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Overstijns M, Rahal AE, Goldberg J, Rölz R, Raabe A, Bischoff K, Neidert NN, Beck J, Fung C. Clinical severity of aneurysmal subarachnoid hemorrhage over time: systematic review. Neurosurg Rev 2024; 47:257. [PMID: 38836919 PMCID: PMC11153276 DOI: 10.1007/s10143-024-02467-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 05/15/2024] [Accepted: 05/19/2024] [Indexed: 06/06/2024]
Abstract
The incidence of aneurysmal subarachnoid hemorrhage (aSAH) is well studied. Yet, little is known about the trend of aSAH severity. This systematic review aims to analyze the distribution of aSAH severity over time. We performed a systematic review of the literature according to the PRISMA-P guidelines. We included studies from January 1968 up to December 2022. Studies were included if they either reported the severity of aSAH as single increments of the corresponding 5-point scale or as a binary measure (good grade 1-3, poor grade 4-5) on the Hunt and Hess (HH) or World Federation of Neurosurgical Societies (WFNS) scale. Studies with fewer than 50 patients, (systematic) reviews, and studies including non-aSAH patients were excluded. A total of 2465 publications were identified, of which 214 met the inclusion and exclusion criteria. In total, 102,845 patients with an aSAH were included. Over the last five decades the number of good-grade HH (0.741 fold, p = 0.004) and WFNS (0.749 fold, p < 0.001) has decreased. Vice versa, an increase in number of poor grade HH (2.427 fold, p = 0.004), WFNS (2.289 fold, p < 0.001), as well as HH grade 5 (6.737 fold, p = 0.010), WFNS grade 4 (1.235 fold, p = 0.008) and WFNS grade 5 (8.322 fold, p = 0.031) was observed. This systematic review shows a worldwide 2-3 fold increase of poor grade aSAH patients and an 6-8 fold increase of grade 5 patients, over the last 50 years. Whether this evolution is due to more severe hemorrhage, improvements in neuro-intensive care and prehospital management, or to a change in grading behavior is unknown. This study strongly emphasizes the necessity for an improved grading system to differentiate grade 4 and grade 5 patients for meaningful clinical decision- making.
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Affiliation(s)
- Manou Overstijns
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Amir El Rahal
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
- Faculty of Medicine of Geneva, University of Geneva, Geneva, Switzerland
| | - Johannes Goldberg
- Department of NeurosurgeryInselspitalBern University Hospital, University of Bern, Bern, Switzerland
| | - Roland Rölz
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Andreas Raabe
- Department of NeurosurgeryInselspitalBern University Hospital, University of Bern, Bern, Switzerland
| | - Karin Bischoff
- Clinical Trials UnitUniversity Medical Center FreiburgFaculty of Medicine, , University of Freiburg, Freiburg, Germany
| | - Nicolas Noël Neidert
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
- Berta-Ottenstein-Programme for Clinician Scientists Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany
| | - Christian Fung
- Department of Neurosurgery, Medical Center University of Freiburg, Freiburg, Germany.
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Park S. Emergent Management of Spontaneous Subarachnoid Hemorrhage. Continuum (Minneap Minn) 2024; 30:662-681. [PMID: 38830067 DOI: 10.1212/con.0000000000001428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE Spontaneous subarachnoid hemorrhage (SAH) carries high morbidity and mortality rates, and the emergent management of this disease can make a large impact on patient outcome. The purpose of this article is to provide a pragmatic overview of the emergent management of SAH. LATEST DEVELOPMENTS Recent trials have influenced practice around the use of antifibrinolytics, the timing of aneurysm securement, the recognition of cerebral edema and focus on avoiding a lower limit of perfusion, and the detection and prevention of delayed cerebral ischemia. Much of the acute management of SAH can be protocolized, as demonstrated by two updated guidelines published by the American Heart Association/American Stroke Association and the Neurocritical Care Society in 2023. However, the gaps in evidence lead to clinical equipoise in some aspects of critical care management. ESSENTIAL POINTS In acute management, there is an urgency to differentiate the etiology of SAH and take key emergent actions including blood pressure management and coagulopathy reversal. The critical care management of SAH is similar to that of other acute brain injuries, with the addition of detecting and treating delayed cerebral ischemia. Strategies for the detection and treatment of delayed cerebral ischemia are limited by disordered consciousness and may be augmented by monitoring and imaging technology.
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Robba C, Busl KM, Claassen J, Diringer MN, Helbok R, Park S, Rabinstein A, Treggiari M, Vergouwen MDI, Citerio G. Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist. Intensive Care Med 2024; 50:646-664. [PMID: 38598130 PMCID: PMC11078858 DOI: 10.1007/s00134-024-07387-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/08/2024] [Indexed: 04/11/2024]
Abstract
Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.
- IRCCS Policlinico San Martino, Genoa, Italy.
| | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jan Claassen
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Raimund Helbok
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Clinical Research Institute for Neuroscience, Johannes Kepler University Linz, Linz, Austria
| | - Soojin Park
- Department of Neurology, New York Presbyterian Hospital, Columbia University, New York, NY, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
| | | | - Miriam Treggiari
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Giuseppe Citerio
- Department of Medicine and Surgery, Milano Bicocca University, Milan, Italy
- NeuroIntensive Care Unit, Neuroscience Department, Fondazione IRCCS San Gerardo Dei Tintori, Monza, Italy
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Wu R, Hu F, Liu C, Liang J. The value of modified hijdra score in patients with aneurysmal subarachnoid hemorrhage. Heliyon 2024; 10:e28550. [PMID: 38590907 PMCID: PMC10999927 DOI: 10.1016/j.heliyon.2024.e28550] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 03/14/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
Background The complexity of calculating the Hijdra score has limited its clinical utility in aiding the diagnosis of intracranial ruptured aneurysms. Objective This study aimed to investigate the diagnostic and prognostic value of the modified Hijdra score in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Data from 773 patients with subarachnoid hemorrhage (SAH) at the First People's Hospital of Lianyungang from January 2018 to June 2023 were collected. The modified Hijdra scoring method simplifies the assessment of 10 basal cisterns/cisterns fissures compared to the traditional scoring method, with scores ranging from 0 to 2 for each item, and assigns specific scores to hematomas larger than 1 cm in diameter. The data were divided into an evaluation group (n = 641) and a validation group (n = 132). In the evaluation group, the performance of the modified Hijdra score in diagnosis and prognostic prediction was assessed, while the diagnostic and prognostic prediction efficacy of the modified Hijdra method was evaluated using the validation set. Results Among the 641 patients in the evaluation group,550 (85. 8%) were diagnosed with intracranial aneurysms. The modified Hijdra score demonstrated an AUC of 0. 894 for aneurysm diagnosis, with a sensitivity of 98. 0% and a specificity of 64. 8% at a CutOff value of 7. 5. The diagnostic efficacy of the modified Hijdra score was 93. 24%, with a negative predictive value of 84. 29%, while the Hijdra score 's diagnostic efficacy was 85. 34% with a negative predictive value of 48. 89%. The AUC of the modified Hijdra score for predicting prognosis in patients with aneurysms was 0. 824, with a sensitivity of 84. 3% and a specificity of 70. 0% at a CutOff value of 16. 5. In CTA-negative patients, the modified Hijdra score was significantly higher (P < 0. 0001) in patients with aneurysmal SAH (15. 48 ± 3. 93) compared to those with non-aneurysmal SAH (6. 31 ± 4. 52). Conclusions The modified Hijdra score is a valuable tool for assisting in the diagnosis and prognosis prediction of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Rongjie Wu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Fangbo Hu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
- Jinzhou Medical University, Liaoning, China
| | - Changtao Liu
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
| | - Jingshan Liang
- The Affiliated Lianyungang Hospital of Xuzhou Medical University/The Affiliated Hospital of Kangda College of Nanjing Medical University/Lianyungang Clinical College of Nanjing Medical University/The First People's Hospital of Lianyungang, Jiangsu, China
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Kawabata S, Takagaki M, Nakamura H, Nishida T, Terada E, Kadono Y, Izutsu N, Takenaka T, Matsui Y, Yamada S, Fukuda T, Nakagawa R, Kishima H. Association of Gut Microbiome with Early Brain Injury After Subarachnoid Hemorrhage: an Experimental Study. Transl Stroke Res 2024; 15:87-100. [PMID: 36484924 DOI: 10.1007/s12975-022-01112-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/05/2022] [Accepted: 11/30/2022] [Indexed: 12/14/2022]
Abstract
The occurrence of early brain injury (EBI) following subarachnoid hemorrhage (SAH) is crucial in the prognosis of SAH; however, no effective treatment for EBI has been developed. Gut microbiome (GM) composition influences the outcome of various diseases, including ischemic stroke. Here, we evaluated whether prior GM alteration could prevent EBI following SAH. We altered the GM of 7-week-old male rats by administering antibiotic-containing water for 2 weeks and performing fecal microbiome transplantation after antibiotic induction. Composition of the GM was profiled using 16S rRNA. We induced SAH by injecting blood in the subarachnoid space of control rats and rats with altered GM. We evaluated EBI indicators such as neurological score, brain water content, Evans blue extravasation, and neuronal injury. Additionally, we studied inflammatory cells using immunohistochemistry, immunocytochemistry, quantitative PCR, and flow cytometry. EBI was significantly averted by alterations in GM using antibiotics. The altered GM significantly prevented neutrophil infiltration into the brain among inflammatory cells, and this anti-inflammatory effect was observed immediately following SAH onset. The altered GM also prevented neutrophil extracellular trap formation in the brain and blood, indicating the systemic protective effect. The cause of the protective effect was attributed to a significant decrease in aged neutrophils (CXCR4high CD62Llow) by the altered GM. These protective effects against EBI disappeared when the altered GM was recolonized with normal flora. Our findings demonstrated that EBI following SAH is associated with GM, which regulated neutrophil infiltration.
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Affiliation(s)
- Shuhei Kawabata
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Masatoshi Takagaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Eisaku Terada
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yoshinori Kadono
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Nobuyuki Izutsu
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tomofumi Takenaka
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Yuichi Matsui
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Shuhei Yamada
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Tatsumaru Fukuda
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Ryota Nakagawa
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan
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Choi YH, Ha EJ, Shim Y, Kim J, Choo YH, Kim HS, Lee SH, Kim KM, Cho WS, Kang HS, Kim JE. Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis. Neurocrit Care 2024; 40:177-186. [PMID: 37610642 DOI: 10.1007/s12028-023-01818-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 07/20/2023] [Indexed: 08/24/2023]
Abstract
BACKGROUND Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH. METHODS This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used. RESULTS A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome. CONCLUSIONS The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.
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Affiliation(s)
- Young Hoon Choi
- Department of Radiology, Seoul National University Hospital, Seoul, Republic of Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea.
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Youngbo Shim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jungook Kim
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101, Daehak-ro Jongno-gu, Seoul, 03080, Republic of Korea
| | - Yoon-Hee Choo
- Department of Neurosurgery, Seoul St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary's Hospital and College of Medicine, The Catholic University of Korea, Incheon, Republic of Korea
| | - Sung Ho Lee
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kang Min Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won-Sang Cho
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun-Seung Kang
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jeoug Eun Kim
- Department of Neurosurgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
- Department of Neurosurgery, Seoul National University Hospital, Seoul, Republic of Korea
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Wang S, Zhang T, Du L, Hu P, Ye M, Sun L, Hong T, Li G, Zhang P, Zhang H, He C. Safety and efficacy of dual antiplatelet drugs for stent-assisted embolization on risk of stroke and prognosis in patients with ruptured intracranial aneurysms: One center results of CIAP-5 clinical trial. Interv Neuroradiol 2024:15910199231219212. [PMID: 38192110 DOI: 10.1177/15910199231219212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Although stent-assisted coiling embolization (SAC) has been associated with a higher risk of ischemic and hemorrhagic complications, the use of SAC continues to rise for treating ruptured intracranial aneurysms (RIAs). This study aims to assess the safety and effectiveness of dual antiplatelet therapy (DAPT) in the context of RIAs. METHODS We conducted a retrospective analysis at a single center, involving patients with aneurysmal subarachnoid hemorrhage (aSAH) between May 1, 2017 and December 31, 2021. Patients were categorized into two groups: the SAC group and the non-SAC (NSC) group. Patients in the SAC group received DAPT. We compared modified Rankin Scale (mRS) score, along with hemorrhagic and ischemic complications, between the two groups to evaluate the safety and efficacy of DAPT for SAC. RESULTS The study included a total of 541 patients, of whom 38 (7.0%) experienced hemorrhagic complications and 48 (8.9%) developed ischemic complications. Additionally, 99 (18.3%) and 84 (15.5%) had poor clinical outcomes at discharge and 6 months, respectively. However, no statistically significant differences were observed between the two groups. Our analysis revealed that aneurysm location in the posterior circulation was a significant risk factor for an unfavorable prognosis when antiplatelet drugs were used following SAC (p = 0.025). CONCLUSIONS Administering antiplatelet drugs after SAC for RIAs has demonstrated both safety and effectiveness. However, caution should be exercised when considering this treatment strategy for RIAs located in the posterior circulation due to the potentially elevated risk.
