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Poppenberg KE, Chien A, Santo BA, Chaves L, Veeturi SS, Waqas M, Monteiro A, Dmytriw AA, Burkhardt JK, Mokin M, Snyder KV, Siddiqui AH, Tutino VM. Profiling of Circulating Gene Expression Reveals Molecular Signatures Associated with Intracranial Aneurysm Rupture Risk. Mol Diagn Ther 2023; 27:115-127. [PMID: 36460938 PMCID: PMC9924426 DOI: 10.1007/s40291-022-00626-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/30/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Following detection, rupture risk assessment for intracranial aneurysms (IAs) is critical. Towards molecular prognostics, we hypothesized that circulating blood RNA expression profiles are associated with IA risk. METHODS We performed RNA sequencing on 68 blood samples from IA patients. Here, patients were categorized as either high or low risk by assessment of aneurysm size (≥ 5 mm = high risk) and Population, Hypertension, Age, Size, Earlier subarachnoid hemorrhage, Site (PHASES) score (≥ 1 = high risk). Modified F-statistics and Benjamini-Hochberg false discovery rate correction was performed on transcripts per million-normalized gene counts. Protein-coding genes expressed in ≥ 50% of samples with a q value < 0.05 and an absolute fold-change ≥ 2 were considered significantly differentially expressed. Bioinformatics in Ingenuity Pathway Analysis was performed to understand the biology of risk-associated expression profiles. Association was assessed between gene expression and risk via Pearson correlation analysis. Linear discriminant analysis models using significant genes were created and validated for classification of high-risk cases. RESULTS We analyzed transcriptomes of 68 IA patients. In these cases, 31 IAs were large (≥ 5 mm), while 26 IAs had a high PHASES score. Based on size, 36 genes associated with high-risk IAs, and two were correlated with the size measurement. Alternatively, based on PHASES score, 76 genes associated with high-risk cases, and nine of them showed significant correlation to the score. Similar ontological terms were associated with both gene profiles, which reflected inflammatory signaling and vascular remodeling. Prediction models based on size and PHASES stratification were able to correctly predict IA risk status, with > 80% testing accuracy for both. CONCLUSIONS Here, we identified genes associated with IA risk, as quantified by common clinical metrics. Preliminary classification models demonstrated feasibility of assessing IA risk using whole blood expression.
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Affiliation(s)
- Kerry E Poppenberg
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Aichi Chien
- Department of Radiology, University of California Los Angeles, Los Angeles, CA, USA
| | - Briana A Santo
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Lee Chaves
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Sricharan S Veeturi
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Andre Monteiro
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA.
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA.
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY, USA.
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RNA Sequencing Data from Human Intracranial Aneurysm Tissue Reveals a Complex Inflammatory Environment Associated with Rupture. Mol Diagn Ther 2021; 25:775-790. [PMID: 34403136 DOI: 10.1007/s40291-021-00552-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intracranial aneurysm (IA) rupture leads to deadly subarachnoid hemorrhages. However, the mechanisms leading to rupture remain poorly understood. Altered gene expression within IA tissue is linked to the pathobiology of aneurysm development and progression. Here, we analyzed expression patterns of control tissue samples and compared them to those of unruptured and ruptured IA tissue samples using data from the Gene Expression Omnibus (GEO). METHODS FASTQ files for 21 ruptured IAs, 21 unruptured IAs, and 16 control tissue samples were accessed from the GEO database. DESeq2 was used for differential expression analysis in three comparisons: unruptured IA versus control, ruptured IA versus control, and ruptured versus unruptured IA. Genes that were differentially expressed in multiple comparisons were evaluated to find those progressively increasing/decreasing from control to unruptured to ruptured. Significance was tested by either analysis of variance/Gabriel or Brown-Forsythe/Games Howell (p < 0.05 was considered significant). We used additional RNA sequencing and proteomics datasets to evaluate if our differentially expressed genes (DEGs) were present in other studies. Bioinformatics analyses were performed with g:Profiler and Ingenuity Pathway Analysis. RESULTS In total, we identified 1768 DEGs, of which 318 were found in multiple comparisons. Unruptured versus control reflected vascular remodeling processes, while ruptured versus control reflected inflammatory responses and cell activation/signaling. When comparing ruptured to unruptured IAs, we found massive activation of inflammation, inflammatory responses, and leukocyte responses. Of the 318 genes in multiple comparisons, 127 were found to be significant in the multi-cohort correlation analysis. Those that progressively increased (70 genes) were associated with immune system processes, while those that progressively decreased (38 genes) did not return any gene ontology terms. Many of our DEGs were also found in the other IA tissue sequencing studies. CONCLUSIONS We found unruptured IAs relate more to remodeling processes, while ruptured IAs reflect more inflammatory and immune responses.
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Tutino VM, Lu Y, Ishii D, Poppenberg KE, Rajabzadeh-Oghaz H, Siddiqui AH, Hasan DM. Aberrant Whole Blood Gene Expression in the Lumen of Human Intracranial Aneurysms. Diagnostics (Basel) 2021; 11:diagnostics11081442. [PMID: 34441376 PMCID: PMC8392298 DOI: 10.3390/diagnostics11081442] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 07/31/2021] [Accepted: 08/06/2021] [Indexed: 01/19/2023] Open
Abstract
The rupture of an intracranial aneurysm (IA) causes devastating hemorrhagic strokes. Yet, most IAs remain asymptomatic and undetected until they rupture. In the search for circulating biomarkers of unruptured IAs, we previously performed transcriptome profiling on whole blood and identified an IA-associated panel of 18 genes. In this study, we seek to determine if these genes are also differentially expressed within the IA lumen, which could provide a mechanistic link between the disease and the observed circulating gene expression patterns. To this end, we collected blood from the lumen of 37 IAs and their proximal parent vessels in 31 patients. The expression levels of 18 genes in the lumen and proximal vessel were then measured by quantitative polymerase chain reaction. This analysis revealed that the expression of 6/18 genes (CBWD6, MT2A, MZT2B, PIM3, SLC37A3, and TNFRSF4) was significantly higher in intraluminal blood, while the expression of 3/18 genes (ST6GALNAC1, TCN2, and UFSP1) was significantly lower. There was a significant, positive correlation between intraluminal and proximal expression of CXCL10, MT2A, and MZT2B, suggesting local increases of these genes is reflected in the periphery. Expression of ST6GALNAC1 and TIFAB was significantly positively correlated with IA size, while expression of CCDC85B was significantly positively correlated with IA enhancement on post-contrast MRI, a metric of IA instability and risk. In conclusion, intraluminal expression differences in half of the IA-associated genes observed in this study provide evidence for IA tissue-mediated transcriptional changes in whole blood. Additionally, some genes may be informative in assessing IA risk, as their intraluminal expression was correlated to IA size and aneurysmal wall enhancement.
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Affiliation(s)
- Vincent M. Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14260, USA; (V.M.T.); (K.E.P.); (H.R.-O.); (A.H.S.)
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY 14260, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14260, USA
| | - Yongjun Lu
- Department of Cardiovascular Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA;
| | - Daizo Ishii
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, 1616 JCP, 200 Hawkins Dr, Iowa City, IA 52242, USA;
| | - Kerry E. Poppenberg
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14260, USA; (V.M.T.); (K.E.P.); (H.R.-O.); (A.H.S.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14260, USA
| | - Hamidreza Rajabzadeh-Oghaz
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14260, USA; (V.M.T.); (K.E.P.); (H.R.-O.); (A.H.S.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14260, USA
| | - Adnan H. Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14260, USA; (V.M.T.); (K.E.P.); (H.R.-O.); (A.H.S.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14260, USA
| | - David M. Hasan
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, 1616 JCP, 200 Hawkins Dr, Iowa City, IA 52242, USA;
- Correspondence: ; Tel.: +1-319-384-8669
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Tutino VM, Zebraski HR, Rajabzadeh-Oghaz H, Waqas M, Jarvis JN, Bach K, Mokin M, Snyder KV, Siddiqui AH, Poppenberg KE. Identification of Circulating Gene Expression Signatures of Intracranial Aneurysm in Peripheral Blood Mononuclear Cells. Diagnostics (Basel) 2021; 11:diagnostics11061092. [PMID: 34203780 PMCID: PMC8232768 DOI: 10.3390/diagnostics11061092] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/04/2021] [Accepted: 06/09/2021] [Indexed: 12/18/2022] Open
Abstract
Peripheral blood mononuclear cells (PBMCs) play an important role in the inflammation that accompanies intracranial aneurysm (IA) pathophysiology. We hypothesized that PBMCs have different transcriptional profiles in patients harboring IAs as compared to IA-free controls, which could be the basis for potential blood-based biomarkers for the disease. To test this, we isolated PBMC RNA from whole blood of 52 subjects (24 with IA, 28 without) and performed next-generation RNA sequencing to obtain their transcriptomes. In a randomly assigned discovery cohort of n = 39 patients, we performed differential expression analysis to define an IA-associated signature of 54 genes (q < 0.05 and an absolute fold-change ≥ 1.3). In the withheld validation dataset, these genes could delineate patients with IAs from controls, as the majority of them still had the same direction of expression difference. Bioinformatics analyses by gene ontology enrichment analysis and Ingenuity Pathway Analysis (IPA) demonstrated enrichment of structural regulation processes, intracellular signaling function, regulation of ion transport, and cell adhesion. IPA analysis showed that these processes were likely coordinated through NF-kB, cytokine signaling, growth factors, and TNF activity. Correlation analysis with aneurysm size and risk assessment metrics showed that 4/54 genes were associated with rupture risk. These findings highlight the potential to develop predictive biomarkers from PBMCs to identify patients harboring IAs.
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Affiliation(s)
- Vincent M. Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
- Department of Mechanical and Aerospace Engineering, University at Buffalo, Buffalo, NY 14228, USA
- Correspondence: ; Tel.: +1-(716)-829-5400; Fax: +1-(716)-854-1850
| | - Haley R. Zebraski
- Department of Biomedical Engineering, University at Buffalo, Buffalo, NY 14228, USA;
| | - Hamidreza Rajabzadeh-Oghaz
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
| | - Muhammad Waqas
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
| | - James N. Jarvis
- Department of Pediatrics, University at Buffalo, Buffalo, NY 14203, USA;
| | - Konrad Bach
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33620, USA; (K.B.); (M.M.)
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL 33620, USA; (K.B.); (M.M.)
| | - Kenneth V. Snyder
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
| | - Adnan H. Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
| | - Kerry E. Poppenberg
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY 14203, USA; (H.R.-O.); (M.W.); (K.V.S.); (A.H.S.); (K.E.P.)
