient subgroups, and mediation analysis evaluated the role of creatinine in the relationship between dexmedetomidine and mortality.

RESULTS

A total of 527 patients were included in this study, with 301 males. Compared with propofol and midazolam, the use of dexmedetomidine was significantly related to the reduction of in-hospital mortality in patients with SAH (odds ratio, 0.369; 95% confidence interval, 0.237-0.574; P < 0.001). After adjusting for variables such as demographics, comorbidities, and laboratory tests, dexmedetomidine remained associated with lower in-hospital mortality. In addition, our findings indicated that dexmedetomidine use was associated with a reduced risk of in-hospital mortality regardless of the presence of cerebrovascular disease. We discovered that creatinine acted as a mediator in the protective effect of dexmedetomidine on in-hospital mortality.

CONCLUSIONS

Dexmedetomidine is associated with significantly lower in-hospital mortality in patients with SAH. These findings underscore the importance of sedative choice for patients with SAH, suggesting that dexmedetomidine could enhance patient outcomes.

Clinical Characteristics and Outcomes in Patients with Ruptured Middle Cerebral Artery Aneurysms: A Multicenter Study in Northern China

INTRODUCTION

The long-term prognosis of ruptured middle cerebral artery aneurysms (MCAAs) in northern China remains unclear. The aim of this study is to analyze the epidemiological characteristics and long-term outcomes of ruptured MCAAs in northern China.

METHODS

We included patients who were consecutively admitted for ruptured MCAAs to 12 tertiary care centers in northern China from January 2017 to December 2020. Kaplan‒Meier curves were used to compare survival in hazard strata. The Cox proportional hazards model was used to analyze risk factors and mortality risk, whereas logistic regression was used to identify factors influencing 2-year survival. Subgroup analyses were performed to verify the robustness of the results.

RESULTS

Data on 959 patients with ruptured MCAAs were analyzed; 16.4% of these patients had ruptured intracranial aneurysms (RIAs) and were registered in the Chinese cerebral aneurysm database. The mean follow-up duration was 3.0 years (range 0-6.2 years). The 3-month and 2-year mortality rates were 15.5% and 18.2%, respectively. The risk factors for mortality were identified via Cox regression and were as follows: age > 70 years, previous stroke, combined intracerebral hemorrhage (ICH)/intraventricular hemorrhage (IVH), poor Hunt and Hess grade, multiple aneurysms, and conservative treatment (CT). The positive association between the risk of death and CT was consistent across subgroups. According to logistic regression, hypertension, previous stroke, combined ICH/IVH, Hunt and Hess grade, and WFNS (World Federation of Neurological Surgeons) score were identified as factors negatively influencing 2-year survival.

CONCLUSION

We detail the epidemiologic characteristics and long-term outcomes of MCAAs. The risk factors for mortality included age > 70 years, previous stroke, combined ICH/IVH, poor Hunt and Hess grade, and multiple aneurysms. Compared with microsurgical treatment (MST), CT is associated with an increased risk of mortality, while the risk of mortality associated with endovascular treatment (EVT) is not significantly different. Two-year survival was associated with hypertension, previous stroke, ICH/IVH, and poor grades at admission.

Regulatory T Cell- and Natural Killer Cell-Mediated Inflammation, Cerebral Vasospasm, and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage-A Systematic Review and Meta-Analysis Approach

Aneurysmal subarachnoid hemorrhage (SAH) involves a significant influx of blood into the cerebrospinal fluid, representing a severe form of stroke. Despite advancements in aneurysm closure and neuro-intensive care, outcomes remain impaired due to cerebral vasospasm and delayed cerebral ischemia (DCI). Previous pharmacological therapies have not successfully reduced DCI while improving overall outcomes. As a result, significant efforts are underway to better understand the cellular and molecular mechanisms involved. This review focuses on the activation and effects of immune cells after SAH and their interactions with neurotoxic and vasoactive substances as well as inflammatory mediators. Particular attention is given to clinical studies highlighting the roles of natural killer (NK) cells and regulatory T cells (Treg) cells. Alongside microglia, astrocytes, and oligodendrocytes, NK cells and Treg cells are key contributors to the inflammatory cascade following SAH. Their involvement in modulating the neuro-inflammatory response, vasospasm, and DCI underscores their potential as therapeutic targets and prognostic markers in the post-SAH recovery process. We conducted a systematic review on T cell- and natural killer cell-mediated inflammation and their roles in cerebral vasospasm and delayed cerebral ischemia. We conducted a meta-analysis to evaluate outcomes and mortality in studies focused on NK cell- and T cell-mediated mechanisms.

Differences between real-world and score-based decision-making in the microsurgical management of patients with unruptured intracranial aneurysms

BACKGROUND

Management of unruptured intracranial aneurysms (UIAs) is complex, balancing the risk of rupture and risk of treatment. Therefore, prediction scores have been developed to support clinicians in the management of UIAs. We analyzed the discrepancies between interdisciplinary cerebrovascular board decision-making factors and the results of the prediction scores in our cohort of patients who received microsurgical treatment of UIAs.

METHODS

Clinical, radiological, and demographical data of 221 patients presenting with 276 microsurgically treated aneurysms were collected, from January 2013 to June 2020. UIATS, PHASES, and ELAPSS were calculated for each treated aneurysm, resulting in subgroups favoring treatment or conservative management for each score. Cerebrovascular board decision-factors were collected and analyzed.

RESULTS

UIATS, PHASES, and ELAPSS recommended conservative management in 87 (31.5%) respectively in 110 (39.9%) and in 81 (29.3%) aneurysms. The cerebrovascular board decision-factors leading to treatment in these aneurysms (recommended to manage conservatively in the three scores) were: high life expectancy/young age (50.0%), angioanatomical factors (25.0%), multiplicity of aneurysms (16.7%). Analysis of cerebrovascular board decision-making factors in the "conservative management" subgroup of the UIATS showed that angioanatomical factors (P=0.001) led more frequently to surgery. PHASES and ELAPSS subgroups "conservative management" were more frequently treated due to clinical risk factors (P=0.002).

CONCLUSIONS

Our analysis showed more aneurysms were treated based on "real-world" decision-making than recommended by the scores. This is because these scores are models trying to reproduce reality, which is yet not fully understood. Aneurysms, which were recommended to manage conservatively, were treated mainly because of angioanatomy, high life expectancy, clinical risk factors, and patient's treatment wish. The UIATS is suboptimal regarding assessment of angioanatomy, the PHASES regarding clinical risk factors, complexity, and high life expectancy, and the ELAPSS regarding clinical risk factors and multiplicity of aneurysms. These findings support the need to optimize prediction models of UIAs.

Interpretable machine learning model for outcome prediction in patients with aneurysmatic subarachnoid hemorrhage

BACKGROUND

Aneurysmatic subarachnoid hemorrhage (aSAH) is a critical condition associated with significant mortality rates and complex rehabilitation challenges. Early prediction of functional outcomes is essential for optimizing treatment strategies.