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Affiliation(s)
- Simin Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Tongyu Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Lei Du
- Department of Neurosurgery, The First Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Peng Hu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Ming Ye
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Liyong Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Tao Hong
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Guilin Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Peng Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
| | - Chuan He
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Xuanwu Hospital, China International Neuroscience Institute, Capital Medical University, Beijing, China
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Umekawa M, Yoshikawa G. Impact of ventriculo-cisternal irrigation on prevention of delayed cerebral infarction in aneurysmal subarachnoid hemorrhage: a single-center retrospective study and literature review. Neurosurg Rev 2023; 47:6. [PMID: 38062206 PMCID: PMC10703947 DOI: 10.1007/s10143-023-02241-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 11/17/2023] [Accepted: 12/04/2023] [Indexed: 12/18/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the effectiveness of ventriculo-cisternal irrigation (VCI) in preventing vasospasms and delayed cerebral infarction (DCI) by washing out subarachnoid clots earlier after aneurysm surgery. METHODS We retrospectively identified 340 subarachnoid hemorrhage (SAH) patients with ruptured intracranial aneurysms treated with postoperative VCI at our institution between December 2010 and January 2020. As VCI therapy, a ventricular drain/cisternal drain was placed during aneurysm surgery, and lactated Ringer's solution was used for irrigation until day 4 of SAH, followed by intracranial pressure control at 5-10 cmH2O until day 14. RESULTS The median age was 65 years (interquartile range 52-75), with 236 female patients (69%). The World Federation of Neurosurgical Societies grade distribution was as follows: grade I or II, 175 patients (51%); grade III or IV, 84 (25%); and grade V, 81 (24%). With VCI management in all patients, total vasospasm occurred in 162 patients (48%), although the DCI incidence was low (23 patients [6.8%]). Major drainage-related complications were observed in five patients (1.5%). Early surgery, performed on SAH day 0 or 1, was identified as a preventive factor against DCI occurrence (odds ratio (OR) 0.21, 95% confidence interval (CI) 0.07-0.67; P = 0.008), while additional surgery (4.76, 1.62-13.98; P = 0.005) and dyslipidemia (3.27, 1.24-8.63; P = 0.017) were associated with DCI occurrence. CONCLUSION Managing vasospasms with VCI after SAH is considered a safe and effective method to prevent DCI. Early surgery after SAH may be associated with a decreased risk of DCI with VCI therapy.
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Affiliation(s)
- Motoyuki Umekawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan.
- Department of Neurosurgery, The University of Tokyo Hospital, Tokyo, Japan.
| | - Gakushi Yoshikawa
- Department of Neurosurgery, Showa General Hospital, Tokyo, 187-8510, Japan
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9
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Shimizu S, Hanai T, Egashira Y, Sato Y, Sekiya K, Nishida S, Ishihara M, Ishihara T, Asada R, Kobayashi R, Suzuki A. Controlling nutritional status score during hospitalization as a predictor of clinical outcome in patients with aneurysmal subarachnoid hemorrhage. Sci Rep 2023; 13:12758. [PMID: 37550344 PMCID: PMC10406813 DOI: 10.1038/s41598-023-39938-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 08/02/2023] [Indexed: 08/09/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a serious condition with high mortality and a high permanent disability rate. In this study, we examined the association of clinical outcome with the Controlling Nutritional Status (CONUT) score during hospitalization in aSAH patients. A single-center, retrospective observational study was conducted at Gifu University Hospital. Patients transported to the emergency room for aSAH and diagnosed with World Federation of Neurosurgical Societies (WFNS) grade III and IV aSAH between April 2004 and March 2021 were enrolled. A logistic regression model was constructed to evaluate the association of the CONUT score with a modified Rankin scale (mRS) ≥ 3 and delayed cerebral ischemia (DCI). 127 patients diagnosed with WFNS grade III and IV aSAH were analyzed. CONUT score was significantly associated with mRS ≥ 3 during hospitalization. The score obtained by subtracting the CONUT score at admission from the maximum CONUT score was significantly associated with mRS ≥ 3 at discharge. Moreover, the score obtained by subtracting the CONUT score at admission from the maximum CONUT score during the first 14 days was significantly associated with DCI within 14 days from admission. These findings indicate that CONUT score during hospitalization may be a useful daily marker for predicting poor outcomes in aSAH patients.
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Affiliation(s)
- Shinya Shimizu
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Tatsunori Hanai
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Yusuke Egashira
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Japan
| | - Yukina Sato
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Kumiko Sekiya
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Shohei Nishida
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
| | - Masashi Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Takuma Ishihara
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ryuta Asada
- Innovative and Clinical Research Promotion Center, Gifu University Hospital, Gifu, Japan
| | - Ryo Kobayashi
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan
| | - Akio Suzuki
- Department of Pharmacy, Gifu University Hospital, 1-1 Yanagido, Gifu, 501-1194, Japan.
- Laboratory of Advanced Medical Pharmacy, Gifu Pharmaceutical University, Gifu, Japan.
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10
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Treggiari MM, Rabinstein AA, Busl KM, Caylor MM, Citerio G, Deem S, Diringer M, Fox E, Livesay S, Sheth KN, Suarez JI, Tjoumakaris S. Guidelines for the Neurocritical Care Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:1-28. [PMID: 37202712 DOI: 10.1007/s12028-023-01713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/03/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND The neurointensive care management of patients with aneurysmal subarachnoid hemorrhage (aSAH) is one of the most critical components contributing to short-term and long-term patient outcomes. Previous recommendations for the medical management of aSAH comprehensively summarized the evidence based on consensus conference held in 2011. In this report, we provide updated recommendations based on appraisal of the literature using the Grading of Recommendations Assessment, Development, and Evaluation methodology. METHODS The Population/Intervention/Comparator/Outcome (PICO) questions relevant to the medical management of aSAH were prioritized by consensus from the panel members. The panel used a custom-designed survey instrument to prioritize clinically relevant outcomes specific to each PICO question. To be included, the study design qualifying criteria were as follows: prospective randomized controlled trials (RCTs), prospective or retrospective observational studies, case-control studies, case series with a sample larger than 20 patients, meta-analyses, restricted to human study participants. Panel members first screened titles and abstracts, and subsequently full text review of selected reports. Data were abstracted in duplicate from reports meeting inclusion criteria. Panelists used the Grading of Recommendations Assessment, Development, and Evaluation Risk of Bias tool for assessment of RCTs and the "Risk of Bias In Nonrandomized Studies - of Interventions" tool for assessment of observational studies. The summary of the evidence for each PICO was presented to the full panel, and then the panel voted on the recommendations. RESULTS The initial search retrieved 15,107 unique publications, and 74 were included for data abstraction. Several RCTs were conducted to test pharmacological interventions, and we found that the quality of evidence for nonpharmacological questions was consistently poor. Five PICO questions were supported by strong recommendations, one PICO question was supported by conditional recommendations, and six PICO questions did not have sufficient evidence to provide a recommendation. CONCLUSIONS These guidelines provide recommendations for or against interventions proven to be effective, ineffective, or harmful in the medical management of patients with aSAH based on a rigorous review of the available literature. They also serve to highlight gaps in knowledge that should guide future research priorities. Despite improvements in the outcomes of patients with aSAH over time, many important clinical questions remain unanswered.