- Department of Neurosurgery, University at Buffalo, Buffalo, NY 14203, USA
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Poppenberg KE, Li L, Waqas M, Paliwal N, Jiang K, Jarvis JN, Sun Y, Snyder KV, Levy EI, Siddiqui AH, Kolega J, Meng H, Tutino VM. Whole blood transcriptome biomarkers of unruptured intracranial aneurysm. PLoS One 2020; 15:e0241838. [PMID: 33156839 PMCID: PMC7647097 DOI: 10.1371/journal.pone.0241838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/21/2020] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The rupture of an intracranial aneurysm (IA) causes devastating subarachnoid hemorrhages, yet most IAs remain undiscovered until they rupture. Recently, we found an IA RNA expression signature of circulating neutrophils, and used transcriptome data to build predictive models for unruptured IAs. In this study, we evaluate the feasibility of using whole blood transcriptomes to predict the presence of unruptured IAs. METHODS We subjected RNA from peripheral whole blood of 67 patients (34 with unruptured IA, 33 without IA) to next-generation RNA sequencing. Model genes were identified using the least absolute shrinkage and selection operator (LASSO) in a random training cohort (n = 47). These genes were used to train a Gaussian Support Vector Machine (gSVM) model to distinguish patients with IA. The model was applied to an independent testing cohort (n = 20) to evaluate performance by receiver operating characteristic (ROC) curve. Gene ontology and pathway analyses investigated the underlying biology of the model genes. RESULTS We identified 18 genes that could distinguish IA patients in a training cohort with 85% accuracy. This SVM model also had 85% accuracy in the testing cohort, with an area under the ROC curve of 0.91. Bioinformatics reflected activation and recruitment of leukocytes, activation of macrophages, and inflammatory response, suggesting that the biomarker captures important processes in IA pathogenesis. CONCLUSIONS Circulating whole blood transcriptomes can detect the presence of unruptured IAs. Pending additional testing in larger cohorts, this could serve as a foundation to develop a simple blood-based test to facilitate screening and early detection of IAs.
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Affiliation(s)
- Kerry E. Poppenberg
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Biomedical Engineering, University at Buffalo, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
| | - Lu Li
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, New York, United States of America
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
| | - Nikhil Paliwal
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Biomedical Engineering, University at Buffalo, Buffalo, New York, United States of America
| | - Kaiyu Jiang
- Genetics, Genomics, and Bioinformatics Program, University at Buffalo, Buffalo, New York, United States of America
| | - James N. Jarvis
- Genetics, Genomics, and Bioinformatics Program, University at Buffalo, Buffalo, New York, United States of America
- Department of Pediatrics, University at Buffalo, Buffalo, New York, United States of America
| | - Yijun Sun
- Genetics, Genomics, and Bioinformatics Program, University at Buffalo, Buffalo, New York, United States of America
- Department of Microbiology and Immunology, University at Buffalo, Buffalo, New York, United States of America
| | - Kenneth V. Snyder
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
- Department of Radiology, University at Buffalo, Buffalo, New York, United States of America
- Department of Neurology, University at Buffalo, Buffalo, New York, United States of America
| | - Elad I. Levy
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
- Department of Radiology, University at Buffalo, Buffalo, New York, United States of America
| | - Adnan H. Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
- Department of Radiology, University at Buffalo, Buffalo, New York, United States of America
| | - John Kolega
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, New York, United States of America
| | - Hui Meng
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Biomedical Engineering, University at Buffalo, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
- Department of Mechanical & Aerospace Engineering, University at Buffalo, Buffalo, New York, United States of America
| | - Vincent M. Tutino
- Canon Stroke and Vascular Research Center, Buffalo, New York, United States of America
- Department of Biomedical Engineering, University at Buffalo, Buffalo, New York, United States of America
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, United States of America
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, New York, United States of America
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6
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Poppenberg KE, Tutino VM, Li L, Waqas M, June A, Chaves L, Jiang K, Jarvis JN, Sun Y, Snyder KV, Levy EI, Siddiqui AH, Kolega J, Meng H. Classification models using circulating neutrophil transcripts can detect unruptured intracranial aneurysm. J Transl Med 2020; 18:392. [PMID: 33059716 PMCID: PMC7565814 DOI: 10.1186/s12967-020-02550-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 09/27/2020] [Indexed: 12/14/2022] Open
Abstract
Background Intracranial aneurysms (IAs) are dangerous because of their potential to rupture. We previously found significant RNA expression differences in circulating neutrophils between patients with and without unruptured IAs and trained machine learning models to predict presence of IA using 40 neutrophil transcriptomes. Here, we aim to develop a predictive model for unruptured IA using neutrophil transcriptomes from a larger population and more robust machine learning methods. Methods Neutrophil RNA extracted from the blood of 134 patients (55 with IA, 79 IA-free controls) was subjected to next-generation RNA sequencing. In a randomly-selected training cohort (n = 94), the Least Absolute Shrinkage and Selection Operator (LASSO) selected transcripts, from which we constructed prediction models via 4 well-established supervised machine-learning algorithms (K-Nearest Neighbors, Random Forest, and Support Vector Machines with Gaussian and cubic kernels). We tested the models in the remaining samples (n = 40) and assessed model performance by receiver-operating-characteristic (ROC) curves. Real-time quantitative polymerase chain reaction (RT-qPCR) of 9 IA-associated genes was used to verify gene expression in a subset of 49 neutrophil RNA samples. We also examined the potential influence of demographics and comorbidities on model prediction. Results Feature selection using LASSO in the training cohort identified 37 IA-associated transcripts. Models trained using these transcripts had a maximum accuracy of 90% in the testing cohort. The testing performance across all methods had an average area under ROC curve (AUC) = 0.97, an improvement over our previous models. The Random Forest model performed best across both training and testing cohorts. RT-qPCR confirmed expression differences in 7 of 9 genes tested. Gene ontology and IPA network analyses performed on the 37 model genes reflected dysregulated inflammation, cell signaling, and apoptosis processes. In our data, demographics and comorbidities did not affect model performance. Conclusions We improved upon our previous IA prediction models based on circulating neutrophil transcriptomes by increasing sample size and by implementing LASSO and more robust machine learning methods. Future studies are needed to validate these models in larger cohorts and further investigate effect of covariates.
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Affiliation(s)
- Kerry E Poppenberg
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Biomedical Engineering, University of Buffalo, Buffalo, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Lu Li
- Department of Computer Science and Engineering, University of Buffalo, Buffalo, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Armond June
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Lee Chaves
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Kaiyu Jiang
- Genetics, Genomics, and Bioinformatics Program, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - James N Jarvis
- Genetics, Genomics, and Bioinformatics Program, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Yijun Sun
- Genetics, Genomics, and Bioinformatics Program, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Microbiology and Immunology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Kenneth V Snyder
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - John Kolega
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA.,Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA
| | - Hui Meng
- Canon Stroke and Vascular Research Center, Clinical and Translational Research Center, 875 Ellicott Street, Buffalo, NY, 14214, USA. .,Department of Biomedical Engineering, University of Buffalo, Buffalo, USA. .,Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, Buffalo, USA. .,Department of Mechanical & Aerospace Engineering, University At Buffalo, Buffalo, NY, USA.
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Ogilvy CS, Gomez-Paz S, Kicielinski KP, Salem MM, Akamatsu Y, Waqas M, Rai HH, Catapano JS, Muram S, Elghareeb M, Siddiqui AH, Levy EI, Lawton MT, Mitha AP, Hoh BL, Polifka A, Fox WC, Moore JM, Thomas AJ. Cigarette smoking and risk of intracranial aneurysms in middle-aged women. J Neurol Neurosurg Psychiatry 2020; 91:985-990. [PMID: 32723730 DOI: 10.1136/jnnp-2020-323753] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/09/2020] [Accepted: 06/23/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE We previously reported a single-centre study demonstrating that smoking confers a six-fold increased risk for having an unruptured intracranial aneurysm (UIA) in women aged between 30 and 60 years and this risk was higher if the patient had chronic hypertension. There are no data with greater generalisability evaluating this association. We aimed to validate our previous findings in women from a multicentre study. METHODS A multicentre case-control study on women aged between 30 and 60 years, that had magnetic resonance angiography (MRA) during the period 2016-2018. Cases were those with an incidental UIA, and these were matched to controls based on age and ethnicity. A multivariable conditional logistic regression was conducted to evaluate smoking status and hypertension differences between cases and controls. RESULTS From 545 eligible patients, 113 aneurysm patients were matched to 113 controls. The most common reason for imaging was due to chronic headaches in 62.5% of cases and 44.3% of controls. A positive smoking history was encountered in 57.5% of cases and in 37.2% of controls. A multivariable analysis demonstrated a significant association between positive smoking history (OR 3.7, 95%CI 1.61 to 8.50), hypertension (OR 3.16, 95% CI 1.17 to 8.52) and both factors combined with a diagnosis of an incidental UIA (OR 6.9, 95% CI 2.49 to 19.24). CONCLUSIONS Women aged between 30 and 60 years with a positive smoking history have a four-fold increased risk for having an UIA, and a seven-fold increased risk if they have underlying chronic hypertension. These findings indicate that women aged between 30 and 60 years with a positive smoking history might benefit from a screening recommendation.
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Affiliation(s)
- Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly P Kicielinski
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Yosuke Akamatsu
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, United States
| | - Hamid Hussain Rai
- Department of Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, United States.,Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, United States
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Sandeep Muram
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Mohammed Elghareeb
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, United States
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, United States.,Department of Neurosurgery and Radiology, Canon Strole and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, United States
| | - Elad I Levy
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, United States.,Department of Neurosurgery and Radiology, Canon Strole and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, United States
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, United States
| | - Alim P Mitha
- Division of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
| | - Brian L Hoh
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, United States
| | - Adam Polifka
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, United States
| | - W Christopher Fox
- Lillian S. Wells Department of Neurosurgery, University of Florida, Gainesville, Florida, United States
| | - Justin M Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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8
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Daga K, Taneja M, Venketasubramanian N. Small Intracranial Aneurysms and Subarachnoid Hemorrhage: Is the Size Criterion for Risk of Rupture Relevant? Case Rep Neurol 2020; 12:161-168. [PMID: 33505289 DOI: 10.1159/000503094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Accepted: 09/01/2019] [Indexed: 11/19/2022] Open
Abstract
The current understanding is that small intracranial aneurysms (<7 mm) are not at a significant risk for rupture. However, there have been several published series of rupture and subarachnoid hemorrhage from aneurysms <5 mm. Three cases of intracranial aneurysms rupturing at <3 mm are presented in this paper. Patient age ranged between 38 and 57 years. The aneurysms were located in different parts of the circulation in the brain. This case series highlights that the size criterion alone is not adequate when evaluating patients with unruptured brain aneurysms for observational follow-up or treatment.