METHODS

A multicenter study was conducted using data collected from 718 patients with aSAH who were treated at five hospitals in Japan. A deep learning model was developed to predict outcomes based on modified Rankin Scale scores using pretherapy clinical data collected from admission to the initiation of physical therapy. The model's performance was assessed using the area under the curve, and interpretability was enhanced using SHapley Additive exPlanations (SHAP). Logistic regression analysis was also performed for further validation.

RESULTS

The area under the receiver operating characteristic curve of the model was 0.90, with age, World Federation of Neurosurgical Societies grade, and higher brain dysfunction identified as key predictors. SHAP analysis supported the importance of these features in the prediction model, and logistic regression analysis further confirmed the model's robustness.

CONCLUSIONS

The novel deep learning model demonstrated strong predictive performance in determining functional outcomes in patients with aSAH, making it a valuable tool for guiding early rehabilitation strategies.

Thrombolysis for aneurysmal subarachnoid haemorrhage

BACKGROUND

Aneurysmal subarachnoid haemorrhage continues to cause a significant burden of morbidity and mortality despite advances in care. Trials investigating local administration of thrombolytics have reported promising results.

OBJECTIVES

- To assess the effect of thrombolysis on improving functional outcome and case fatality following aneurysmal subarachnoid haemorrhage - To determine the effect of thrombolysis on the risk of cerebral artery vasospasm, delayed cerebral ischaemia, and hydrocephalus following subarachnoid haemorrhage - To determine the risk of complications of local thrombolysis in aneurysmal subarachnoid haemorrhage SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (last searched 9 March 2023), MEDLINE Ovid (1946 to 9 March 2023), and Embase Ovid (1974 to 9 March 2023). We also searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP). We performed forward and reverse citation tracking of included studies using Google Scholar.

SELECTION CRITERIA

We included randomised controlled trials comparing subarachnoid thrombolysis via any route of administration into any anatomical site continuous with the subarachnoid space versus placebo, sham thrombolysis, or standard treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion in the review. We extracted study data and used version 2 of the Cochrane risk-of-bias tool for randomised trials to assess the risk of bias in the studies. We resolved any disagreement through discussion with a third author. Our primary outcome was poor functional outcome. Secondary outcomes were case fatality, haemorrhagic complications, cerebral artery vasospasm, delayed cerebral ischaemia, cerebral infarction, and hydrocephalus. We performed meta-analyses for each outcome and performed sensitivity analysis excluding studies at high risk of bias. We presented results as risk ratios (RRs) with 95% confidence intervals (CIs). We performed further sensitivity analysis by including all intervention groups from studies reporting more than one intervention group. For each outcome, we used the GRADE criteria to determine the certainty of the evidence.

MAIN RESULTS

We included eight studies from six countries in this review. The studies had a total of 410 participants, of whom 205 received thrombolysis. We identified three ongoing trials. We assessed one trial as having a high risk of bias for all outcomes; we assessed the remainder as having a low risk of bias or some concerns. Thrombolysis likely results in a reduction in poor functional outcome when compared to placebo or standard care (29.4% versus 39.7%, RR 0.73, 95% CI 0.56 to 0.94; 8 studies, 408 participants; moderate-certainty evidence). Thrombolysis likely results in little to no difference in case fatality (12.8% versus 17.7%, RR 0.71, 95% CI 0.46 to 1.10; 8 studies, 408 participants; moderate-certainty evidence). Thrombolysis may result in little to no difference in haemorrhagic complications (10.3% versus 7.2%, RR 1.40, 95% CI 0.73 to 2.68; 6 studies, 341 participants; low-certainty evidence). Thrombolysis likely results in a reduction in cerebral artery vasospasm (32.9% versus 47.6%, RR 0.70, 95% CI 0.54 to 0.91; studies, participants; moderate-certainty evidence), and may result in a reduction in delayed cerebral ischaemia (23.8% versus 38.2%, RR 0.62, 95% CI 0.45 to 0.88; studies, participants; low-certainty evidence). Thrombolysis may result in little to no difference in cerebral infarction (28.6% versus 37.5%, RR 0.76, 95% CI 0.44 to 1.31; studies, participants; low-certainty evidence), and likely results in little to no difference in the risk of hydrocephalus (18.3% versus 24.1%, RR 0.77, 95% CI 0.54 to 1.10; studies, participants; moderate-certainty evidence).

AUTHORS' CONCLUSIONS

There is some evidence that thrombolysis can probably improve outcomes after aneurysmal subarachnoid haemorrhage, without increasing the risk of haemorrhagic complications. Thrombolysis likely reduces the risk of poor functional outcome and cerebral artery vasospasm, and may reduce the risk of delayed cerebral ischaemia, but it likely makes little to no difference to case fatality or hydrocephalus, and may make little to no difference to the risk of cerebral infarction. However, the current evidence is still uncertain. The uncertainty is primarily due to the small total number of participants and outcome events. Data from further studies are required to confirm the efficacy of thrombolysis for improving outcomes after aneurysmal subarachnoid haemorrhage.

One-year outcome and quality of life of patients with subarachnoid hemorrhage admitted to intensive care unit: a single-center retrospective pilot study

Patients admitted to intensive care unit (ICU) after non-traumatic subarachnoid hemorrhage (SAH) represent a group with distinctive characteristics and few data are available on long-term outcome in this population. We conducted a single-center retrospective study in an Italian intensive care unit. All patients with non-traumatic SAH (ICD-9-CM Diagnosis Code 430) admitted to ICU were included. Disability and quality of life were evaluated via telephone interview after 12-15 months after initial bleeding using GOSE and EuroQoL, respectively. Baseline and clinical course characteristics were analyzed to evaluate relation with poor outcome defined as GOSE ≤ 3. Final population consisted of 38 patients. Twenty-four patients (63.2%) had favorable outcome (GOSE ≥ 4). Among 29 patients (76.3%) who survived at 1 year, median EQ-5D Index was 0.743 (IQR 0.287), while median EQ-VAS was 74.79 (IQR 18.5). Median EQ-5D Index and median EQ-VAS were higher among patients with favorable outcome (EQ-5D Index p = 0.037, EQ-VAS p = 0.003). Among baseline characteristics, only HH scale showed a significant relation with disability at one year (p = 0.033). Between complications occurred during ICU-stay only early HICP was related with unfavorable outcome (p = 0.028). Higher HH scale and early HICP were related with unfavorable outcome. Among patients with unfavorable outcome, quality of life has a broad range of variability, and this result should be taken into account when reporting patient-centered outcomes.

Comparative Analysis of Stent-Assisted Versus Non-Stent-Assisted Coiling in the Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-Analysis

OBJECTIVE

To systematically evaluate the safety and efficacy of SAC compared to non-SAC in the treatment of RIA, integrating evidence from high-quality studies to guide clinical practice.

METHODS

A meta-analysis was conducted to compare SAC with coiling alone and BAC in the treatment of RIA. Primary outcomes were immediate and follow-up aneurysm occlusion rates, along with perioperative hemorrhagic and ischemic complication rates.