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Affiliation(s)
- Miriam M Treggiari
- Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, 5692 HAFS, Box 3059, Durham, NC, 27710, USA.
| | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Meghan M Caylor
- Department of Pharmacy, Temple University Hospital, Philadelphia, PA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Università Milano Bicocca, Milan, Italy
- NeuroIntensive Care Unit, Department Neuroscience, IRCCS Fondazione San Gerardo dei Tintori, Monza, Italy
| | - Steven Deem
- Neurocritical Care, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Michael Diringer
- Departments of Neurology and Neurosurgery, Washington University in St. Louis, St. Louis, MO, USA
| | - Elizabeth Fox
- Neurocritical Care, Stanford Health Care, Palo Alto, CA, USA
| | - Sarah Livesay
- Neurocritical Care, University of Washington, Seattle, WA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Farber Institute for Neuroscience, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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11
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Kobata H, Ikawa F, Sato A, Kato Y, Sano H. Significance of Pupillary Findings in Decision Making and Outcomes of World Federation of Neurological Societies Grade V Subarachnoid Hemorrhage. Neurosurgery 2023; 93:309-319. [PMID: 36825904 DOI: 10.1227/neu.0000000000002410] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 12/15/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND There is considerable debate regarding the definition of grade V subarachnoid hemorrhage (SAH). Recently, the Glasgow Coma Scale-Pupil (GCS-P) score was advocated for assessing traumatic brain injury. OBJECTIVE To study the significance of pupillary findings and GCS-P in the management and outcomes of the World Federation of Neurological Societies (WFNS) grade V SAH. METHODS We analyzed data obtained from a Japanese nationwide prospective registration study on the modified WFNS SAH grading system. Bilateral pupillary dilatation without reactivity was defined as pupil score 2, unilateral pupil dilation without reactivity as score 1, and no pupil dilatation with reactivity as score 0. The GCS-P score was calculated by subtracting the pupil score from the total GCS score. The characteristics and pupillary findings were examined in patients with each GCS score in WFNS grade V. RESULTS Among 1638 patients, 472 (men/women = 161/311, age 67.0 ± 14.0 years) had a GCS score of ≤6 after initial resuscitation on arrival. Overall, lower GCS scores were associated with poorer neurological outcomes and higher mortality. Aneurysms were treated in 20.5%, 53.9%, and 67.5% of patients with pupil scores of 2, 1, and 0, respectively. Favorable outcomes (modified Rankin Scale 0-2) at 3 months occurred in 4.5%, 10.8%, and 21.4% in patients with pupil scores 2, 1, and 0, respectively ( P < .0001), and in 0%, 0%, 13.6%, 28.6%, 16.7%, and 18.8% of patients with GCS-P scores 1 to 6 ( P < .0001), respectively. CONCLUSION Our study confirmed the significance of pupillary findings in decision making and outcomes of WFNS grade V SAH.
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Affiliation(s)
- Hitoshi Kobata
- Department of Neurosurgery, Osaka Mishima Emergency Critical Care Center, Takatsuki, Japan
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Japan
| | - Fusao Ikawa
- Department of Neurosurgery, Shimane Prefectural Central Hospital, Izumo, Japan
| | - Akira Sato
- Gotanda Rehabilitation Hospital, Tokyo, Japan
| | - Yoko Kato
- Department of Neurosurgery, Banbuntane Hotokukai Hospital, Nagoya, Aichi, Japan
| | - Hirotoshi Sano
- Department of Neurosurgery, Shinkawabashi Hospital, Kawasaki, Japan
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12
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Hou F, Zhang Q, Zhang W, Xiang C, Zhang G, Wang L, Zheng Z, Guo Y, Chen Z, Hernesniemi J, Feng G, Gu J. A correlation and prediction study of the poor prognosis of high-grade aneurysmal subarachnoid hemorrhage from the neutrophil percentage to albumin ratio. Clin Neurol Neurosurg 2023; 230:107788. [PMID: 37229954 DOI: 10.1016/j.clineuro.2023.107788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 04/30/2023] [Accepted: 05/13/2023] [Indexed: 05/27/2023]
Abstract
OBJECTIVE Inflammatory response and nutritional status play crucial roles in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study mainly investigated the correlation between neutrophil percentage to albumin ratio (NPAR) and clinical prognosis in aSAH patients with high-grade Hunt-Hess and its predictive model. METHODS A retrospective analysis was conducted based on 806 patients with aneurysmal subarachnoid hemorrhage who were admitted to the studied hospital from January 2017 to December 2021. Modified Fisher grade and Hunt-Hess grade were obtained according to their status at admission and hematological parameters within 48 h after hemorrhage. Univariate and multivariate logistic regression analysis were conducted to evaluate the relationship between NPAR and the clinical prognosis of patients with aSAH. And propensity matching analysis of patients with aSAH in the severe group. Receiver operating characteristic (ROC) curve analysis was used to determine the optimal cut-off value of NPAR at admission to predict prognosis and its sensitivity and specificity. The nomogram diagram and Calibration curve were further used to examine the prediction model. RESULTS According to the mRS score at discharge, 184 (22.83 %) cases were classified as having poor outcomes (mRS > 2). Through multivariate logistic regression analysis, it was found that the Modified Fisher grade at admission, Hunt-Hess grade, eosinophils, neutrophil to lymphocyte ratio (NLR), and NPAR were independent risk factors for poor outcome in patients with aSAH (p < 0.05). The NPAR of aSAH patients with poor outcomes in the high-grade group was significantly higher than that in the low-grade group. The optimal cut-off value for NPAR was 21.90, the area under the ROC curve was 0.780 (95 % CI 0.700 - 0.861, p < 0.001). The Calibration curves show that the predicted probability of the drawn nomogram is overall consistent with the actual probability. (Mean absolute error = 0.031) CONCLUSION: The NPAR value of patients with aSAH at admission is significantly correlated with Hunt-Hess grade in a positive manner, namely, the higher the Hunt-Hess grade, the higher the NPAR value, and the worse the prognosis. Findings indicate that early NPAR value can be used as a feasible biomarker to predict the clinical prognosis of patients with aSAH.
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Affiliation(s)
- Fandi Hou
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Qingqing Zhang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China; Henan University, Kaifeng, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Wanwan Zhang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China; Henan University, Kaifeng, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Chao Xiang
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Gaoqi Zhang
- Department of Neurosurgery, Henan University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China; Henan University, Kaifeng, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Lintao Wang
- Henan University, Kaifeng, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Zhanqiang Zheng
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Yong Guo
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Zhongcan Chen
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Juha Hernesniemi
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Guang Feng
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China
| | - Jianjun Gu
- Department of Neurosurgery, Henan Provincial People's Hospital, Zhengzhou University People's Hospital, China; Department of Neurosurgery, The Second Affiliated Hospital of Jiaxing University, Jiaxing, Zhejiang 314000, China.