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Affiliation(s)
- Karan Daga
- Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, United Kingdom
| | - Manish Taneja
- Raffles Neuroscience Centre, Raffles Hospital, Singapore, Singapore
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9
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Zhang Y, Wang J, Xiao J, Fang T, Hu N, Li M, Deng L, Cheng Y, Zhu Y, Cui W. An electrospun fiber-covered stent with programmable dual drug release for endothelialization acceleration and lumen stenosis prevention. Acta Biomater 2019; 94:295-305. [PMID: 31195144 DOI: 10.1016/j.actbio.2019.06.008] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 05/28/2019] [Accepted: 06/07/2019] [Indexed: 11/17/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) causes high rates of mortality and morbidity. A covered stent is an effective endovascular treatment for complicated aneurysms intractable to endovascular coiling and surgical clipping. However, in-stent restenosis and delayed endothelialization are the main challenges contributing to its safety. In this study, we designed a biofunctional stent covered with dual drug-loaded electrospun fibers to achieve programmed vascular endothelial growth factor (VEGF) and paclitaxel (PTX) release for the early promotion of stent endothelialization and long-term inhibition of stenosis caused by smooth muscle hyperplasia. By encapsulating PTX-loaded mesoporous silica nanoparticles (MSNs) within electrospun polylactic acid (PLA) fibers, the release period of PTX was effectively extended. Furthermore, VEGF was conjugated onto the surface of the membrane by reacting with polydopamine (PDA) for quick release. The in vitro drug release profile revealed the sustained release of PTX, which persisted for 63 days without early burst release, while up to 87.05% of VEGF was rapidly released within 3 days. After 6 days of incubation, cell experiments demonstrated that the dual drug-loaded scaffold effectively prompted endothelial cell proliferation (488% vs. 386% in the control group, P = 0.001) and inhibited the proliferation of smooth muscle cells (SMCs) using the 21-day extracts (155% vs. 303% in the control group, P = 0.039). Animal studies showed that compared to bare stents, the drug-loaded covered stents improved the immediate- and mid-term complete aneurysm occlusion rates (P < 0.05). The drug-loaded covered stents also showed earlier endothelialization promotion and better lumen restenosis than normal covered stents (0% vs. 25%, P = 0.29) for 12 weeks. Overall, a programmed dual drug-loaded scaffold that effectively occluded the aneurysm sac was developed in this study, and the discrete release of VEGF and PTX promoted endothelialization and prevented in-stent stenosis. This study provided a new method to improve the biosafety of implanted covered stents for the treatment of intracranial aneurysms. STATEMENT OF SIGNIFICANCE: Aneurysmal subarachnoid hemorrhage (SAH) is one of the most common hemorrhage stroke resulted in a nearly 40% mortality and 33% morbidity due to sudden rupture of an intracranial aneurysm. Endovascular coil embolism is a popular treatment for aneurysm but this technique run high risk of bleeding, mass effect, low complete occlusion rate and higher recanalization rate due to its operation conducted within aneurysm sac. A bio-functional membrane knitted by dual-drug loaded electrospun fibers covered on a stent was designed to realize programed vascular endothelial growth factor and paclitaxel release for the early promotion of vascular endothelium and long-term inhibition of stenosis caused by smooth muscle hyperplasia. This study provides new method to improve the biosafety of covered stent insertion for the treatment of intracranial aneurysms.
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Affiliation(s)
- Yiran Zhang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China; Shanghai Institute of Traumatology and Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, PR China
| | - Jienan Wang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China
| | - Junyuan Xiao
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China
| | - Tonglei Fang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China
| | - Nan Hu
- Department of Intervention and Vascular Surgery, Shanghai Tenth People's Hospital Affiliated to Tongji University, 301 Yanchang Road, Shanghai 200072, PR China
| | - Minghua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China
| | - Lianfu Deng
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, PR China
| | - Yingsheng Cheng
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China
| | - Yueqi Zhu
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, No. 600, Yishan Road, Shanghai 200233, PR China.
| | - Wenguo Cui
- Shanghai Institute of Traumatology and Orthopaedics, Shanghai Key Laboratory for Prevention and Treatment of Bone and Joint Diseases, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, 197 Ruijin 2nd Road, Shanghai 200025, PR China.
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10
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Wei L, Wang Q, Zhang Y, Yang C, Guan H, Chen Y, Sun Z. Identification of key genes, transcription factors and microRNAs involved in intracranial aneurysm. Mol Med Rep 2018; 17:891-897. [PMID: 29115560 PMCID: PMC5780181 DOI: 10.3892/mmr.2017.7940] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 08/10/2017] [Indexed: 01/17/2023] Open
Abstract
Intracranial aneurysm (IA) is a devastating disease, the pathogenesis of which remains to be elucidated. The present study aimed to determine the molecular mechanism of IA and to identify potential therapeutic targets using bioinformatics analysis. The GSE54083 dataset, which includes data from patients with ruptured IA and superficial temporal artery controls, was downloaded from the Gene Expression Omnibus, and differentially expressed genes (DEGs) were identified in the ruptured IA samples using the limma package in R. Subsequently, the Database for Annotation, Visualization and Integrated Discovery software was used to perform function and pathway enrichment analyses and the Search Tool for the Retrieval of Interacting Genes database was used to construct the protein‑protein interaction (PPI) network. Then, microRNA (miRNA) target and transcription factor (TF) target pairs were identified using the miR2Disease, MiRwalk2, ITFP and TRANSFAC databases. Finally, an integrated network of TF‑target‑miRNAs was constructed using Cytoscape. A total of 402 upregulated DEGs and 375 downregulated DEGs were identified from the ruptured IA samples compared with the superficial temporal artery samples. The majority of the upregulated DEGs were significantly enriched in the immune system development category, including CD40 ligand (CD40LG) and CD40 and the downregulated DEGs, such as striatin (STRN), were enriched in neuron projection development. In addition, nitric oxide synthase 1 (NOS1), a target of miRNA‑125b, and myosin heavy chain 11 (MYH11), a target of minichromosome maintenance complex component 4 (MCM4), had higher degree scores in the integrated network. These findings suggest that CD40, CD40LG, NOS1, STRN, MCM4, MYH11 and miR‑125b may be potential therapeutic targets for the treatment of IA.
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Affiliation(s)
- Liang Wei
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Qi Wang
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Yanfei Zhang
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Cheng Yang
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Hongxin Guan
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Yiming Chen
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
| | - Zhiyang Sun
- Department of Neurosurgery, East Hospital, Tongji University School of Medicine, Shanghai 200120, P.R. China
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11
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Ibrahim TF, Jahromi BR, Miettinen J, Raj R, Andrade-Barazarte H, Goehre F, Kivisaari R, Lehto H, Hernesniemi J. Long-Term Causes of Death and Excess Mortality After Carotid Artery Ligation. World Neurosurg 2016; 90:116-122. [DOI: 10.1016/j.wneu.2016.01.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 01/03/2016] [Accepted: 01/04/2016] [Indexed: 01/22/2023]
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12
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Chua MH, Griessenauer CJ, Stapleton CJ, He L, Thomas AJ, Ogilvy CS. Documentation of Improved Outcomes for Intracranial Aneurysm Management Over a 15-Year Interval. Stroke 2016; 47:708-12. [PMID: 26839350 DOI: 10.1161/strokeaha.115.011959] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/31/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Despite rapid advancements in intracranial aneurysm management, there is no evidence as of yet that this has translated into improvement in overall prognosis. METHODS We compared 2 periods of aneurysm management, 1998 to 2003 (n=1023 aneurysms) and 2007 to 2013 (n=1499 aneurysms), at a single, high-volume neurovascular center. Our outcome of interest was low or moderate disability (Glasgow Outcome Scale score of 4 or 5) at 6 months or more post treatment. RESULTS There were significant improvements in outcome for surgical, endovascular, and overall treatment of unruptured (adjusted odds ratio [OR], 2.33; P=0.0091; adjusted OR, 4.40; P=0.0271; and adjusted OR, 2.58; P=0.0008, respectively) and ruptured (adjusted OR, 3.18; P=0.0004; adjusted OR, 3.54; P=0.0001; and adjusted OR, 3.11; P<0.0001, respectively) aneurysms from the first to the second time period. In 2007 to 2013, the proportion of cases with low or moderate disability at 6 months post subarachnoid hemorrhage was 75.6% for surgical clipping and 76.6% for endovascular therapy. CONCLUSIONS We report significantly improved outcomes over time for overall aneurysm management and for multiple patient subgroups, associated with increased usage of endovascular therapy.
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Affiliation(s)
- Michelle H Chua
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christoph J Griessenauer
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christopher J Stapleton
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Lucy He
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Ajith J Thomas
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.)
| | - Christopher S Ogilvy
- From the Neurosurgical Service, Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Harvard Medical School, Boston, MA (M.H.C., C.J.G., L.H., A.J.T., C.S.O.); and Department of Neurosurgery, Massachusetts General Hospital, Boston (C.J.S.).
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13
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Huhtakangas J, Lehto H, Seppä K, Kivisaari R, Niemelä M, Hernesniemi J, Lehecka M. Long-Term Excess Mortality After Aneurysmal Subarachnoid Hemorrhage. Stroke 2015; 46:1813-8. [DOI: 10.1161/strokeaha.115.009288] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 05/05/2015] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
There is high case-fatality rate and loss of productive life-years related to aneurysmal subarachnoid hemorrhage (aSAH) but data on long-term survival of patients with aSAH are scarce. We aim to evaluate long-term excess mortality and related risk factors after an aSAH event.
Methods—
Survivors (n=3078) of aSAH who had survived for ≥1 year were reviewed for this retrospective follow-up study, which was conducted in the Department of Neurosurgery in Helsinki between 1980 and 2007. Follow-up started 1 year after the aSAH and continued until death or the end of 2012 (48 918 patient-years). Mortality and relative survival ratios were derived using a matched general population.
Results—
Survivors of aSAH after 20 years showed 17% excess mortality compared with the general population. Even young patients and patients with good recovery showed excess mortality. The highest excess mortality was among patients with multiple aneurysms, old age, poor preoperative clinical condition, conservative aneurysm treatment, and unfavorable clinical outcome at 1 year.