RESULTS

A total of thirteen retrospective cohort studies were included, comprising 3,086 patients, with 1,078 in the SAC group and 2,008 in the non-SAC group. The immediate complete occlusion rates were similar between the SAC and non-SAC groups (59.1% vs. 61.4%; RR = 1.00; 95% CI [0.94, 1.07]; p = 0.92). However, the SAC group demonstrated a significantly higher long-term complete occlusion rate (61.3% vs. 40.6%; RR = 1.44; 95% CI [1.22, 1.69]; p < 0.001). The incidence of ischemic complications was greater in the SAC group (12.2% vs. 10.0%; RR = 1.68; 95% CI [1.37, 2.07]; p < 0.001), as was the incidence of hemorrhagic complications (7.3% vs. 5.1%; RR = 1.55; 95% CI [1.15, 2.08]; p = 0.004). Perioperative mortality was also elevated in the SAC group (6.7% vs. 6.8%; RR = 1.37; 95% CI [1.00, 1.88]; p = 0.048), with a non-significant trend towards higher long-term mortality (9.8% vs. 9.2%; RR = 1.35; 95% CI [0.98, 1.87]; p = 0.068). Functional outcomes at discharge (76.0% vs. 71.0%; RR = 0.97; 95% CI [0.92, 1.02]; p = 0.237), six months (57.8% vs. 60.8%; RR = 0.93; 95% CI [0.81, 1.07]; p = 0.296), and at the last follow-up (RR = 1.01; 95% CI [0.97, 1.06]; p = 0.592) were comparable between the two groups.

CONCLUSIONS

SAC significantly improves long-term occlusion rates for RIA compared to non-SAC, despite a higher incidence of complications. Careful patient selection and optimization of antiplatelet therapy may enhance the safety and efficacy of SAC for RIA treatment.

Predictors of mortality at 3 months in patients with skull base tumor resections in a low-income setting

Objective

Globally, skull base tumors are among the most challenging tumors to treat and are known for their significant morbidity and mortality. Hence, this study aimed to identify robust associated factors that contribute to mortality of patients following surgical resection for a variety of skull base tumors at the 3-month follow-up period. This in turn helps devise an evidence-based meticulous treatment strategy and baseline input for quality improvement work.

Methodology

A retrospective cohort study of patients undergoing skull base tumor resection was conducted at two large-volume neurosurgery centers in Ethiopia. The categorical variables were expressed in frequencies and percentages. Normal distribution of continuous data was checked by histogram and the Shapiro-Wilk test. Median with interquartile range (IQR) was calculated for skewed data, while mean with standard deviation (SD) was used for normally distributed data. Odds ratio and adjusted odds ratio (AOR) were used to express the result of univariate and multivariate binary logistic analyses, respectively. A p-value <0.005 was considered statistically significant at 95% confidence interval (CI).

Result

The study involved 266 patients. Of this, women accounted for 63.5% of patients. The median age of patients was 37 (±IQR = 17) years while the median size of the tumor in this study was 4.9 (±IQR 1.5) cm. The mean duration of symptoms at time of presentation was 17.3 (±SD = 11.1) months. Meningioma, pituitary adenoma, and craniopharyngioma contributed to 68.4%, 19.2%, and 9% of the skull-based tumors, respectively. Mortality following skull base tumor resection was 21.1%. On multivariable binary logistic regression analysis, intraoperative iatrogenic vascular insult (AOR = 28.76, 95% CI: 6.12-135.08, p = 0.000), intraventricular hemorrhage (AOR = 6.32, 95% CI: 1.19-33.63, p = 0.031), hospital-associated infection (AOR = 6.96, 95% CI: 2.04-23.67, p = 0.002), and extubation time exceeding 24 h (AOR = 12.89, 95% CI: 4.89-40.34, p = 0.000) were statistically significant with 3-month mortality.

Conclusion

Mortality from skull base tumor resection remains high in our setting. Holistic pre-operative surgical planning, meticulous intraoperative execution of procedures, and post-operative dedicated follow-up of patients in a neurointensive care unit alongside quality improvement works on identified risks of mortality are strongly recommended to improve patient outcomes. The urgent need for setup improvement and further training of neurosurgeons is also underscored.

Subarachnoid haemorrhage and intracranial aneurysms in Greenland in the period 2018-2021: incidence, outcome and familial disposition

Subarachnoid haemorrhages (SAH) caused by rupture of intracranial aneurysms (IA) are a severe condition. Earlier studies found a higher incidence of SAH in Greenlandic patients compared to Danish patients, with familial aggregation also higher in Greenland. However, updated data is lacking. To investigate the contemporary incidence, outcome, and familial disposition of SAH/IA in Greenlandic patients in 2018-2021. Greenlandic patients diagnosed with ruptured or unruptured IA (UIA) during 2018-2021 were included. Data was obtained from patient files, x-ray department, and discharge registry. Incidence rates were estimated as cases/100,000/year. Direct age-standardised incidence rates were calculated using WHO 2000-2025 as standards. Of 30 SAH patients, 20 (66.7%) were females, 10 (33.3%) males. Of 36 UIA patients, 27 (75.0%) were females, 9 (25.0%) males. For SAH, crude incidence was 13.4/100,000/year, age-standardised incidence was 10.8/100,000/year. Familial history was observed in 30.0% of SAH patients. 5 patients (16.7%) died before treatment, 28-day case-fatality rate (CFR) for all patients was 23.3%. Overall and age-standardised incidence rates were similar to previous studies but higher among females and compared to neighbouring countries. A high occurrence of familial history was reported. SAH remains a serious condition in Greenland, as evidenced by five fatalities before treatment was administered.

Predictors of survival after aneurysmal subarachnoid hemorrhage: The long-term observational cohort study

OBJECTIVE

Despite recent advances in neuro-intensive care, there is still considerable mortality in patients with aneurysmal subarachnoid hemorrhage (SAH). In this long-term monocentric observational cohort study, we aimed to analyze the rates, timing, and predictors of mortality after SAH.

METHODS

All consecutive SAH cases treated between January 2003 and June 2016 were included. Patients' demographic characteristics, previous medical history, SAH-related parameters, and available post-treatment follow-up data were collected and evaluated as potential mortality predictors in univariate and multivariate analyses.

RESULTS

Of 992 patients, 179 died during the initial treatment and 33 during the follow-up time reaching an overall mortality rate of 21.4 %. Of over 119 tested variables, we identified the following independent predictors in the final multivariate Cox regression analysis: age >55 years (p<0.0001); World Federation of Neurosurgical Societies (WFNS) admission grade IV or V (p=0.025); Hijdra sum score ≥15 points (p=0.003); intracranial pressure (ICP) increase (p<0.0001); and delayed cerebral ischemia (DCI) (p<0.0001). Being exposed to all five risk factors resulted in the case fatality rate of 75 % within a median survival of 14 days, compared to 2.5 % within a median of 1525 days when none of these features were present.

CONCLUSIONS

The initial impact of aneurysmal bleeding is amongst the major mortality causes after SAH. Of potentially preventable adverse events, ICP increase and DCI occurring during initial treatment also present eminent clinical relevance for patients' survival in the long-term follow-up. Further ICP and DCI management optimization might help to decrease the mortality rate after SAH.

Predictors of Neurological Outcomes in Patients with Poor Glasgow Coma Scale Scores 1 Week After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

This study assessed neurological outcomes and variables associated with favorable outcomes in aneurysmal subarachnoid hemorrhage patients with low functional status (Glasgow Coma Scale [GCS] score ≤8) on postbleed day 7 (PBD7).