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13
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Ahmetspahić A, Janković D, Burazerovic E, Rovčanin B, Šahbaz A, Hasanagić E, Džurlić A, Granov N, Feletti A. Clinical Characteristics of Poor-Grade Aneurysmal Subarachnoid Hemorrhage Treatment. Asian J Neurosurg 2023; 18:132-138. [PMID: 37056885 PMCID: PMC10089758 DOI: 10.1055/s-0043-1764118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Abstract
Background The initial clinical status after aneurysm rupture, whether primary or secondary, determines the final outcome. The most common cause of patient deterioration is a high Hunt and Hess (HH) score, which correlates closely with a high mortality rate. Poor-grade aneurysmal subarachnoid hemorrhage (SAH) is determined as an HH score 4 or 5. The aim of this study was to evaluate the clinical characteristics of poor graded aneurysmal SAH at our institution.
Patients and Methods During the 5-year period, 415 patients with intracranial aneurysm were admitted to our institution. Patients with poor-grade aneurysmal SAH accounted 31.08% (n = 132) of the total number of ruptured aneurysms. Interventional treatment was predominantly in the form of surgery, whereas conservative treatment included medication and external ventricular drainage. Final outcome was assessed with a modified Rankin score (mRs). Statistical analysis was performed using SPSS version 23.0 with a significance level set to 5% (α = 0.05).
Results The majority of patients (57.6%) were in the age range from 51 to 69 years. Twenty-five patients (18.9%) had an HH score of 4, whereas 107 patients (81.1%) had an HH score of 5. Depending on the location, the majority of patients (n = 43) had an aneurysm on the medial cerebral artery (MCA). The final aneurysm occlusion was performed in 71 patients, of whom 94.36% were treated surgically. A positive outcome (mRs 0–4) was found in 49.25% of patients who underwent primarily surgical, treatment with a mortality of 42.3%. Although the outcome was better in patients with an HH score 4, both groups benefited from surgical treatment.
Conclusion Poor-grade aneurismal SAH is a condition of the middle and older age, with most patients with an HH 5 score and deep comatose state. There was better outcome in patients with an HH score of 4 compared to an HH score of 5 and both groups benefited from surgical treatment, which resulted in a positive outcome in almost 50% of surgically treated patients.
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14
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Florez WA, Martinez-Perez R, Deora H, Joaquim AF, García-Ballestas E, Quiñones-Ossa GA, Rivas-Palacios C, Agrawal A, Serrato SA, Jabbour P, Moscote-Salazar LR. An update of predictors of cerebral infarction after aneurysmal subarachnoid hemorrhage: systematic review and meta-analysis. J Neurosurg Sci 2023; 67:1-9. [PMID: 36112119 DOI: 10.23736/s0390-5616.22.05445-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Evidence about predictors of poor outcomes such as cerebral infarction (CI) after aneurysmal subarachnoid hemorrhage (aSAH) has not been fully elucidated. EVIDENCE ACQUISITION We performed a systematic review and meta-analysis on studies with adults with aSAH considering RCT and non-RCT, prospective, and retrospective cohort studies describing clinical, imaging as well as angiographic studies in patients with aSAH. EVIDENCE SYNTHESIS After reviewing the complete text, 11 studies were considered eligible, out of which four were ruled out. Degree of clinical severity was the most predictive factor with a higher degree at the presentation on different severity scales being associated with a statistically significant increasing the risk of suffering a CI following aSAH (OR 2.49 [95% CI 1.38-4.49] P=0.0003). Aneurysm size increased the risk of CI (OR 1.49 [95% CI 1.20-1.85] P=0.0003; I2=4%). In six studies analyzed, it was found that an important factor for the subsequent development of CI is vasospasm (OR 7.62 [2.19, 26.54], P=0.0001). CONCLUSIONS The development of vasospasm is a risk factor for CI development after aSAH. In our review, three factors were associated with an increased risk of CI: clinical severity at presentation, vasospasm, and aneurysm size. The major limitation of this meta-analysis is that included studies were conducted retrospectively or were post hoc analyses of a prospective trial.
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Affiliation(s)
- William A Florez
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
| | - Rafael Martinez-Perez
- Department of Neurosurgery, Wexner Medical Center, The Ohio State University, Columbus, OH, USA.,Division of Neurosurgery, Institute of Neurosciences, Austral University of Chile, Valdivia, Chile
| | - Harsh Deora
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bangalore, India
| | - Andrei F Joaquim
- Department of Neurosurgery. University of Campinas (UNICAMP), São Paulo, Brazil
| | - Ezequiel García-Ballestas
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Gabriel A Quiñones-Ossa
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia - .,Faculty of Medicine, El Bosque University, Bogotá, Colombia
| | - Claudio Rivas-Palacios
- Centro De Investigaciones Biomédicas (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, India
| | | | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Luis R Moscote-Salazar
- Consejo Latinoamericano de Neurointensivismo- CLaNi, Cartagena, Colombia.,Faculty of Medicine, Universidad Surcolombiana, Neiva, Colombia
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Akimoto T, Ohtake M, Kawasaki T, Fushimi S, Shimohigoshi W, Manaka H, Kawasaki T, Sakata K, Takeuchi I, Yamamoto T. Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:47-55. [PMID: 37502127 PMCID: PMC10370525 DOI: 10.5797/jnet.oa.2022-0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 11/09/2022] [Indexed: 07/29/2023]
Abstract
Objective To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH). Methods We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis. Results Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration. Conclusion Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.
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Affiliation(s)
- Taisuke Akimoto
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Makoto Ohtake
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takafumi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Shuto Fushimi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Wataru Shimohigoshi
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Hiroshi Manaka
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Takashi Kawasaki
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Katsumi Sakata
- Department of Neurosurgery, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Ichiro Takeuchi
- Department of Emergency and Critical Care, Yokohama City University Medical Center, Yokohama, Kanagawa, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Kanagawa, Japan
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16
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Eliava SS, Pilipenko YV, Belousova OB, Gvazava GI, Grebenev FV, Konovalov AN, Mikeladze KG, Varyukhina MD. [Surgical treatment of intracranial aneurysms in acute period of hemorrhage in Hunt-Hess grade IV-V patients at Burdenko Neurosurgical Center between 2006 and 2020]. ZHURNAL VOPROSY NEIROKHIRURGII IMENI N. N. BURDENKO 2023; 87:5-13. [PMID: 38054222 DOI: 10.17116/neiro2023870615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
BACKGROUND Management of patients in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V is still a complex and unsolved problem, especially regarding surgical treatment and various complications. OBJECTIVE To analyze postoperative outcomes in patients undergoing surgery in acute period of aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V between 2006 and 2020, as well as to assess various factors influencing treatment outcomes. MATERIAL AND METHODS We analyzed 163 patients who underwent surgery within 21 days after aneurysmal subarachnoid hemorrhage Hunt-Hess grade IV-V. All patients were divided into 2 groups depending on the period: 2006-2011 (group 1) and 2012-2020 (group 2). RESULTS Mortality reduced from 28.6% in group 1 to 8.3% in group 2. At the same time, incidence of vegetative state (GOS grade 2) increased from 4.8% to 17.4%. Incidence of outcomes GOS grade 3 - 5 was similar. CONCLUSION Large or giant aneurysm, repeated preoperative subarachnoid hemorrhage, intraoperative aneurysm rupture and prolonged temporary clipping can impair postoperative outcomes in patients with hemorrhage Hunt-Hess grade IV-V. External ventricular drainage, intraarterial injection of verapamil, intracisternal administration of calcium channel blockers and active surgical tactics improve postoperative outcomes and reduce mortality.