Conclusions—
Even after initially favorable recovery from an aSAH, survivors experience excess mortality in the long run in comparison to a matched general population. Cardiovascular disease at younger age and cerebrovascular events were overrepresented as causes of death, which indicates the importance of treatment of vascular risk factors. Young patients and patients with multiple aneurysms who are recovering from an aSAH should be followed-up and treated most actively.
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Affiliation(s)
- Justiina Huhtakangas
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Hanna Lehto
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Karri Seppä
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Riku Kivisaari
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Mika Niemelä
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Juha Hernesniemi
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
| | - Martin Lehecka
- From the Department of Neurosurgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland (J.H., H.L., R.K., M.N., J.H., M.L.); and Finnish Cancer Registry, Helsinki, Finland (K.S.)
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14
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Arterial Wall Degeneration Plus Hemodynamic Insult Cause Arterial Wall Remodeling and Nascent Aneurysm Formation at Specific Sites in Dogs. J Neuropathol Exp Neurol 2014; 73:808-19. [DOI: 10.1097/nen.0000000000000100] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Serafin Z, Strześniewski P, Beuth W. Predictors of residual flow in embolized intracranial ruptured aneurysms at early follow-up. Pol J Radiol 2014; 79:42-6. [PMID: 24611084 PMCID: PMC3945010 DOI: 10.12659/pjr.889919] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 12/10/2013] [Indexed: 11/09/2022] Open
Abstract
Background The possibility of recanalization and the need for retreatment are the most important drawbacks of intracranial aneurysm embolization. The purpose of the study was to prospectively analyze the results of early follow-up angiography of embolized ruptured aneurysms in an attempt to determine factors predicting the presence of residual flow. Material/Methods Evaluation included 72 patients with 72 aneurysms, which were followed-up 3 months after the treatment. Analysis of residual flow predictors included: age and gender, clinical state in Hunt-Hess scale, aneurysm localization, aneurysm three dimensions and volume, neck width, sac-to-neck ratio, initial result of embolization, number of coils used and the use of hydrogel coils and stents. Results Mean sac diameter was 6.5±3.9 mm, and mean neck width was 2.9±1.4 mm. Follow-up angiography presented residual flow in 26 aneurysms (36.1%): class 2 in 8 aneurysms (11.1%), and class 3 in 18 cases (25.0%). Stable aneurysm filling was observed in 45 cases (62.5%), progression of residual flow in 25 cases (34.7%), and regression in 2 cases (2.8%). According to ROC analysis independent predictors of residual flow were aneurysm neck diameter (AUC 0.857, 95% CI: 0.755–0.928, p<0.0001) and sac-to-neck ratio (AUC 0.817, 95% CI: 0.708–0.898, p<0.0001). Cut-off point of the ROC curve was established at 2.8 mm for neck diameter, and 1.73 for sac-to-neck ratio. Conclusions Aneurysm neck diameter and sac-to-neck ratio are independently related to the residual flow in embolized ruptured aneurysms at early follow-up.
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Affiliation(s)
- Zbigniew Serafin
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Piotr Strześniewski
- Department of Radiology and Diagnostic Imaging, Nicolaus Copernicus University, Collegium Medicum in Bydgoszcz, Bydgoszcz, Poland
| | - Wojciech Beuth
- Faculty of Health Sciences, Higher School of Humanities and Economics in Włocławek, Włocławek, Poland
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16
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Pyysalo L, Luostarinen T, Keski-Nisula L, Öhman J. Long-term excess mortality of patients with treated and untreated unruptured intracranial aneurysms. J Neurol Neurosurg Psychiatry 2013; 84:888-92. [PMID: 23424191 PMCID: PMC3717756 DOI: 10.1136/jnnp-2012-303073] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND AIM Subarachnoid haemorrhage (SAH) patients have an excess mortality proportion in long-term outcome studies because of the high rate of cerebrovascular and cardiovascular deaths. The aim of the present study was to assess the excess long-term mortality among patients with unruptured aneurysms with no previous SAH and to compare excess mortality after coiling, clipping and without treatment. METHODS Between 1989 and 1999, a total of 1294 patients with intracranial aneurysms were admitted to our hospital. Of these, 1154 had previous SAH and were excluded leaving 140 patients with 178 intracranial unruptured aneurysms as the study population. The patients were followed up until death or by the end of April 2011. Causes of death were determined. Relative survival ratios (RSRs) were calculated and compared with the matched general population. RESULTS Mean follow-up time was 13 years (range 1-19). During the follow-up period, 36% of patients died. Death was caused by cerebrovascular event in half of the cases. There were 12% excess mortality at 15 years in men and 35% excess mortality in women compared with general population. Excess mortality among women over 50 years was significantly higher than that among men (p=0.018). CONCLUSIONS Patients with untreated unruptured aneurysms have 50% excess long-term mortality compared with general population. Men with treated unruptured aneurysms have a survival proportion comparable with matched general population. Women, instead, have 28% excess mortality after surgical treatment and 23% excess mortality after endovascular treatment of unruptured aneurysms.
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Affiliation(s)
- Liisa Pyysalo
- Department of Neurosurgery, Tampere University Hospital, PO Box 2000, Tampere FIN-33521, Finland.
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17
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Zaroff JG, Leong J, Kim H, Young WL, Cullen SP, Rao VA, Sorel M, Quesenberry CP, Sidney S. Cardiovascular predictors of long-term outcomes after non-traumatic subarachnoid hemorrhage. Neurocrit Care 2013; 17:374-81. [PMID: 21769457 DOI: 10.1007/s12028-011-9592-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND AND PURPOSE Cardiac injury is common after subarachnoid hemorrhage (SAH) and is associated with adverse early outcomes, but long-term effects are unknown. The first aim of this study was to compare the long-term rates of death, stroke, and cardiac events in SAH survivors versus a matched population without SAH. The second aim was to quantify the effects of cardiac injury on the outcome rates. METHODS This was a retrospective cohort study of patients with and without non-traumatic SAH. For aim #1, the predictor variable was SAH and the outcome variables were all-cause and cerebrovascular mortality, stroke, cardiac mortality, acute coronary syndrome (ACS), and heart failure (HF) admission. A multivariable Cox proportional hazards analysis was performed. For aim #2, the predictor variables were cardiac injury (elevated serum cardiac enzymes or a diagnosis code for ACS) and dysfunction (pulmonary edema on X-Ray or a diagnosis code for HF). RESULTS Compared with 4,695 members without SAH, the 910 SAH patients had higher rates of all-cause mortality (hazard ratio [HR 2.6], 95% confidence intervals [CI] 2.0-3.4), cerebrovascular mortality (HR 30.6, CI 13.5-69.4), and stroke (HR 10.2, CI 7.5-13.8). Compared with the non-SAH group, the SAH patients with cardiac injury had increased rates of all-cause mortality (HR 5.3, CI 3.0-9.3), cardiac mortality (HR 7.3, CI 1.7-31.6), and heart failure (HR 4.3, CI 1.53-11.88). CONCLUSIONS SAH survivors have increased long-term mortality and stroke rates compared with a matched non-SAH population. SAH-induced cardiac injury is associated with an increased risk of death and heart failure hospitalization.
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Affiliation(s)
- Jonathan G Zaroff
- Kaiser Northern California Division of Research, San Francisco, CA, USA.
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18
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Sauerbeck L, Hornung R, Woo D, Moomaw CJ, Anderson C, Connolly ES, Rouleau GA, Brown RD, Broderick JP. Mortality and causes of death in the Familial Intracranial Aneurysm study. Int J Stroke 2012; 8:696-700. [PMID: 22928607 DOI: 10.1111/j.1747-4949.2012.00857.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Higher mortality for patients with aneurysmal subarachnoid haemorrhage has been reported. AIMS In families with intracranial aneurysms, we sought to determine whether mortality among subjects with intracranial aneurysm (affected) was higher and related to rupture, compared with unaffected family members. METHODS Subjects enrolled in the Familial Intracranial Aneurysm protocol were contacted yearly and their status was obtained. If reported to be deceased, the cause of death was verified by available records. A Cox proportional hazards model was utilized to compare mortality rates. RESULTS Of the 2794 subjects, 1073 were affected and 1721 were unaffected. There were 8525 person-years of follow-up (mean 3·05 ± 1·73 years) and 85 deaths. Age at study entry for the affected (58·4 ± 11·9 years) was significantly older (P < 0·0001) than for the unaffected (52·2 ± 16·1). After adjusting for age, the overall mortality rate for the affected subjects was not significantly different from that for the unaffected (Rate Ratio [RR] 1·26, 95% confidence interval 0·82-1·93, P = 0·292). There was a strong effect modification due to age. The mortality rate ratio of the affected to the unaffected who were ≤60 years of age was RR = 3·48 (95% confidence interval: 1·59-7·63, P = 0·002), the rate for the affected subjects who were ≥60 was less than the rate for the unaffected (RR = 0·69, 95% confidence interval: 0·404-1·19, P = 0·178). The affected who had ruptures had 2·62 times the mortality rate as those without ruptures (95% confidence interval 1·43-4·80, P = 0·002). CONCLUSION The overall mortality was similar for the affected and unaffected subjects in this cohort. Among the affected only, those with ruptured intracranial aneurysm had a higher mortality rate than those without ruptured.
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Affiliation(s)
- Laura Sauerbeck
- Department of Medicine, The University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Guimond JG, Chagnon P, Bojanowski M. Clippage versus coiling dans le cas d’une hémorragie sous-arachnoïdienne par rupture d’anévrisme : la condition médicale du patient doit-elle influencer le choix du traitement ? Neurochirurgie 2012. [DOI: 10.1016/j.neuchi.2012.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Clipping vs. coiling in acute aneurysmal subarachnoid haemorrhage: Should the patient's medical condition influence treatment modality? Neurochirurgie 2012; 58:115-24. [PMID: 22464600 DOI: 10.1016/j.neuchi.2012.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2012] [Accepted: 02/13/2012] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Acute subarachnoid haemorrhage (SAH) resulting from aneurysmal rupture is a medical condition associated with significant morbidity and mortality. Medical complications resulting from the bleeding itself, along with the patient's underlying medical conditions are known to represent possible prognostic factors in acute SAH. However, their respective significance on the patient's overall clinical outcome following either endovascular coiling (EC) or surgical clipping (SC) remains to be ascertained as well as their potential role in choosing a definitive treatment option. We thus reviewed the evidence concerning the patient's medical condition as a factor in this decision making process. METHODOLOGY Source data were obtained from a MEDLINE search of the medical literature and by manual review of published randomised trials comparing EC to SC. RESULTS The last three decades allowed for detection of medical complications with increasing frequency in the context of SAH, as awareness for them has improved. Despite the fact that a patient's extra-neurological condition can be a significant prognostic factor after a SAH, our review demonstrates that medical conditions in general were not taken into consideration in randomized trials comparing EC to SC. Also, we found no analysis comparing the potential role of prior versus post-SAH medical conditions in choosing either therapeutic avenue. CONCLUSION It is not determined whether it is appropriate for SAH patients to be offered treatment for a ruptured aneurysm based mostly on anatomical criteria or if, within certain subgroups of patients, EC and SC should also be recommended in light of what the patient can tolerate from a medical standpoint. Although we hypothesize that in practice, the patient's medical condition is considered in the decision making process, it remains to be documented. Patient, aneurysm and institution-related factors are all interrelated, as is patient care. Data on all of these factors are thus needed and their analysis by association rather than by dissociation may be the key in answering our question.