METHODS

A retrospective analysis was conducted of all patients in the Barrow Ruptured Aneurysm Trial (January 1, 2014-July 31, 2019) treated for a ruptured aneurysm and who had a GCS score ≤8 on PBD7. The primary outcome was a favorable neurological outcome (modified Rankin Scale score ≤2) at last follow-up.

RESULTS

Of 312 patients, 63 had low GCS scores at PBD7. These patients had a significantly greater proportion of poor Hunt and Hess scale grades (≥4) (44/63 [70%] vs. 49/249 [19.7%], P < 0.001) and poor Fisher grades (grade = 4) (58/63 [92%] vs. 174/249 [69.9%], P < 0.001) compared to patients who did not have low GCS scores on PBD7, but no differences were found in age, sex, anterior location, aneurysm size, or type of treatment. Of the 63 patients, 7 (11%) experienced a favorable neurological outcome. On univariate analysis, none of the physical examination reflexes predicted a favorable neurological outcome. The middle cerebral artery aneurysm territory was the only significant predictor of a favorable neurological outcome by multivariate analysis (odds ratio, 10.8; 95% confidence interval, 1.16-100], P = 0.04).

CONCLUSIONS

This study yielded no significant physical examination findings that predict a favorable outcome in patients with a GCS score ≤8 on PBD7. This finding may inform the decision of whether to prolong hospital management or arrange for end-of-life care.

Can a single basal cistern urokinase bolus help to prevent subarachnoid hemorrhage consequences?

Study design

Retrospective.

Background

In the 1980s, aneurysmal subarachnoid clot lysis with urokinase or alteplase (rtPA) was proven to effectively reduce vasospasm and neurological ischemic deficits, improving survival and clinical outcomes. This therapeutic option has been less commonly used since the introduction of endovascular treatment, but renewed interest has sparked in recent years.

Aims

To investigate if single bolus cisternal urokinase subarachnoid clot lysis reduces vasospasm, neurological ischemic deficits, mortality, and permanent CSF diversion rates and improves outcomes. Additionally, we want to unveil which subgroup of patients benefit most.

Material and methods

Study period January 2007-December 2019. 415 patients with saccular aneurysms and >1-year follow-up analyzed. Six groups created according to the treatment applied: no treatment (42), only external ventricular drain (16), endovascular treatment (155), clipping (53), clipping + 100,000UI urokinase (116), and incidental brain aneurysm (33).

Results

The rates and severity of vasospasm, permanent CSF diversion, and mortality in Fisher grades ≥3 subarachnoid hemorrhages were higher with endovascular treatment than with surgical clipping with simultaneous cisternal urokinase administration. The best GOSE results on discharge and 6- and 12-month follow-ups happened in this latter group. The differences were more significant the higher the Fisher grade. We neither saw intraventricular, subarachnoid, subdural, or epidural hemorrhages nor systemic fibrinolysis or infections that could be related to the urokinase administration.

Conclusions

Single bolus cisternal 100,000UI urokinase administration during emergency aneurysm clipping reduces vasospasm, mortality, and the need for permanent CSF diversion. It is not associated with a significant increase in intracranial hemorrhages or systemic fibrinolysis.

Logistic organ dysfunction system as an early risk stratification tool after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) not only causes neurological deficits but also influences extracerebral organ functions. The Logistic Organ Dysfunction System (LODS) reliably captures organ dysfunctions and predicts mortality of critically ill patients. This study investigated LODS in the setting of aSAH as a surrogate marker for early brain injury (EBI). Patients with aSAH treated between 2012 and 2020 were retrospectively analyzed. LODS was calculated within 24 h upon admission applying functional parameters for each organ system. The EBI was evaluated based on 1-persistent loss of consciousness, 2-global cerebral edema, and 3-intracranial blood burden. The outcome was assessed with the modified Rankin scale (mRS) at 3-months after ictus (mRS > 2 = unfavorable outcome). A total of 324 patients with a mean age of 55.9 years were included. Severe EBI (EBI grade ≥ 3) was found in 38% (124/324) of patients. Higher LODS score correlated with severe EBI (p < 0.0001) and poor outcome (p < 0.0001). LODS with a cutoff of 7 allowed a reliable discrimination (AUC 78%, p < 0.0001) of patients with severe from those with mild EBI. The LODS-calculation as an early risk stratification and prognostic tool reliably reflected the severity of EBI after aSAH and correlated with outcome.

Safety and efficacy of glibenclamide on cerebral oedema following aneurysmal subarachnoid haemorrhage: a randomised, double-blind, placebo-controlled clinical trial

BACKGROUND

Glibenclamide has garnered attention due to its multifaceted neuroprotective effects in cases of acute central nervous system injury. We initiated a trial to explore the effectiveness and safety of a high dose of glibenclamide in the management of cerebral oedema following aneurysmal subarachnoid haemorrhage (aSAH).

METHODS

This trial constituted a single-centre, randomised clinical study. Half of the 56 patients assigned to the glibenclamide group received 15 mg of glibenclamide tablets daily for 10 days (5 mg, three times/day). The primary outcome was the proportion of patients achieving the subarachnoid haemorrhage early brain oedema score dichotomy (defined as Subarachnoid Haemorrhage Early Brain Oedema Score 0-2) at the 10-day postmedication. The secondary outcome of cerebral oedema was the concentration of sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) in the plasma and cerebrospinal fluid.

RESULTS

We enrolled 56 patients diagnosed with aSAH, who were admitted to the neurosurgery intensive care unit between 22 August 2021 and 25 April 2023. The primary outcome revealed that the glibenclamide group exhibited a notably higher proportion of mild cerebral oedema in comparison to the placebo group (60.7% vs 42.9%, adjusted OR: 4.66, 95% CI 1.14 to 19.10, p=0.032). Furthermore, the concentration of SUR1-TRPM4 in the cerebrospinal fluid of the glibenclamide group was significantly higher than the placebo group (p=0.0002; p=0.026), while the plasma TRPM4 concentration in the glibenclamide group was significantly lower than the placebo group (p=0.001).

CONCLUSION

Oral administration of high-dose glibenclamide notably reduced radiological assessment of cerebral oedema after 10 days of medication. Significant alterations were also observed in the concentration of SUR1-TRPM4 in plasma and cerebrospinal fluid. However, it is worth noting that glibenclamide was associated with a higher incidence of hypoglycaemia. Larger trials are warranted to evaluate the potential benefits of glibenclamide in mitigating swelling and then improving neurological function.

TRIAL REGISTRATION NUMBER

ChiCTR2100049908.