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Affiliation(s)
| | | | | | - G I Gvazava
- Burdenko Neurosurgical Center, Moscow, Russia
| | | | | | | | - M D Varyukhina
- Federal Research Clinical Center of Intensive Care and Rehabilitology, Moscow, Russia
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17
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Inhibition of Delayed Cerebral Ischemia by Magnesium Is Insufficient for Subarachnoid Hemorrhage Patients: A Network Meta-Analysis. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:9357726. [PMID: 36065271 PMCID: PMC9440634 DOI: 10.1155/2022/9357726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022]
Abstract
Objective After subarachnoid hemorrhage, magnesium could reduce the incidence of delayed cerebral ischemia; however, it is still controversial. This study updated the results of recently published magnesium-related studies and conducted an exploratory analysis of the impact of application strategies and intervention factors on the results. Methods Public databases were searched from the date of their inception to May 10, 2021. Randomized controlled trials on magnesium agent-related regimens for subarachnoid hemorrhage patients were included. Results In total, 28 articles were included in the meta-analysis. For delayed cerebral ischemia, magnesium-related interventions significantly reduced the risk of delayed cerebral ischemia compared with nonmagnesium interventions (odds ratios: 0.40; 95% confidence interval: 0.28–0.56; p < 0.01). For cerebral vasospasm, a random effects model showed that magnesium significantly reduced the risk of cerebral vasospasm (odds ratios: 0.46; 95% confidence interval: 0.33–0.63; p < 0.01). In the subgroup analysis, intracranial magnesium (odds ratios: 6.67; 95% confidence interval: 1.14–38.83; p=0.03) and magnesium plus hydrogen (odds ratios: 10; 95% confidence interval: 1.59–62.73; p=0.01) produced significant results in improving the good recovery rate compared to the control. In the network meta-analysis, magnesium plus nimodipine and simvastatin even showed an effective trend in death/persistent vegetative status improvement. Conclusion This study supports the beneficial effect of magnesium in reducing the risk of delayed cerebral ischemia. Based on a single randomized controlled trial, immediate intracranial magnesium therapy with intravenous hydrogen after subarachnoid hemorrhage can increase the good recovery rate. Therefore, more high-quality studies are needed to confirm this finding.
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18
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Wen L, Zhou L, Wu Q, Zhou X, Zhang X. Feasibility of FDCT Early Brain Parenchymal Blood Volume Maps in Predicting Short-Term Prognosis in Patients With Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:888369. [PMID: 35911895 PMCID: PMC9329812 DOI: 10.3389/fneur.2022.888369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 06/16/2022] [Indexed: 11/13/2022] Open
Abstract
Purpose Aneurysmal subarachnoid hemorrhage (SAH) is accompanied by cerebral perfusion changes. We aimed to measure the parenchymal blood volume (PBV) maps acquired by C-arm flat-panel detector CT (FDCT) to assess the cerebral blood volume at an early stage in aneurysmal SAH and to explore the correlation with the outcomes at discharge. Methods Data of 66 patients with aneurysmal SAH who underwent FDCT PBV examination were retrospectively analyzed. The PBV of regions of interest, including the cortices of the bilateral frontal lobe, the parietal lobe, the occipital lobe, and the cerebral hemisphere, as well as the basal ganglia, were measured and quantitatively analyzed. The clinical and imaging data of the patients were also collected, and logistic regression analysis was performed to explore the correlation between the perfusion parameters and outcomes at discharge. Results The favorable and poor outcomes at discharge were found in 37 (56.06%) and 29 (43.94%) patients, respectively. The whole-brain PBV was significantly correlated with the Hunt-Hess grades (p < 0.005) and the WFNSS grades (p < 0.005). The whole-brain PBV of the poor prognosis was significantly higher than that of the favorable prognosis (35.17 ± 7.66 vs. 29.78 ± 5.54, p < 0.005). The logistic regression analysis showed that the PBV of the parietal lobe at the bleeding side (OR = 1.10, 95%CI: 1.00-1.20, p = 0.04) was an independent risk factor predicting the short-term prognosis. Conclusions Parenchymal blood volume (PBV) maps could reflect the cerebral blood volume throughout the brain to characterize its perfusion status at an early stage in aneurysmal SAH. It enables a one-stop imaging evaluation and treatment in the same angio-suite and may serve as a reliable technique in clinical assessment of aneurysmal SAH.
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Affiliation(s)
- Lili Wen
- Department of Neurosurgery, Sir Run Run Hospital, Nanjing Medical University, Nanjing, China
| | - Longjiang Zhou
- Medical Imaging Center, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qi Wu
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xiaoming Zhou
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
| | - Xin Zhang
- Department of Neurosurgery, Jinling Hospital, Nanjing University School of Medicine, Nanjing, China
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19
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de Winkel J, Cras TY, Dammers R, van Doormaal PJ, van der Jagt M, Dippel DWJ, Lingsma HF, Roozenbeek B. Early predictors of functional outcome in poor-grade aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. BMC Neurol 2022; 22:239. [PMID: 35773634 PMCID: PMC9245240 DOI: 10.1186/s12883-022-02734-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/19/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH) often receive delayed or no aneurysm treatment, although recent studies suggest that functional outcome following early aneurysm treatment has improved. We aimed to systematically review and meta-analyze early predictors of functional outcome in poor-grade aSAH patients. METHODS: We included studies investigating the association of early predictors and functional outcome in adult patients with confirmed poor-grade aSAH, defined as World Federation of Neurological Surgeons (WFNS) grade or Hunt and Hess (H-H) grade IV-V. Studies had to use multivariable regression analysis to estimate independent predictor effects of favorable functional outcome measured with the Glasgow Outcome Scale or modified Rankin Scale. We calculated pooled adjusted odds ratios (aOR) and 95% confidence intervals (CI) with random effects models. RESULTS: We included 27 studies with 3287 patients. The likelihood of favorable outcome increased with WFNS grade or H-H grade IV versus V (aOR 2.9, 95% CI 1.9-4.3), presence of clinical improvement before aneurysm treatment (aOR 3.3, 95% CI 2.0-5.3), and intact pupillary light reflex (aOR 2.9, 95% CI 1.6-5.1), and decreased with older age (aOR 0.7, 95% CI 0.5-1.0, per decade), increasing modified Fisher grade (aOR 0.4, 95% CI 0.3-0.5, per grade), and presence of intracerebral hematoma on admission imaging (aOR 0.4, 95% CI 0.2-0.8). CONCLUSIONS We present a summary of early predictors of functional outcome in poor-grade aSAH patients that can help to discriminate between patients with favorable and with unfavorable prognosis and may aid in selecting patients for early aneurysm treatment.