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Huttunen T, Riihinen A, Pukkala E, von und zu Fraunberg M, Koivisto T, Ronkainen A, Rinne J, Hernesniemi J, Sankila R, Jääskeläinen JE. Increased Relative Risk of Lung Cancer in 2,904 Patients with Saccular Intracranial Aneurysm Disease in Eastern Finland. Neuroepidemiology 2012; 38:93-9. [DOI: 10.1159/000335041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2011] [Accepted: 11/14/2011] [Indexed: 12/31/2022] Open
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Serafin Z, Strześniewski P, Lasek W, Beuth W. Methods and time schedule for follow-up of intracranial aneurysms treated with endovascular embolization: a systematic review. Neurol Neurochir Pol 2011; 45:421-30. [DOI: 10.1016/s0028-3843(14)60309-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Huttunen T, von und zu Fraunberg M, Koivisto T, Ronkainen A, Rinne J, Sankila R, Seppä K, Jääskeläinen JE. Long-term Excess Mortality of 244 Familial and 1502 Sporadic One-Year Survivors of Aneurysmal Subarachnoid Hemorrhage Compared With a Matched Eastern Finnish Catchment Population. Neurosurgery 2011; 68:20-7. [DOI: 10.1227/neu.0b013e3181ff33ca] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
Abstract
BACKGROUND:
Saccular intracranial aneurysms (sIAs) develop in 2% of the population. Rupture of the sIA wall causes almost all cases of aneurysmal subarachnoid hemorrhage (aSAH).
OBJECTIVE:
We analyzed the long-term excess mortality of 244 familial and 1502 sporadic 1-year survivors of aSAH from sIA compared with a matched Eastern Finnish catchment population.
METHODS:
The Kuopio Neurosurgery Database contains 1746 one-year survivors of aSAH (1980–2007) from a defined population. The median follow-up time, until death (n = 494) or the end of 2008, was 12 years. Relative survival ratios were calculated compared with the matched (sex, age, calendar time) catchment population. Relative excess risk of death (RER) was estimated for variables known on admission for aSAH as well as Glasgow Outcome Scale score at 12 months.
RESULTS:
There was 12% excess mortality at 15 years (cumulative relative survival ratio: 0.88; 95% confidence interval: 0.85-0.91). Independent risk factors were male sex (RER: 1.6), age older than 64 years (RER: 2.9), ruptured basilar tip sIA (RER: 4.5), severe hydrocephalus on admission (RER: 3.6), no occlusive therapy (RER: 6.0), and Glasgow Outcome Scale scores of 2, 3, or 4 at 12 months (RER: 23, 4.1, 2.1, respectively), but not familial sIA disease. There were lethal rebleeds from 13 of the 1440 clipped sIAs, 2 of the 265 coiled sIAs, and 2 from the 17 nonoccluded sIAs, and 14 new lethal bleeds from other sIAs.
CONCLUSION:
The impact of both sporadic and familial aSAH and their sequelae in the central nervous and cardiovascular systems may cause long-term morbidity and mortality. The complex sIA disease may predispose to other vascular events later in life. The causes of the long-term excess mortality are heterogeneous, and more detailed analyses are required.
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Affiliation(s)
- Terhi. Huttunen
- Neurosurgery of Kuopio University Hospital, NeuroCenter, Kuopio, Finland
| | | | - Timo. Koivisto
- Neurosurgery of Kuopio University Hospital, NeuroCenter, Kuopio, Finland
| | - Antti. Ronkainen
- Neurosurgery of Kuopio University Hospital, NeuroCenter, Kuopio, Finland
| | - Jaakko. Rinne
- Neurosurgery of Kuopio University Hospital, NeuroCenter, Kuopio, Finland
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Aoki T, Nishimura M. Targeting chronic inflammation in cerebral aneurysms: focusing on NF-κB as a putative target of medical therapy. Expert Opin Ther Targets 2010; 14:265-73. [DOI: 10.1517/14728221003586836] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Alexander S, Poloyac S, Hoffman L, Gallek M, Dianxu Ren, Balzer J, Kassam A, Conley Y. Endothelial nitric oxide synthase tagging single nucleotide polymorphisms and recovery from aneurysmal subarachnoid hemorrhage. Biol Res Nurs 2009; 11:42-52. [PMID: 19419976 DOI: 10.1177/1099800409334751] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is a hemorrhagic stroke subtype with a poor recovery profile. Cerebral vasospasm (CV), a narrowing of the cerebral vasculature, significantly contributes to the poor recovery profile. Variation in the endothelial nitric oxide (NO) synthase (eNOS) gene has been implicated in CV and outcome after SAH. The purpose of this project was to explore the potential association between three eNOS tagging single nucleotide polymorphisms (SNPs) and recovery from SAH. We included 195 participants with a diagnosis of SAH and DNA and 6-month outcome data available but without preexisting neurologic disease/deficit. Genotyping was performed using an ABI Prism 7000 Sequence Detection System and TaqMan assays. CV was verified by cerebral angiogram independently read by a neurosurgeon on 118 participants. Modified Rankin Scores (MRS) and Glasgow Outcome Scale (GOS) scores were collected 6 months posthemorrhage. Data were analyzed using descriptive statistics, analysis of variance (ANOVA) and chi-square analysis as appropriate. The sample was primarily female (n=147; 75.4%) and White (n=178; 91.3%) with a mean age of 54.6 years. Of the participants with CV data, 56 (47.5%) developed CV within 14 days of SAH. None of the SNPs individually were associated with CV presence; however, a combination of the three variant SNPs was significantly associated with CV (p=.017). Only one SNP (rs1799983, variant allele) was associated with worse 6-month GOS scores (p<.001) and MRS (p<.001). These data indicate that the eNOS gene plays a role in the response to SAH, which may be explained by an influence on CV.
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Affiliation(s)
- Sheila Alexander
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania 15261, USA.
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26
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Edlow JA, Malek AM, Ogilvy CS. Aneurysmal Subarachnoid Hemorrhage: Update for Emergency Physicians. J Emerg Med 2008; 34:237-51. [DOI: 10.1016/j.jemermed.2007.10.003] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2007] [Revised: 08/13/2007] [Accepted: 10/16/2007] [Indexed: 10/22/2022]
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Aikawa H, Kazekawa K, Nagata SI, Onizuka M, Iko M, Tsutsumi M, Kodama T, Nii K, Matsubara S, Etou H, Tanaka A. Rebleeding after endovascular embolization of ruptured cerebral aneurysms. Neurol Med Chir (Tokyo) 2008; 47:439-45; discussion 446-7. [PMID: 17965560 DOI: 10.2176/nmc.47.439] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study retrospectively reviewed 227 patients with ruptured solitary cerebral aneurysm who underwent endovascular embolization with detachable coils between March 1997 and March 2006 to establish the incidence of rebleeding after endovascular treatment for ruptured cerebral aneurysm and identify the risk factors. The site and size of the aneurysm, the interval between treatment and rebleeding, and the outcome were investigated in six of the 227 patients (2.6%) who rebled after treatment. Four patients had large or giant aneurysms located on the internal carotid artery at the origin of the posterior communicating artery. The interval between treatment and rebleeding was less than 1 year in four patients (mean 394.2 days). Two patients died, and the survivors had modified Rankin Scale scores of 0, 2, 3, and 4. Re-embolization was performed in four patients and no further bleeding occurred during the mean follow-up period of 1.9 years after re-treatment. Patients with giant aneurysms of the internal carotid artery are at increased risk for rebleeding. Re-treatment should be considered if there is conventional and/or magnetic resonance angiographic evidence of dome filling. Patients with ruptured cerebral aneurysms must be followed up with diagnostic imaging closely during the first 12 months post-embolization because rebleeding frequently occurs within 1 year after initial treatment. Re-embolization is safe and effective in patients with recurrent hemorrhage from aneurysms previously embolized with detachable coils.
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Affiliation(s)
- Hiroshi Aikawa
- Department of Neurosurgery, Fukuoka University Chikushi Hospital, Chikushino, Fukuoka, Japan
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Becker TA, Preul MC, Bichard WD, Kipke DR, McDougall CG. Preliminary investigation of calcium alginate gel as a biocompatible material for endovascular aneurysm embolization in vivo. Neurosurgery 2007; 60:1119-27; discussion 1127-8. [PMID: 17538387 DOI: 10.1227/01.neu.0000255447.90106.12] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE We sought to expand our assessment of calcium alginate as an embolic agent in an aneurysm model in swine that survived from 30 to 90 days. The objective of this study was to assess the biocompatibility and stability of calcium alginate in aneurysms in vivo. METHODS Ten models were created from a venous pouch sutured to the carotid artery, simulating flow to a side-wall aneurysm. Eight swine received complete embolizations, and two were less than 50% embolized to be used as controls. Alginate and calcium chloride were injected from concentric-tube microcatheters to form a mass that filled the aneurysm pouch. RESULTS Angiography and histology verified complete aneurysm occlusion and neck healing up to 90 days in eight swine. Both control animal aneurysms ruptured within 8 days. No animals showed evidence of downstream calcium alginate gel propagation. A minor bioactive response to the alginate gel was noted at 30 days, and fibrous tissue grew over the aneurysm orifice, sealing off the defect. No degenerative or inflammatory response was observed. At 90 days, moderate fibrous tissue surrounded the alginate. Tissue growth across the aneurysm neck remained complete and stable with no signs of neointimal growth into the parent vessel. CONCLUSION Calcium alginate was an effective endovascular occlusion material that filled the aneurysm and provided an effective template for tissue growth across the aneurysm neck after 30 days and up to 90 days. Complete filling of the aneurysm with calcium alginate ensures stability, biocompatibility, and optimal healing for up to 90 days in swine.