Therapeutic utility of Perfluorocarbon Oxygent in limiting the severity of subarachnoid hemorrhage in mice

Subarachnoid hemorrhage (SAH) is the deadliest form of hemorrhagic stroke; however, effective therapies are still lacking. Perfluorocarbons (PFCs) are lipid emulsion particles with great flexibility and their much smaller size as compared to red blood cells (RBCs) allows them to flow more efficiently within the blood circulation. Due to their ability to carry oxygen, a specific PFC-based emulsion, PFC-Oxygent, has been used as a blood substitute; however, its role in cerebral blood flow regulation is unknown. Adult C57BL/6 wildtype male mice were subjected to an endovascular perforation model of SAH followed by an intravenous (i.v.) injection of 9 ml/kg PFC-Oxygent or no treatment at 5 h after SAH. At 48 h after SAH, functional and anatomical outcomes were assessed. We found that SAH resulted in significant neurologic and motor deficits which were prevented by PFC-Oxygent treatment. We found that SAH-induced vasospasm, reduced RBC deformability, and augmented endothelial dysfunction were also restricted by PFC-Oxygent treatment. Moreover, mitochondrial activity and fusion proteins were also markedly decreased as assessed by oxidative phosphorylation (OXPHOS) after SAH. Interestingly, PFC-Oxygent treatment brought the mitochondrial activity close to the basal level. Moreover, SAH attenuated the level of phosphorylated AMP-activated protein kinase (pAMPK), whereas PFC treatment improved pAMPK levels. These data show the beneficial effects of PFC-Oxygent in limiting the severity of SAH. Further studies are needed to fully understand the mechanism through which PFC-Oxygent exerts its beneficial effects in limiting SAH severity.

Sensitivity of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) to detect aneurysms at high-risk of rupture: Retrospective analysis in a cohort of 346 patients with a proven subarachnoid hemorrhage

INTRODUCTION

The aim of this study was to assess the capability of the Unruptured Intracranial Aneurysm Treatment Score (UIATS) to discriminate unruptured intracranial aneurysms (UIAs) at high risk for subarachnoid hemorrhage (aSAH).

MATERIAL AND METHOD

During the period from January 2012 to December 2022, we included all consecutive adult patients admitted to our institution for an aSAH caused by the rupture of a saccular IA. The patient-related, aneurysm-related and treatment-related risk factors considered by UIATS were retrieved from medical records. After UIATS calculation for all ruptured IAs in the cohort, patients were categorized as "true positives (TP)" if UIATS would have (appropriately) oriented the management toward treatment, whereas patients for whom the UIATS would have (inappropriately) recommended observation were categorized as "false negatives (FN)". Patients for whom UIATS was inconclusive were categorized as "undetermined (UND)". Sensitivity of the UIATS (Se UIATS) was calculated by using the following formula: TP/(TP + FN).

RESULTS

A total of 346 patients (253 women, 73%; mean age = 56 ± 1.45 years) were incorporated into the final analysis. There were 140 T P (40%), 79 F N (23%) and 127 UND (37%), leading to a Se UIATS of 63.9% (CI 58.3-69.5). Cumulatively, the UIATS failed to provide an appropriate recommendation in 60% of the entire cohort.

CONCLUSION

By retrospectively applying the UIATS in a cohort of ruptured IAs, our study emphasizes how vulnerable the UIATS can be. Even if the UIATS suggests conservative management, clinicians should inform patients that there is still a small risk of rupture.

Impact of age on surgical outcomes for world federation of neurosurgical societies grade I and II aneurysmal subarachnoid haemorrhage: a novel prognostic model using recursive partitioning analysis

This study aimed to evaluate age as a prognostic factor and develop a comprehensive prognostic model for patients undergoing clipping surgery for World Federation of Neurosurgical Societies (WFNS) grade I/II aneurysmal subarachnoid haemorrhage (SAH). We retrospectively investigated 188 patients with WFNS grade I/II SAH who underwent microsurgical clipping at our institute between December 2010 and January 2020. The data of 176 patients (75 with grade I and 101 with grade II) were analysed. Data on patient demographics, aneurysm characteristics, SAH factors, surgical details, and clinical outcomes were collected. Prognostic factors were assessed using bivariate and multivariable logistic regression analyses, and recursive partitioning analysis. Favourable outcomes (mRS 0-2) were observed in 76% of patients. Age, a significant negative prognostic factor in multivariable analysis (odds ratio 0.55, 95% confidence interval 0.40-0.76, p < 0.001), was cutoff at 70 years by the receiver operating characteristic curve. Patients aged ≤ 70 years had significantly better outcomes than those aged > 70 years (84% vs. 46%, respectively; p < 0.001). Epileptic seizures were significantly associated with poor outcomes in older adults (p < 0.001). A prognostic model (favourable, intermediate, and poor) based on age and postoperative adverse events showed significantly different outcomes between age groups (p < 0.001). Age was a stronger prognostic factor than WFNS grading for patients with grade I/II SAH undergoing microsurgical clipping. For patients aged ≤ 70 years, precise microsurgeries with fewer complications were associated with favourable outcomes beyond WFNS grade. For older patients, postoperative intensive seizure management may prevent poor outcomes.

A National Cohort with Aneurysmal Subarachnoid Hemorrhage-Patient Characteristics, Choice of Treatment, Clinical Outcome, and Factors of Prognostic Importance

OBJECTIVE

To study associations of clinical characteristics and treatment choice with functional outcome, mortality, and time to death in a national sample of aneurysmal subarachnoidal hemorrhage patients.

METHODS

Data were extracted from a prospective nationwide multicenter study performed in September 2014 to March 2018. Glasgow Outcome Scale Extended (GOSE) grade, 1-year mortality, and survival probability were assessed at one year after ictus. Logistic univariate, multivariate, and Cox regression analyses were used to study the variables' associations with the outcomes.

RESULTS

Unfavorable dichotomized GOSE (dGOSE; grades 1-4) was observed in 35.4% of patients. Microsurgery was preferred for middle cerebral artery aneurysms and Fisher grade 4. Treatment modality was not associated with any outcome measure. Dichotomized World Federation of Neurosurgical Societies (dWFNS), age, and delayed ischemic neurological deficit (DIND) showed significant correlations with dGOSE and 1-year mortality in multivariate regression analyses. Pupil dilatation was associated with a 1-year mortality outcome. Cox regression analysis showed lower survival probability for pupil dilatation (hazard ratio [HR]: 3.546), poor dWFNS (HR: 3.688), higher age (HR: 1.051), and DIND occurrence (HR: 2.214).

CONCLUSIONS

The patient selection in Sweden after aneurysmal subarachnoidal hemorrhage showed similar values for dGOSE, 1-year mortality, and survival probability between patients treated with microsurgery or endovascular technique. Poor dWFNS, higher age, and DIND were significantly associated with unfavorable dGOSE, mortality, and survival probability. Pupil dilatation was significantly associated with mortality and survival probability.

Functionally dependent status is an independent predictor for worse perioperative outcomes following craniotomy for aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency, and functional status is often a predictor of adverse outcomes perioperatively. Patients with different functional statuses may have different perioperative outcomes during surgery for aSAH. This study retrospectively examines the effect of functional status on specific perioperative outcomes in patients receiving craniotomy for aSAH.

Methods

Patients with aSAH who underwent neurosurgery were identified using International Classification of Diseases (ICD) codes (ICD10, I60; ICD9, 430) in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2005 to 2021. Subjects were stratified into two study groups: functionally dependent and functionally independent, based on their documented functional status on NSQIP. Significant preoperative differences were present between groups so a multivariable regression was performed between functionally dependent and independent patients. The 30-day perioperative outcomes of the two groups were compared. Perioperative outcomes included death, major adverse cardiovascular events (MACEs), cardiac complications, stroke, wound complications, renal complications, sepsis, clot formation, pulmonary complications, return to the operating room, operation time >4 h, length of stay longer than 7 days, discharge not to home, and bleeding.