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Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. .,Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Tim Y Cras
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
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20
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Monsour M, Croci DM, Agazzi S. Microclots in subarachnoid hemorrhage: an underestimated factor in delayed cerebral ischemia? Clin Neurol Neurosurg 2022; 219:107330. [PMID: 35700661 DOI: 10.1016/j.clineuro.2022.107330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 06/02/2022] [Accepted: 06/03/2022] [Indexed: 12/01/2022]
Abstract
Subarachnoid hemorrhage has a poor prognosis due to the wide array of associated complications such as vasospasm, early brain injury, cortical spreading depression, oxidative stress, inflammation, and apoptosis. Each of these complications increases the risk of delayed cerebral ischemia (DCI), but recent research has suggested microclots play a substantial role in DCI incidence. This review will focus on the underlying inflammatory and coagulative mechanisms of microthrombosis while also outlining the current literature relating microclot burden to DCI. With a better understanding DCI pathophysiology as it relates to microthrombosis, more effective therapies can be developed in the future to improve clinical outcomes of SAH.
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Affiliation(s)
- Molly Monsour
- University of South Florida Morsani College of Medicine, 12901 Bruce B. Downs Blvd., Tampa, FL 33612, USA
| | - Davide Marco Croci
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA.
| | - Siviero Agazzi
- Department of Neurosurgery and Brain Repair, University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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21
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Al-Mufti F, Mayer SA, Kaur G, Bassily D, Li B, Holstein ML, Ani J, Matluck NE, Kamal H, Nuoman R, Bowers CA, S Ali F, Al-Shammari H, El-Ghanem M, Gandhi C, Amuluru K. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism. Neuroradiol J 2021; 34:542-551. [PMID: 34476991 PMCID: PMC8649190 DOI: 10.1177/19714009211024633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND PURPOSE Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. MATERIALS AND METHODS We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. RESULTS Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. CONCLUSIONS Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Daniel Bassily
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Boyi Li
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Matthew L Holstein
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Jood Ani
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Nicole E Matluck
- School of Medicine, New York Medical College, New York Medical College, Valhalla, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Maria Fareri Children’s Hospital, Westchester Medical Center, Valhalla, USA
| | | | - Faizan S Ali
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Hussein Al-Shammari
- Department of Neurology, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Mohammad El-Ghanem
- Department of Neurology, Neurosurgery and Medical Imaging, University of Arizona, Tucson, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Westchester Medical Center, Valhalla, USA
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Indianapolis, USA
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22
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Best Motor Response Predicts Favorable Outcome for "True" WFNS Grade V Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:106075. [PMID: 34481320 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 08/13/2021] [Accepted: 08/16/2021] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The universal application of ultra-early surgery for World Federation of Neurological Societies (WFNS) grade V aneurysmal subarachnoid hemorrhage (aSAH) patients may lead to the increased implementation of unnecessary treatment. Therefore, this study aimed to refine the patient selection process for timely definitive treatment. METHODS From January 2011 to March 2020, a total of 517 aSAH patients were treated at our institution. Among these, 177 aSAH patients with WFNS grade V on admission were identified from our database. Patients with improved grades in response to the initial supportive treatment, with clinical or radiological signs of herniation, and with irreversible signs of brain damage such as bilaterally dilated pupils and global ischemia on follow-up CT scan were excluded. The outcome of definitive treatment for 54 patients without herniation who remained with WFNS grade V after the initial supportive treatment were analyzed to seek any factor for a favorable outcome (modified Rankin scale 0-2). RESULTS Among 54 patients, 19 (35.2%) had a favorable outcome after a definitive treatment. Multivariate logistic regression analysis showed that the best motor response (BMR) 4 on Glasgow Coma Scale was significantly associated with favorable outcomes (odds ratio, 3.76; 95% confidence interval, 1.09-13.0, p = 0.03). The positive predictive value of BMR 4 was 48.3%. CONCLUSIONS Albeit being simple, BMR 4 may facilitate the prompt aggressive treatment for patients with WFNS grade V including those with "true" grade V who do not have any clinical and radiological signs of herniation.
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23
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Bruder M, Kashefiolasl S, Brawanski N, Keil F, Won SY, Seifert V, Konczalla J. Vitamin K Antagonist (Phenprocoumon) and Subarachnoid Hemorrhage: A Single-Center, Matched-Pair Analysis. Neurocrit Care 2021; 33:105-114. [PMID: 31659679 DOI: 10.1007/s12028-019-00868-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Demographic changes are leading to an aging society with a growing number of patients relying on anticoagulation, and vitamin K antagonists (VKA) are still widely used. As mortality and functional outcomes are worse in case of VKA-associated hemorrhagic stroke, phenprocoumon treatment seems to be a negative prognostic factor in case of subarachnoid hemorrhage (SAH). The purpose of this study was to analyze whether phenprocoumon treatment does worsen the outcome after non-traumatic SAH. METHODS All patients treated for non-traumatic SAH between January 2007 and December 2016 in our institution were retrospectively analyzed. After exclusion of patients with anticoagulant or antiplatelet treatment other than phenprocoumon, we analyzed 1040 patients. Thirty-three patients (3%) of those were treated with continuous phenprocoumon. In total, 132 out of all 1007 patients without anticoagulant treatment of the remaining patients were matched as control group (ratio = 1:4). RESULTS Patients with phenprocoumon treatment were significantly older (66.5 years vs. 53.9 years; p < .0001), and admission status was significantly more often poor (66.7% vs. 41.8%, p = .007) compared to all patients without anticoagulant treatment. Further, bleeding pattern and rates of early hydrocephalus did not differ. Matched-pair analysis revealed a significant higher rate of angio-negative SAH in the study group (p = .001). Overall rates of hemorrhagic or thromboembolic complications did not differ (21.4% vs. 18.8%; NS) but were more often fatal, and 30-day mortality rate was significantly higher in the phenprocoumon group than in patients of the matched-pair control group (33% vs. 24%; p < .001). 30% of the phenprocoumon group and 37% of the matched-pair control group reached favorable outcome. However, poor outcome was strong associated with the reason for phenprocoumon treatment. CONCLUSION Patients with phenprocoumon treatment at the time of SAH are significantly older, admission status is worse, and 30-day mortality rates are significantly higher compared to patients without anticoagulant treatment. However, outcome at 6 months did not differ to the matched-pair control group but seems to be strongly associated with the underlying cardiovascular disease. Treatment of these patients is challenging and should be performed on an interdisciplinary base in each individual case. Careful decision-making regarding discontinuation and bridging of anticoagulation and close observation is mandatory.