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Affiliation(s)
- Timothy A Becker
- Neural Engineering Laboratory, Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan, USA
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29
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Edner G, Almqvist H. THE STOCKHOLM 20-YEAR FOLLOW-UP OF ANEURYSMAL SUBARACHNOID HEMORRHAGE OUTCOME. Neurosurgery 2007; 60:1017-23; discussion 1023-4. [PMID: 17538374 DOI: 10.1227/01.neu.0000255458.07140.e6] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
OBJECTIVE
To assess the clinical and radiological long-term outcome after aneurysmal subarachnoid hemorrhage (SAH) in a defined referral area regarding recurrent SAH and de novo aneurysm formation.
METHODS
One hundred and two 1-year survivors after aneurysmal SAH, who were treated at the Neurosurgical Clinic, South Hospital, Stockholm, Sweden, between 1983 and 1985, were followed for 20 years. Forty-nine surviving patients were reevaluated. Hospital records and death certificates were scrutinized for all 53 nonsurviving patients. Clinical history penetration, Mini Mental Status, Rankin Disability Score, and Barthel Index were used to evaluate the outcome. Computed tomographic angiography was used to investigate the cerebral arteries.
RESULTS
One hundred and two patients were traced. Fifty-three patients were deceased. One patient had a hospital record of sustaining an aneurysmal SAH from a known but not clipped aneurysm. Three patients had nonaneurysmal intracerebral hemorrhage and two sustained traumatic SAH. There were 49 surviving patients. Six refused follow-up. None of these patients had hospital records of intracranial disease. Three of the 43 remaining patients could not be tested. None of the survivors had experienced a new SAH. Aneurysm base remnants were observed in 1% (eight patients, 790 person-years of follow-up) and de novo aneurysms were observed in 0.9% (seven patients, 790 person-years of follow-up).
CONCLUSION
From this epidemiological survey of patients with aneurysmal SAH, it was found that none of the patients experienced a recurrent subarachnoid bleed from the treated aneurysm during a 20-year follow-up period. Thus, a routine extreme long-term follow-up period is not necessary. De novo aneurysm formation and possible enlargements of aneurysm base remnants were observed in almost 2% of patients per person year and should, therefore, be subject of a routine, long-term follow-up.
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Affiliation(s)
- Göran Edner
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
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Lee WC, Joshi AV, Wang Q, Pashos CL, Christensen MC. Morbidity and mortality among elderly Americans with different stroke subtypes. Adv Ther 2007; 24:258-68. [PMID: 17565915 DOI: 10.1007/bf02849893] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The long-term outcomes of hemorrhagic stroke (HS), which includes subarachnoid hemorrhage (SAH) and intracerebral hemorrhage (ICH), are not well understood relative to ischemic stroke (IS). This analysis was undertaken to assess short and long-term survival and morbidity of patients with hemorrhagic stroke, as well as risk factors associated with these outcomes. American Medicare beneficiaries >65 y of age in whom SAH, ICH, or IS was diagnosed were identified and followed over 4 y through the use of longitudinal claims data. Primary endpoints consisted of survival, recurrence of stroke, and readmission. A survival analysis estimated long-term survival. Logistic regression and Cox proportional hazards models identified factors associated with recurrence and death. A total of 11,430 patients with SAH (3.0%), ICH (17.1%), or IS (79.9%) were identified. At stroke onset, about 45% of SAH and ICH cohorts had congestive heart failure, about 50% had diabetes, and more than 90% had hypertension. In comparison, 30% of the IS cohort had congestive heart failure, 32%, diabetes, and 75%, hypertension. Acute in hospital mortality rates were 31.9%, 25.6%, and 6.8% for SAH, ICH, and IS, respectively; estimated median survival through 4 y was 256 d for SAH, 353 d for ICH, and 533 d for IS. The recurrence rate was highest among patients with SAH. Those with HS tended to be younger than those with IS and had a greater number of comorbidities at the time of stroke. Among the elderly, patients with HS have a substantially worse prognosis than do those with IS, which highlights the need for more effective treatment of patients with HS.
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Affiliation(s)
- Won Chan Lee
- HERQuLES, Abt Associates Inc, Bethesda, MD 20814-5341, USA.
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31
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Linfante I, Wakhloo AK. Brain aneurysms and arteriovenous malformations: advancements and emerging treatments in endovascular embolization. Stroke 2007; 38:1411-7. [PMID: 17322071 DOI: 10.1161/01.str.0000259824.10732.bb] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Brain aneurysms and vascular malformations can cause cerebral hemorrhages, with devastating consequences for the patients and their families. Since the development of microcatheters and materials used for endovascular embolization, we have witnessed a rapid advancement in the technology and in the number or patients treated with this approach. The aim of this review is to survey recent data relevant to new technologies and emerging treatment strategies in these areas. SUMMARY OF REVIEW Clinical trials assessing the safety and efficacy of coil embolization for cerebral aneurysms were based on the use of bare platinum, helical coils. Since then, endovascular operators have been testing and using new materials such as bioactive coils, expandable coils, and complex-shaped coils. Based on the data so far obtained, third and fourth generation coil designs are rapidly emerging and will be ready for clinical application in the near future. Balloon- and stent-assisted coil embolization is enabling the treatment of complex, large-neck aneurysms and the vascular reconstruction of lesions previously considered not treatable. New open- and closed-cell designs allow the navigation and deployment of stents in extremely tortuous vessels. With regards to the embolization of vascular malformations, it is possible to safely navigate microcatheters and microwires through very small arteries previously considered not accessible. In addition, embolization materials such as n-butyl cyanoacrylate and ethylene-vinyl alcohol copolymer are now routinely injected to safely reduce or obliterate large and complex arteriovenous malformations and fistulae. CONCLUSIONS Advancements in technology are rapidly improving the endovascular approach to the treatment of cerebral aneurysms and arteriovenous malformations.
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Affiliation(s)
- Italo Linfante
- Division of Neuroimaging and Intervention, Department of Radiology, University of Massachusetts, Worcester, MA 01655, USA.
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Lehecka M, Niemelä M, Seppänen J, Lehto H, Koivisto T, Ronkainen A, Rinne J, Sankila R, Jääskeläinen J, Hernesniemi J. NO LONG-TERM EXCESS MORTALITY IN 280 PATIENTS WITH RUPTURED DISTAL ANTERIORCEREBRAL ARTERY ANEURYSMS. Neurosurgery 2007; 60:235-40; discussion 240-1. [PMID: 17290173 DOI: 10.1227/01.neu.0000249261.95826.8f] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE The aim of this study was to assess the long-term excess mortality after the rupture of distal anterior cerebral artery (DACA) aneurysms compared with that of a matched general Finnish population in an unselected, population-based series. METHODS We identified 280 consecutive patients (119 men, 161 women) treated for ruptured DACA aneurysms (clipped, 262; coiled, 10; no intervention, 8) at two neurosurgical centers serving solely the southern and eastern parts of Finland from 1976 to 2003. All patients were followed from subarachnoid hemorrhage until death or the end of 2004. No patients were lost to follow-up. Long-term excess mortality was estimated using the annual relative survival ratio compared with the general Finnish population matched by age, sex, and calendar time. RESULTS The median follow-up period was 9.6 years (range, 0.1-29 yr). The 3-year cumulative relative survival ratio was 0.84 (95% confidence interval, 0.78-0.88), implying 16% excess mortality in the patient group during the first 3 years after subarachnoid hemorrhage. The annual relative survival ratio attained 1.0 at the fourth year of follow-up, indicating no excess mortality thereafter. There were four episodes of recurrent subarachnoid hemorrhage and only one from a treated DACA aneurysm, with a 10-year cumulative risk of 1.4% (95% confidence interval, 0.0-3.0). Cardiovascular disease and cancer were the leading causes of death after 10 years of follow-up. CONCLUSION After surviving 3 years after the rupture of a DACA aneurysm, the patients' long-term survival became similar to that of the matched general population. Rebleeding of treated DACA aneurysm was rare.
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Affiliation(s)
- Martin Lehecka
- Department of Neurosurgery, Helsinki University Central Hospital, Helsinki, Finland.
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Hui ACF, Tong PY, Wong A, Leung TWH, Kwan P, Wong LKS. Simple partial status epilepticus in Chinese adults. J Clin Neurosci 2005; 12:902-4. [PMID: 16257216 DOI: 10.1016/j.jocn.2004.11.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2004] [Accepted: 11/19/2004] [Indexed: 10/25/2022]
Abstract
Simple partial status epilepticus (SPSE) is uncommon compared with generalized tonic-clonic status epilepticus. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with this condition. We identified 32 patients above the age of 14 years with SPSE from a large urban hospital over an eleven-year period. Factors for poor outcome, defined as death or morbidity, were analyzed. The most common underlying causes were due to cerebrovascular disease (46.9%), CNS infection (15.6%), metabolic derangement (12.5%) and tumor (12.5%). At 30 days from the onset of seizures, 13(40.5%) patients had recovered fully and seven (21.9%) had died. Poor outcome was associated with the presence of an acute symptomatic injury.
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Affiliation(s)
- Andrew C F Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong, China.
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Britz GW, Salem L, Newell DW, Eskridge J, Flum DR. Impact of Surgical Clipping on Survival in Unruptured and Ruptured Cerebral Aneurysms. Stroke 2004; 35:1399-403. [PMID: 15118171 DOI: 10.1161/01.str.0000128706.41021.01] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The management of aneurysms is controversial because little is known about the impact of clipping on long-term outcome. This study was designed to evaluate long-term survival of patients with aneurysms undergoing clipping in a statewide population.
Methods—
We used a retrospective design using an administrative database to identify patients hospitalized with aneurysms (1987 to 2001). Time-to-event analysis was used to determine the risk of death from all causes and from neurological causes.
Results—
4619 patients (mean age 54.7±15.3, 66.3% female) were hospitalized with cerebral aneurysms. Survival among patients with ruptures was significantly lower compared with patients with unruptured aneurysm (
P
<0.001) with adjusted hazard ratio (HR) of death after clipping 40% higher (HR: 1.4; 95% CI: 1.2, 1.7) in patients with rupture compared with those that were unruptured. Survival estimates for unruptured patients who underwent clipping were significantly higher than among those unruptured patients who did not undergo clipping (
P
<0.001), with adjusted HR of death 30% higher in patients with unruptured aneurysm that were not clipped compared with unruptured patients who were clipped (HR: 1.3; 95% CI: 1.1, 1.6). Patients with unruptured aneurysm who underwent clipping and survived beyond the 30-day postoperative period were less likely to die from neurologically related causes (5.6 versus 2.3%,
P
<0.001). Patients with ruptures and aneurysms who underwent clipping have a higher rate of death compared with the general population in the long-term.