Results

For aSAH patients receiving craniotomy repair, functionally dependent patients had significantly greater rates of MACE, cardiac complications, sepsis, pulmonary complications, and discharge not to home compared to functionally independent patients.

Conclusion

This study shows specific perioperative variables influenced by dependent functional status when treating aSAH through craniotomy, thus leading to a more complicated postoperative course. Additional research is needed to confirm these findings among the specific variables that we analyzed.

Spontaneous subarachnoid hemorrhage in a referral health Centre in Central Africa

Background

Spontaneous subarachnoid hemorrhage (sSAH) is a medicosurgical emergency with high morbidity and mortality. The aimed of this study was to describe the clinical features and outcome of sSAH in Cameroon.

Methods

We reviewed medical records of patients aged ≥15 years old, admitted for sSAH from Januray 2011 to December 2020 in the Douala General Hospital. The diagnosis of sSAH was confirmed by neuroimaging (CT scan or MRI). Clinical and radiological severities were assessed by the WFNS score and the modified Fisher score respectively. Factors associated to in-hospital mortality was identified using cross-table (RR and 95%CI).

Results

Among the 111 cases of sSAH reviewed in emergencies records, we included 70 patients. The mean age was of 55.6 ± 13.6 years. Female were predominant (57.1%). Altered consciousness was the main clinical feature (55.7%). The WFNS score was grade 4-5 in 54.3% of patients. And 75.7% of cases presented a modified Fisher score of 3-4. Ruptured of intracranial aneurysm was the most common etiology (46.2%). Endovascular treatment and/or surgical treatment were not avaible. Hospital-based mortality was 40% and factor associated with death were Altered consciousness (RR: 4.3, 95%CI:1.52-12.33, p = 0.004), coma (RR: 23.9, 95%CI:2.85-200.62, p = 0.004), WFNS grade 5 (RR: 18.2, 95%CI:3.7-92.3, p < 0.001), and hospital length ≤ 7 days (RR: 13.5, 95%CI:4.28-42.56, p < 0.001).

Conclusion

Mortality and disability of sSAH are still high in our setting. Further studies with prospective follow up of patients are needed to determine the long-term outcome of these patients.

The Relationship Between Ionized Calcium Levels and Prognosis in Patients with Spontaneous Subarachnoid Hemorrhage

BACKGROUND

The serum calcium plays a role as a cofactor in critical steps such as cardiac contractility, vascular tone, and the coagulation cascade. This study aimed to determine if the level of ionized calcium can predict outcomes in patients with spontaneous subarachnoid hemorrhage (SAH) in the emergency department.

METHODS

The study was a retrospective cross-sectional case series. Patients aged 18 and over diagnosed with spontaneous SAH in the emergency department were included in the study. Patients' demographic characteristics, comorbidities, vital signs, laboratory parameters, World Federation of Neurosurgical Societies score, SAH grading according to the Fisher scale, needs of mechanical ventilation and inotropic treatment, administered treatments, complications, Rankin scores at discharge, and outcome were recorded in a standard data form.

RESULTS

A total of 267 patients were studied, with a mean age of 55.5 ± 13.4 years, and 53.9% (n = 144) were female. Hydrocephalus was present in 16.5% of patients. The average hospital stay was 20.4 ± 19.8 days. Mortality rate was 34.8% (n = 93). Mortality was significantly higher in patients with low calcium levels upon admission (P = 0.024). Ionized calcium levels during complication development independently predicted mortality (OR: 0.945, 95% CI: 0.898-0.996, P = 0.034). Patients with poor neurologic outcomes (Rankin: 3-6) had significantly lower initial ionized calcium levels (P = 0.002).

CONCLUSIONS

The ionized calcium level is a readily accessible blood gas parameter that assists clinicians in predicting functional independence and mortality at discharge in patients presenting to the emergency department with spontaneous SAH.

Ligation of cervical lymphatic vessels decelerates blood clearance and worsens outcomes after experimental subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is characterized by the extravasation of blood into the subarachnoid space, in which erythrocyte lysis is the primary contributor to cell death and brain injuries. New evidence has indicated that meningeal lymphatic vessels (mLVs) are essential in guiding fluid and macromolecular waste from cerebrospinal fluid (CSF) into deep cervical lymph nodes (dCLNs). However, the role of mLVs in clearing erythrocytes after SAH has not been completely elucidated. Hence, we conducted a cross-species study. Autologous blood was injected into the subarachnoid space of rabbits and rats to induce SAH. Erythrocytes in the CSF were measured with/without deep cervical lymph vessels (dCLVs) ligation. Additionally, prior to inducing SAH, we administered rats with vascular endothelial growth factor C (VEGF-C), which is essential for meningeal lymphangiogenesis and maintaining integrity and survival of lymphatic vessels. The results showed that the blood clearance rate was significantly lower after dCLVs ligation in both the rat and rabbit models. DCLVs ligation aggravated neuroinflammation, neuronal damage, brain edema, and behavioral impairment after SAH. Conversely, the treatment of VEGF-C enhanced meningeal lymphatic drainage of erythrocytes and improved outcomes in SAH. In summary, our research highlights the indispensable role of the meningeal lymphatic pathway in the clearance of blood and mediating consequences after SAH.

Aneurysmal Subdural Hematoma: A Systematic Review

BACKGROUND

Aneurysmal subdural hematoma (aSDH) is a rare complication of aneurysm rupture, affecting between 0.5 and 7.9% of patients with aneurysmal subarachnoid hemorrhage (aSAH). The clinical presentation, course, and outcomes of these patients are largely unknown.

OBJECTIVE

This study aims to systematically review the literature to evaluate the demographics, clinical presentation, aneurysm location, treatment options, and outcomes of patients with aSDH with and without aSAH.

METHODS

In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we conducted a systematic review of three databases (PubMed, EMBASE, and Google Scholar). From identified reports, we extracted data on patients' demographics, clinical presentation, imaging findings, surgical interventions, and clinical outcomes. We compared clinical outcomes, need for surgical treatment, and aneurysm location between patients with aSDH with and without concurrent aSAH using χ2 and Fisher's exact tests. We used simple and multivariable logistic regression models to further examine the association between the presence of aSAH and surgical treatment with clinical outcomes.

RESULTS

We identified 112 articles with a total of 270 patients (70% women, mean age 52.8 [± 15.5] years). The most common aneurysm locations were the middle cerebral artery, followed by the posterior communicating artery, and the internal carotid artery. Patients with isolated aSDH fully recovered more frequently than those with concomitant aSAH (38% vs. 6%). The presence of aSAH increased the odds of unfavorable outcome (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.34-5.37). Surgical treatment was inversely associated with unfavorable outcome in the univariable (OR 0.48, 95% CI 0.28-0.84) but not in the multivariable analysis (OR 0.76, 95% CI 0.35-1.66).