Conclusions—
Short-term and long-term mortality after clipping of cerebral aneurysms is higher than previously reported. Patients with unruptured aneurysms who undergo clipping have improved survival compared with those who do not undergo clipping. This study supports the use of early intervention in the management of patients with unruptured aneurysms.
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Affiliation(s)
- Gavin W Britz
- Department of Neurosurgery, University of Washington, Seattle, Wash 98195-6410, USA
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Matsumoto K, Akagi K, Abekura M, Nakajima Y, Yoshiminie T. Investigation of the surgically treated and untreated unruptured cerebral aneurysms of the anterior circulation. ACTA ACUST UNITED AC 2003; 60:516-22; discussion 522-3. [PMID: 14670666 DOI: 10.1016/s0090-3019(03)00318-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The natural history of unruptured cerebral aneurysms and the surgical risks are modified by several factors including size, location, and presence of subarachnoid hemorrhage (SAH). The main confusion arises because the backgrounds of the past reports describing the natural history or the surgical complication of unruptured cerebral aneurysms were different. The present study aimed to adjust the backgrounds and investigate the surgical indication with close monitoring of both surgically treated and untreated unruptured cerebral aneurysms. METHODS In the past 9 years, 201 patients who had unruptured anterior circulation aneurysms were monitored. The decision of the operation was not randomized. The patients were divided into three subgroups by the size of the aneurysms (small group: below 5 mm, medium group: between 5 and 15 mm, large group: over 15 mm). In both surgically untreated and treated patients, overall mortality and morbidity corresponding to Rankin score II or worse was counted as unruptured aneurysm related event. The ratio of event free was compared between surgically treated and untreated patients using Log-rank test. RESULTS In untreated patients, SAH was noted in 1 in the small group and 4 in the medium group. The annual rupture rate of the medium group was 12 times higher than that of the small group. In surgically treated patients, overall mortality and morbidity of the surgery was 2.3% in the small group, 3.6% in the medium group, and 20% in the large group. One surgically treated patient had SAH because of regrowth of aneurysm. When ratio of event free was compared, no significant advantage of surgery was noted in the small group and in all of the patients. However, the benefit of surgery was significant in the medium group (Log-rank p = 0.0189). CONCLUSIONS The present results indicated that prophylactic surgery has a benefit for the medium-size aneurysms (5-15 mm) of the anterior circulation. For large aneurysms, individual investigation is necessary because of the variety of surgical difficulties, and the complex symptoms because of rupture and the mass effect as well as cerebral embolism. In small aneurysms, careful observation may be a reasonable choice unless the aneurysm is at a specially high risk of rupture.
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Affiliation(s)
- Katsumi Matsumoto
- Department of Neurosurgery, Stroke Center, Wakakusa Daiichi Hospital Higashi, Osaka, Japan
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Ballard J, Kreiter KT, Claassen J, Kowalski RG, Connolly ES, Mayer SA. Risk factors for continued cigarette use after subarachnoid hemorrhage. Stroke 2003; 34:1859-63. [PMID: 12843355 DOI: 10.1161/01.str.0000080522.36041.9f] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Cigarette smoking is a risk factor for the formation and rupture of intracranial aneurysms. Few studies have examined predictors of resumption of cigarette smoking after a first episode of subarachnoid hemorrhage (SAH). METHODS Of 620 SAH patients treated between July 1996 and November 2002, we prospectively evaluated continued cigarette use in 152 smokers alive at 3 months. Univariate and multivariate logistic regression analyses were used to identify potential demographic, social, and clinical predictors of continued cigarette use, defined as smoking > or =1 cigarette per week in the month before follow-up. RESULTS Thirty-seven percent (56 of 152) resumed smoking after their SAH. Patients who continued smoking were younger, were more often black, had begun smoking at an earlier age, and had a higher frequency of prior alcohol or cocaine use and self-reported depression or anxiety than those who quit (all P<0.05). Smoking at < or =16 years of age (odds ratio [OR], 5.88; 95% confidence interval [CI], 2.33 to 14.29), self-reported depression (OR, 5.29; 95% CI, 2.10 to 13.35), and prior alcohol use (OR, 4.51; 95% CI, 1.45 to 14.05) independently predicted continued cigarette use. Smokers had a functional outcome similar to that of nonsmokers at 3 months but were more likely to resume alcohol consumption (OR, 3.88; 95% CI, 1.91 to 7.88). CONCLUSIONS More than one third of prior smokers continue to use nicotine after SAH. Young age at smoking onset and a history of depression or alcohol use are risk factors for continued cigarette use. Targeted smoking cessation programs are needed to reduce the high rate of smoking resumption after SAH.
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Affiliation(s)
- Jennifer Ballard
- Division of Critical Care Neurology, Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA.
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Johnston SC, Higashida RT, Barrow DL, Caplan LR, Dion JE, Hademenos G, Hopkins LN, Molyneux A, Rosenwasser RH, Vinuela F, Wilson CB. Recommendations for the endovascular treatment of intracranial aneurysms: a statement for healthcare professionals from the Committee on Cerebrovascular Imaging of the American Heart Association Council on Cardiovascular Radiology. Stroke 2002; 33:2536-44. [PMID: 12364750 DOI: 10.1161/01.str.0000034708.66191.7d] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Abstract
OBJECT In this article, pathological, radiological, and clinical information regarding unruptured intracranial aneurysms is reviewed. METHODS Treatment decisions require that surgeons and interventionists take into account information obtained in pathological, radiological, and clinical studies of unruptured aneurysms. The author has performed a detailed review of the literature and has compared, contrasted, and summarized his findings. Unruptured aneurysms may be classified as truly incidental, part of a multiple aneurysm constellation, or symptomatic by virtue of their mass, irritative, or embolic effects. Unruptured aneurysms with clinical pathological profiles resembling those of ruptured lesions should be considered for treatment at a smaller size than unruptured lesions with profiles typical of intact aneurysms, as has been determined at autopsy in patients who have died of other causes. The track record of the surgeon or interventionist and the institution in which treatment is to be performed should be considered while debating treatment options. In cases in which treatment is not performed immediately, ongoing periodic radiological assessment may be wise. Radiological investigations to detect unruptured aneurysms in asymptomatic patients should be restricted to high-prevalence groups such as adults with a strong family history of aneurysms or patients with autosomal dominant polycystic kidney disease. All patients with intact lesions should be strongly advised to discontinue cigarette smoking if they are addicted. CONCLUSIONS The current state of knowledge about unruptured aneurysms does not support the use of the largest diameter of the lesion as the sole criterion on which to base treatment decisions, although it is of undoubted importance.
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Affiliation(s)
- Bryce Weir
- Section of Neurosurgery, The University of Chicago, Illinois 60637-1470, USA
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Ronkainen A, Niskanen M, Rinne J, Koivisto T, Hernesniemi J, Vapalahti M. Evidence for excess long-term mortality after treated subarachnoid hemorrhage. Stroke 2001; 32:2850-3. [PMID: 11739986 DOI: 10.1161/hs1201.099711] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The purpose of this study was to examine the long-term mortality rate of patients with aneurysmal subarachnoid hemorrhage (SAH) compared with that of the general population. METHODS Aneurysmal SAH patients who were treated for ruptured aneurysm from 1977 through 1998 in a tertiary referral center (n=1537) were followed up for a median of 7.5 years. Dates and causes of death were determined. Standardized mortality ratios (observed/expected deaths) according to age, sex, and Glasgow Outcome Scale at 12 months after surgery were calculated. RESULTS The mortality rate among patients with good recovery at 12 months was twice that of the general population. The excess mortality appeared to be most evident in younger age groups. Cerebrovascular and cardiovascular diseases were the principal causes of premature death. The result was similar among patients without preexisting cardiovascular diseases at the time of SAH. CONCLUSIONS Aneurysmal SAH patients have an excess mortality rate even after successful treatment of ruptured aneurysms. Therefore, aneurysmal SAH should be viewed more as one aspect of a chronic general vascular disease, and more attention should be given to treatment of risk factors and long-term follow-up of these patients.
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Affiliation(s)
- A Ronkainen
- Department of Neurosurgery, University Hospital of Kuopio, Kuopio, Finland.
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Vinters HV. Cerebrovascular disease--practical issues in surgical and autopsy pathology. CURRENT TOPICS IN PATHOLOGY. ERGEBNISSE DER PATHOLOGIE 2001; 95:51-99. [PMID: 11545057 DOI: 10.1007/978-3-642-59554-7_2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Affiliation(s)
- H V Vinters
- Department of Pathology and Laboratory Medicine, Section of Neuropathology, Brain Research Institute and Neuropsychiatric Institute, UCLA Medical Center, CHS 18-170, Los Angeles, California 90095-1732, USA
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Tsutsumi K, Ueki K, Morita A, Usui M, Kirino T. Risk of aneurysm recurrence in patients with clipped cerebral aneurysms: results of long-term follow-up angiography. Stroke 2001; 32:1191-4. [PMID: 11340232 DOI: 10.1161/01.str.32.5.1191] [Citation(s) in RCA: 207] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With many patients living long after microsurgical aneurysm clipping for subarachnoid hemorrhage (SAH) and with the evolution of intravascular procedures as less invasive alternatives, knowledge of the long-term results of clipping is becoming important. METHODS Of 412 patients who underwent clipping of ruptured or unruptured cerebral aneurysms at our institution between 1976 and 1994 and who survived >3 years after surgery, 225 patients who were in good general condition and younger than 80 years were offered follow-up angiography to detect newly formed aneurysms. Of the 225, 80 patients (35.6%) agreed to undergo angiography. In addition, 32 patients underwent angiography for new medical indications other than SAH. Therefore, 112 patients underwent angiography, representing a total of 140 clipped aneurysms. RESULTS The mean interval from surgery was 9.3 years for all patients and 9.0 years for the clipped aneurysms (range 3 to 21 years). Four aneurysm regrowths were detected of the 140 (2.9%) clipped aneurysms, representing 3 of 125 completely clipped aneurysms, 1 of 14 incompletely clipped aneurysms, and 0 of 1 aneurysm not studied with postoperative angiography. De novo aneurysms were detected in 9 of 112 (8.0%) patients. The annual rate of de novo aneurysm formation was 0.89%. CONCLUSIONS This study shows that the annual rate of de novo aneurysm formation is relatively high (0.89%) and that the cumulative risk becomes significant after 9 years. In consideration of the fatality rate of SAH, follow-up angiography may be indicated for patients with clipped aneurysms 9 to 10 years after surgery.
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Affiliation(s)
- K Tsutsumi
- Department of Neurosurgery, Aizu Chuou Hospital, Aizuwakamatsu, Japan.
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Sturaitis MK, Rinne J, Chaloupka JC, Kaynar M, Lin Z, Awad IA. Impact of Guglielmi detachable coils on outcomes of patients with intracranial aneurysms treated by a multidisciplinary team at a single institution. J Neurosurg 2000; 93:569-80. [PMID: 11014534 DOI: 10.3171/jns.2000.93.4.0569] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT The goal of this study was to investigate the impact of the introduction of the Guglielmi detachable coil (GDC) therapeutic option on the overall management outcome of intracranial aneurysms. The authors accomplished this by assessing patient morbidity and mortality, inflation-adjusted hospital charges, lengths of stay in the hospital and the intensive care unit (ICU), and treatment efficacy. METHODS The authors conducted a retrospective analysis of consecutive cases of intracranial intradural aneurysms managed by a single multidisciplinary neurovascular team at a tertiary care, academic referral center during the 24 months preceding the introduction of the GDC procedure (Group I or pre-GDC era, 77 patients) and during the first 24 months after its introduction (Group II or GDC era, 99 patients). Treatment with GDCs was considered for cases of higher clinical grade or poor surgical risk, or in response to patient preference (27 [27%] of 99 patients in Group II). Host and lesion parameters in our cohort were validated against outcome parameters by using univariate and multivariate analyses. The pre-GDC and GDC subgroups of patients were comparable for major disease severity parameters (patient age, lesion location, clinical grade, and hemorrhage severity). There was no significant difference in clinical outcome at 6 months, infarcts on computerized tomography scanning, or aneurysm obliteration rates before and after introduction of GDC treatment. Decreasing trends in duration of hospital and ICU stay and in inflation-adjusted hospital charges occurred well before and thus were unrelated to the introduction of the GDC therapeutic option. CONCLUSIONS The results of this study do not demonstrate any significant impact of integration of the GDC modality on clinical outcome, mortality, morbidity, or effectiveness of treatment. Ongoing improvements in hospital charges and length of hospital stay appeared unrelated to the introduction of the GDC option.
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Affiliation(s)
- M K Sturaitis
- Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut 06520, USA
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Olafsson E, Gudmundsson G, Hauser WA. Risk of epilepsy in long-term survivors of surgery for aneurysmal subarachnoid hemorrhage: a population-based study in Iceland. Epilepsia 2000; 41:1201-5. [PMID: 10999560 DOI: 10.1111/j.1528-1157.2000.tb00326.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Epilepsy is known to result from aneurysmal subarachnoid hemorrhage (SAH). There are no population-based estimates of the absolute risk or the duration for which this risk is elevated. We have conducted a population-based study in Iceland of the risk of epilepsy after a ruptured cerebral aneurysm to address these questions. METHODS The index patients are all of the patients who presented with SAH caused by ruptured cerebral aneurysm in Iceland during an 11-year period (1958 to 1968) and survived more than 6 months. We determined the number of index patients who developed epilepsy. The observed number of cases of epilepsy was compared with that expected based on the incidence of epilepsy in Iceland. RESULTS There were 44 index patients; 11 (25%) developed epilepsy, all within 4 years of the insult. Seven (70%) of 10 patients with acute symptomatic seizures (defined as seizures during the first 2 weeks after the hemorrhage) developed epilepsy (relative risk, 7.0; 95% confidence interval, 2.3-21.6). Epilepsy was more frequent in patients with severe neurological residua (48%) compared with patients without (20%) (relative risk, 2.5; 95% confidence interval, 0.9-6.3). CONCLUSIONS The risk for epilepsy among survivors of SAH caused by ruptured cerebral aneurysm is substantially increased. Both acute symptomatic seizure and persistent neurological impairment are associated with a further increase in the risk of epilepsy.
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Affiliation(s)
- E Olafsson
- Department of Neurology, National University Hospital Landspitalinn, Reykjavik, Iceland.
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Arboix A, Martí-Vilalta JL. [Hospital mortality in subarachnoid hemorrhage. Experience of the "Barcelona Registry of Cerebrovascular Diseases"]. Med Clin (Barc) 2000; 114:161-4. [PMID: 10738719 DOI: 10.1016/s0025-7753(00)71230-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To determine clinical predictors of in-hospital mortality in patients with non-traumatic subarachnoid hemorrhage. PATIENTS AND METHODS Data de 184 patients with subarachnoid hemorrhage were obtained from consecutive stroke included in the prospective "Barcelona Stroke Registry". Demographic, anamnestic, clinical, neuroimaging and outcome variables in the subgroup of patients who died were compared with those in the surviving subgroup. The independent predictive value of each variable on the development of death was assessed with a logistic regression analysis. Three predictive models were constructed. A first model was based on demographic and clinical variables (total 10 variables). A second model was based on demographic, clinical and neuroimaging variables (total 17). A third model was based on demographic, clinical, neuroimaging and outcome variables (total 21). RESULTS In-hospital death was observed in 44 patients (24%). Transient neurological deficit (OR = 13.92; 95% CI: 1.01-191.95), progressive deficit (OR = 4.21; 95% IC: 1.28-13.86), limb weakness (OR = 3.24; 95% IC: 1.49-7.08) and age (OR = 1.05; 95% CI: 1.02-1.09) appeared to be independent prognostic factors of in-hospital mortality in the first predictive model. In addition to these variables, intraventricular hemorrhage (OR = 5.51; 95% CI: 1.94-16.04) was selected in the second predictive model. Transient neurological deficit (OR = 41.2; 95% CI: 1.61-1056.2), neurological complications (OR = 11.04; CI del 95%: 3.85-31.74), carotid aneurysm (OR = 6.61; 95% CI: 1.23-35.43), intraventricular hemorrhage (OR = 5.51; 95% CI: 1.65-18.4), progressive deficit (OR = 5.35; 95% CI: 1.11-25.90) and hemispheric intracerebral hemorrhage (OR = 4.32; 95% CI: 1.35-13.90), appeared to be independent prognostic factors of in-hospital mortality in the third model. CONCLUSIONS Clinical features easily obtained at the patient's bedside in addition to neuroimaging data easily obtained in routine neuroimaging studies help clinicians to predict in-hospital mortality in patients with subarachnoid hemorrhage. Transient neurological deficit prior to definitive subarachnoid hemorrhage was the main clinical predictor of in-hospital mortality.
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Affiliation(s)
- A Arboix
- Unidad de Patología Vascular Cerebral, Hospital del Sagrat Cor, Barcelona
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Arboix A, Martí-Vilalta JL. Predictive clinical factors of very early in-hospital mortality in subarachnoid hemorrhage. Clin Neurol Neurosurg 1999; 101:100-5. [PMID: 10467904 DOI: 10.1016/s0303-8467(99)00026-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study was conducted to determine clinical predictors of very early in-hospital mortality (within the first 72 h) in patients with non-traumatic subarachnoid hemorrhage. Data of 184 patients with subarachnoid hemorrhage were obtained from consecutive stroke patients included in the prospective Barcelona Stroke Registry. Demographic, anamnestic, clinical, neurological and neuroimaging variables in the subgroup of patients who died within 72 h after the onset of symptoms were compared with those in the subgroup of patients that had survived this initial period. The independent predictive value of each variable on the development of very early death was assessed with a logistic regression analysis. Very early in-hospital death was observed in 18 patients (9.8%). These patients were significantly more likely to have progressive deficit, seizures, altered consciousness, limb weakness, sensory involvement and basal ganglia hematoma than patients without very early death. After multivariate analysis, only progressive deficit (odds ratio (OR) 6.90; 95% confidence interval (95% CI) 2-23.80) and limb weakness (OR 5.46; 95% CI 1.78-16.77) were independent clinical predictors of very early mortality. Progressive neurological deficit and limb weakness at the onset of stroke was independent predictive factors of very early death in patients with non-traumatic subarachnoid hemorrhage. These results further emphasize the need to establish an early etiological diagnosis and to manage these patients aggressively including early surgery in selected cases.
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Affiliation(s)
- A Arboix
- Department of Neurology, Hospital del Sagrat Cor, Barcelona, Spain
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Subarachnoid hemorrhage and intracerebral hemorrhage. Curr Opin Crit Care 1999. [DOI: 10.1097/00075198-199904000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Tsutsumi K, Ueki K, Usui M, Kwak S, Kirino T. Risk of recurrent subarachnoid hemorrhage after complete obliteration of cerebral aneurysms. Stroke 1998; 29:2511-3. [PMID: 9836760 DOI: 10.1161/01.str.29.12.2511] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The neck clipping of cerebral aneurysms is a well-established treatment for subarachnoid hemorrhage (SAH) caused by aneurysmal rupture. However, it is still unclear how great a risk of recurrence patients with a successfully treated aneurysm carry over a long-term period. METHODS Of 425 patients with SAH surgically treated in Aizu Chuou Hospital from 1976 to 1994, 220 cases meeting the following criteria were studied: (1) all aneurysms detected by 3- or 4-vessel cerebral angiography were clipped, (2) complete obliteration of aneurysm(s) was confirmed by postoperative angiography, and (3) the patient survived >3 years. All patients were traced until January 1998 for recurrent SAH or death. The mean follow-up period was 9.9 (range, 3 to 21) years. RESULTS Six patients (2.7%) had recurrent SAH, each with an interval ranging from 3 to 17 years (mean, 11 years) since the original treatment. In addition, 2 patients were found to have regrowth of the originally operated aneurysms. The cumulative recurrence rate of SAH, calculated using the Kaplan-Meier method, was 2.2% at 10 years and 9. 0% at 20 years after the original treatment. CONCLUSIONS The recurrence rate was considerably higher than the previously reported risk of SAH in the normal population, and the rate increased with time. These data indicate that patients with ruptured cerebral aneurysms still carry higher risks for SAH in a long-term period, even after complete obliteration of the aneurysm, and that periodic examination to detect recurrent aneurysms may be indicated for such patients.
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Affiliation(s)
- K Tsutsumi
- Department of Neurosurgery, Aizu Chuou Hospital, Tokyo, Japan
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