CONCLUSION

aSDH occurs infrequently. Simultaneous presence of both aSDH and aSAH from an aneurysmal source is associated with poor outcomes. Surgical treatment is associated with lower rates of unfavorable outcomes including death and severe disability.

Performance Metrics, Algorithms, and Applications of Artificial Intelligence in Vascular and Interventional Neurology: A Review of Basic Elements

Artificial intelligence (AI) is currently being used as a routine tool for day-to-day activity. Medicine is not an exception to the growing usage of AI in various scientific fields. Vascular and interventional neurology deal with diseases that require early diagnosis and appropriate intervention, which are crucial to saving patients' lives. In these settings, AI can be an extra pair of hands for physicians or in conditions where there is a shortage of clinical experts. In this article, the authors have reviewed the common metrics used in interpreting the performance of models and common algorithms used in this field.

Predictors of Intrahospital Mortality in Aneurysmal Subarachnoid Hemorrhage after Endovascular Embolization

Background and Objectives: Aneurysmal subarachnoid hemorrhage (ASAH) is defined as bleeding in the subarachnoid space caused by the rupture of a cerebral aneurysm. About 11% of people who develop ASAH die before receiving medical treatment, and 40% of patients die within four weeks of being admitted to hospital. There are limited data on single-center experiences analyzing intrahospital mortality in ASAH patients treated with an endovascular approach. Given that, we wanted to share our experience and explore the risk factors that influence intrahospital mortality in patients with ruptured intracranial aneurysms treated with endovascular coil embolization. Materials and Methods: Our study was designed as a clinical, observational, retrospective cross-sectional study. It was performed at the Department for Radiology, University Clinical Center Kragujevac in Kragujevac, Serbia. The study inclusion criteria were ≥18 years, admitted within 24 h of symptoms onset, acute SAH diagnosed on CT, aneurysm on DSA, and treated by endovascular coil embolization from January 2014 to December 2018 at our institution. Results: A total of 66 patients were included in the study-48 (72.7%) women and 18 (27.3%) men, and 19.7% of the patients died during hospitalization. After adjustment, the following factors were associated with in-hospital mortality: a delayed ischemic neurological deficit, the presence of blood in the fourth cerebral ventricle, and an elevated urea value after endovascular intervention, increasing the chances of mortality by 16.3, 12, and 12.6 times. Conclusions: Delayed cerebral ischemia and intraventricular hemorrhage on initial head CT scan are strong predictors of intrahospital mortality in ASAH patients. Also, it is important to monitor kidney function and urea levels in ASAH patients, considering that elevated urea values after endovascular aneurysm embolization have been shown to be a significant risk factor for intrahospital mortality.

The Difference in Serum Metabolomic Profiles between the Good and Poor Outcome Groups at 3 Months in the Early and Late Phases of Aneurysmal Subarachnoid Hemorrhage

We aimed to investigate the characteristics of serum metabolomics in aneurysmal subarachnoid hemorrhage patients (aSAH) with different 3-month outcomes (good = modified Rankin score: 0-3 vs. poor = mRS 4-6). We collected serum samples from 46 aSAH patients at 24 (D1) and 168 (D7) hours after injury for analysis by liquid chromatography-mass spectrometry. Ninety-six different metabolites were identified. Groups were compared using multivariate (orthogonal partial least squares discriminant analysis), univariate, and receiving operator characteristic (ROC) methods. We observed a marked decrease in serum homocysteine levels at the late phase (D7) compared to the early phase (D1). At both D1 and D7, mannose and sorbose levels were notably higher, alongside elevated levels of kynurenine (D1) and increased 2-hydroxybutyrate, methyl-galactoside, creatine, xanthosine, p-hydroxyphenylacetate, N-acetylalanine, and N-acetylmethionine (all D7) in the poor outcome group. Conversely, levels of guanidinoacetate (D7) and several amino acids (both D1 and D7) were significantly lower in patients with poor outcomes. Our results indicate significant changes in energy metabolism, shifting towards ketosis and alternative energy sources, both in the early and late phases, even with adequate enteral nutrition, particularly in patients with poor outcomes. The early activation of the kynurenine pathway may also play a role in this process.

The Role of Serum Monocytes and Tissue Macrophages in Driving Left Ventricular Systolic Dysfunction and Cardiac Inflammation Following Subarachnoid Hemorrhage

BACKGROUND

Neurocardiogenic injury is common after aneurysmal subarachnoid hemorrhage (aSAH) despite low prevalence of preexisting cardiac disease. Potential mechanisms include autonomic dysregulation due to excess catecholamines as well as systemic inflammation. Understanding how inflammation contributes to cardiac dysfunction may aid in identifying novel therapeutic strategies. Here, we investigated serum leukocytes as predictors of left ventricular systolic dysfunction in patients with aSAH. We also investigated increased cardiac macrophages in an animal model of SAH and whether immunomodulatory treatment could attenuate this inflammatory response.

METHODS

We retrospectively analyzed 256 patients with aSAH admitted to University of Illinois Hospital between 2013 and 2019. Our inclusion criteria included patients with aSAH receiving an echocardiogram within 72 h of admission. Our primary outcome was echocardiographic evidence of systolic dysfunction. We performed multinomial regression and receiver operating curve analysis. We also used the endovascular perforation model of SAH in male Sprague-Dawley rats to assess for myocardial inflammation. Two days after surgery, hearts were collected and stained for the macrophage marker Iba-1. We compared the presence and morphology of macrophages in cardiac tissue isolated from SAH animals and sham controls treated with and without the immunomodulatory agent fingolimod.

RESULTS

Of 256 patients with aSAH, 233 (91.0%) underwent echocardiography within 72 h of admission. Of 233, 81 (34.7%) had systolic dysfunction. Patients had baseline differences in the presence of hypertension, alcohol use, and admission Glasgow Coma Scale and Hunt-Hess score. On multivariable analysis, total leukocytes (odds ratio 1.312, p < 0.001), neutrophils (odds ratio 1.242, p = 0.012), and monocytes (odds ratio 6.112, p = 0.008) were independent predictors of reduced systolic function, whereas only monocytes (odds ratio 28.014, p = 0.030) predicted hyperdynamic function. Within the rodent heart, there were increased macrophages after SAH relative to controls, and this was attenuated by fingolimod treatment (p < 0.0001).

CONCLUSIONS

Increased serum leukocytes are associated with abnormal left ventricular systolic function following aSAH. The strongest independent predictor of both reduced and hyperdynamic systolic function was increased monocytes. Increased cardiac macrophages after experimental SAH can also be targeted by using immunomodulatory drugs.

Early Intravenous Magnesium Sulfate and Its Impact on Cerebral Vasospasm as well as Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Retrospective Matched Case-Control Analysis

BACKGROUND

Magnesium sulfate (MgSO4) is a potential neuroprotective agent for patients with aneurysmal subarachnoid hemorrhage (SAH). We analyzed the effect of early application of intraoperative intravenous MgSO4 and compared cerebral vasospasm (CV), delayed cerebral ischemia (DCI), and neurological outcome in 2 patient cohorts.

METHODS

A retrospective matched-pair analysis from patients at a single center in Germany was performed without (group A) and with (group B) MgSO4 application <24 hours after diagnosis. Pairs were matched according to the known risk factors for DCI and CV (age, Fisher grade, smoking, severity of SAH). Incidence of CV and DCI and neurological outcome using the modified Rankin Scale score 3 and 12 months after SAH were recorded.

RESULTS

The inclusion criteria were met by 196 patients. After risk stratification, 48 patients were included in the final analysis (age 54.2 ± 8.1 years; 30 women and 18 men) and were assigned to group A (n = 24) or group B (n = 24). CV occurred less frequently in group B (33%) than in group A (46%). Likewise, DCI was present in 13% in group B compared with 42% in group A. After 12 months, 22 patients in group B had a favorable functional outcome (modified Rankin Scale score 0-3) compared with 15 patients in group A.

CONCLUSIONS

In this study, the incidence of CV and DCI was lower in patients receiving intravenous MgSO4 within 24 hours after aneurysmal SAH onset. Favorable functional outcome was more likely in the MgSO4 group after 12 months of follow-up.

Role of microglia after subarachnoid hemorrhage

Subarachnoid hemorrhage is a devastating sequela of aneurysm rupture. Because it disproportionately affects younger patients, the population impact of hemorrhagic stroke from subarachnoid hemorrhage is substantial. Secondary brain injury is a significant contributor to morbidity after subarachnoid hemorrhage. Initial hemorrhage causes intracranial pressure elevations, disrupted cerebral perfusion pressure, global ischemia, and systemic dysfunction. These initial events are followed by two characterized timespans of secondary brain injury: the early brain injury period and the delayed cerebral ischemia period. The identification of varying microglial phenotypes across phases of secondary brain injury paired with the functions of microglia during each phase provides a basis for microglia serving a critical role in both promoting and attenuating subarachnoid hemorrhage-induced morbidity. The duality of microglial effects on outcomes following SAH is highlighted by the pleiotropic features of these cells. Here, we provide an overview of the key role of microglia in subarachnoid hemorrhage-induced secondary brain injury as both cytotoxic and restorative effectors. We first describe the ontogeny of microglial populations that respond to subarachnoid hemorrhage. We then correlate the phenotypic development of secondary brain injury after subarachnoid hemorrhage to microglial functions, synthesizing experimental data in this area.

Impact of fludrocortisone on the outcomes of subarachnoid hemorrhage patients: A retrospective analysis

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.

Single Component Polymers, Polymer Blends, and Polymer Composites for Interventional Endovascular Embolization of Intracranial Aneurysms

Intracranial aneurysm is the abnormal focal dilation in brain arteries. When untreated, it can enlarge to rupture points and account for subarachnoid hemorrhage cases. Intracranial aneurysms can be treated by blocking the flow of blood to the aneurysm sac with clipping of the aneurysm neck or endovascular embolization with embolics to promote the formation of the thrombus. Coils or an embolic device are inserted endovascularly into the aneurysm via a micro-catheter to fill the aneurysm. Many embolization materials have been developed. An embolization coil made of soft and thin platinum wire called the "Guglielmi detachable coil" (GDC) enables safer treatment for brain aneurysms. However, patients may experience aneurysm recurrence because of incomplete coil filling or compaction over time. Unsatisfactory recanalization rates and incomplete occlusion are the drawbacks of endovascular embolization. So, the fabrication of new medical devices with less invasive surgical techniques is mandatory to enhance the long-term therapeutic performance of existing endovascular procedures. For this aim, the current article reviews polymeric materials including blends and composites employed for embolization of intracranial aneurysms. Polymeric materials used in embolic agents, their advantages and challenges, results of the strategies used to overcome treatment, and results of clinical experiences are summarized and discussed.

Predictive Model for Estimating the Risk of Epilepsy After Aneurysmal Subarachnoid Hemorrhage: The RISE Score

BACKGROUND AND OBJECTIVES

The occurrence of seizures after aneurysmal subarachnoid hemorrhage (aSAH) is associated with a poorer functional and cognitive prognosis and less favorable quality of life. It would be of value to promptly identify patients at risk of epilepsy to optimize follow-up protocols and design preventive strategies. Our aim was to develop a predictive score to help stratify epilepsy risk in patients with aSAH.

METHODS

This is a retrospective, longitudinal study of all adults with aSAH admitted to our center (2012-2021). We collected demographic data, clinical and radiologic variables, data on early-onset seizures (EOSs), and data on development of epilepsy. Exclusion criteria were previous structural brain lesion, epilepsy, and ≤7 days' follow-up. Multiple Cox regression was used to evaluate factors independently associated with unprovoked remote seizures (i.e., epilepsy). The best fitting regression model was used to develop a predictive score. Performance was evaluated in an external validation cohort of 308 patients using receiver-operating characteristic curve analysis.

RESULTS

From an initial database of 743 patients, 419 met the inclusion criteria and were included in the analysis. The mean age was 60 ± 14 years, 269 patients (64%) were women, and 50 (11.9%) developed epilepsy within a median follow-up of 4.2 years. Premorbid modified Rankin Score (mRS) (hazard ratio [HR] 4.74 [1.8-12.4], p = 0.001), VASOGRADE score (HR 2.45 [1.4-4.2], p = 0.001), surgical treatment (HR 2.77 [1.6-4.9], p = 0.001), and presence of EOSs (HR 1.84 [1.0-3.4], p = 0.05) were independently associated with epilepsy. The proposed scale, designated RISE, scores 1 point for premorbid mRS ≥ 2 (R), VASOGRADE-Yellow (I, Ischemia), surgical intervention (S), and history of EOSs (E) and 2 points for VASOGRADE-Red. RISE stratifies patients into 3 groups: low (0-1), moderate (2-3), and high (4-5) risk (2.9%, 20.8%, and 75.7% developed epilepsy, respectively). On validation in a cohort from a different tertiary care center (N = 308), the new scale yielded a similar risk distribution and good predictive power for epilepsy within 5 years after aSAH (area under the curve [AUC] 0.82; 95% CI 0.74-0.90).

DISCUSSION

The RISE scale is a robust predictor of post-SAH epilepsy with immediate clinical applicability. In addition to facilitating personalized diagnosis and treatment, RISE may be of value for exploring future antiepileptogenesis strategies.

Could Phosphorous MR Spectroscopy Help Predict the Severity of Vasospasm? A Pilot Study

One of the main causes of the dismal prognosis in patients who survive the initial bleeding after aneurysmal subarachnoidal hemorrhage is the delayed cerebral ischaemia caused by vasospasm. Studies suggest that cerebral magnesium and pH may potentially play a role in the pathophysiology of this adverse event. Using phosphorous magnetic resonance spectrocopy (31P-MRS), we calculated the cerebral magnesium (Mg) and pH levels in 13 patients who suffered from aSAH. The values between the group that developed clinically significant vasospasm (n = 7) and the group that did not (n = 6) were compared. The results of this study show significantly lower cerebral Mg levels (p = 0.019) and higher pH levels (p < 0.001) in the cumulative group (all brain voxels together) in patients who developed clinically significant vasospasm. Further clinical studies on a larger group of carefully selected patients are needed in order to predict clinically significant vasospasm.