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Affiliation(s)
- Markus Bruder
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany.
| | | | - Nina Brawanski
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, Goethe University, Frankfurt am Main, Germany
| | - Sae-Yeon Won
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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24
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Lu X, Huang Y, Zhou P, Zhu W, Wang Z, Chen G. Cerebral revascularization for the management of complex middle cerebral artery aneurysm: A case series. Exp Ther Med 2021; 22:883. [PMID: 34194561 PMCID: PMC8237261 DOI: 10.3892/etm.2021.10315] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Accepted: 05/12/2021] [Indexed: 11/06/2022] Open
Abstract
Complex middle cerebral artery (MCA) aneurysms, including aneurysms that are sizeable (large or giant), fusiform, wide-necked or calcified, remain a significant challenge during microsurgical clipping or endovascular coiling as treatment strategies. In the present study, a retrospective analysis of cases of this type of aneurysm treated between August 2012 and December 2019 was performed. From the hospital's database, a total of 13 patients (7 males and 6 females) with a mean age of 39.0 years (range, 13-65 years) were identified. The mean size of the aneurysms was 17.5 mm (range, 3.9-35.0 mm). A total of four patients (30.8%) had ruptured aneurysms and nine (69.2%) had unruptured aneurysms. All aneurysms were treated by proximal occlusion of the parent artery, trapping or excision combined with cerebral revascularization. The bypasses performed included 10 extracranial-intracranial bypasses and 3 intracranial-intracranial bypasses (1 end-to-end re-anastomosis, 1 interpositional graft and 1 end-to-side reimplantation). Postoperative angiography confirmed that the bypass patency was 92.3% and the clinical outcomes were indicated to be favorable, with a modified Rankin Scale score ≤2 in 12 out of 13 patients (92.3%) at the last follow-up. Taken together, the results of the present analysis suggested that treatment strategies for complex MCA aneurysms should depend on the status and characteristics of the aneurysm, including aneurysm size, location and morphology. For aneurysms that lack perforating arteries in the aneurysm dome, clip trapping or aneurysm excision with or without bypass are preferred as treatment strategies. When there are perforating arteries (particularly the lenticulostriate artery) arising from the aneurysm dome, however, the aneurysms should be treated with bypass followed by proximal occlusion of the parent artery or clip reconstruction.
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Affiliation(s)
- Xiaocheng Lu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Yabo Huang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Peng Zhou
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Weiwei Zhu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
| | - Gang Chen
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215006, P.R. China
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25
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Ehlert A, Starekova J, Manthei G, Ehlert-Gamm A, Flack J, Gessert M, Gerss J, Hesselmann V. Nitric Oxide-Based Treatment of Poor-Grade Patients After Severe Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2021; 32:742-754. [PMID: 31418143 PMCID: PMC7272492 DOI: 10.1007/s12028-019-00809-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background Patients with aneurysmal subarachnoid hemorrhage (aSAH) require close treatment in neuro intensive care units (NICUs). The treatments available to counteract secondary deterioration and delayed ischemic events remain restricted; moreover, available neuro-monitoring of comatose patients is undependable. In comatose patients, clinical signs are hidden, and timing interventions to prevent the evolution of a perfusion disorder in response to fixed ischemic brain damage remain a challenge for NICU teams. Consequently, comatose patients often suffer secondary brain infarctions. The outcomes for long-term intubated patients w/wo pupil dilatation are the worst, with only 10% surviving. We previously added two nitroxide (NO) donors to the standard treatment: continuous intravenous administration of Molsidomine in patients with mild-to-moderate aSAH and, if required as a supplement, intraventricular boluses of sodium nitroprusside (SNP) in high-risk patients to overcome the so-called NO-sink effect, which leads to vasospasm and perfusion disorders. NO boluses were guided by clinical status and promptly reversed recurrent episodes of delayed ischemic neurological deficit. In this study, we tried to translate this concept, the initiation of intraventricular NO application on top of continuous Molsidomine infusion, from awake to comatose patients who lack neurological–clinical monitoring but are primarily monitored using frequently applied transcranial Doppler (TCD). Methods In this observational, retrospective, nonrandomized feasibility study, 18 consecutive aSAH comatose/intubated patients (Hunt and Hess IV/V with/without pupil dilatation) whose poor clinical status precluded clinical monitoring received standard neuro-intensive care, frequent TCD monitoring, continuous intravenous Molsidomine plus intraventricular SNP boluses after TCD-confirmed macrospasm during the daytime and on a fixed nighttime schedule. Results Very likely associated with the application of SNP, which is a matter of further investigation, vasospasm-related TCD findings promptly and reliably reversed or substantially weakened (p < 0.0001) afterward. Delayed cerebral ischemia (DCI) occurred only during loose, low-dose or interrupted treatment (17% vs. an estimated 65% with secondary infarctions) in 17 responders. However, despite their worse initial condition, 29.4% of the responders survived (expected 10%) and four achieved Glasgow Outcome Scale Extended (GOSE) 8–6, modified Rankin Scale (mRS) 0–1 or National Institutes of Health Stroke Scale (NIHSS) 0–2. Conclusions Even in comatose/intubated patients, TCD-guided dual-compartment administration of NO donors probably could reverse macrospasm and seems to be feasible. The number of DCI was much lower than expected in this specific subgroup, indicating that this treatment possibly provides a positive impact on outcomes. A randomized trial should verify or falsify our results.
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Affiliation(s)
- Angelika Ehlert
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany.
| | - Jitka Starekova
- Department of Radiology, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20251, Hamburg, Germany
| | - Gerd Manthei
- Department of Neurosurgery, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | | | - Joachim Flack
- Doctor's Office, Breitenfelderstr. 7, 20251, Hamburg, Germany
| | - Marie Gessert
- Department of Neurology, Asklepios Hospital St. Georg, Lohmühlenstr. 5, 20099, Hamburg, Germany
| | - Joachim Gerss
- Institute of Biostatistics and Clinical Research, University Hospital Münster, Schmeddingstr. 56, 48149, Münster, Germany
| | - Volker Hesselmann
- Department of Neuroradiology, Asklepios Hospital Nord, Tangstedter Landstr. 400, 22417, Hamburg, Germany
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26
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Samuels OB, Sadan O, Feng C, Martin K, Medani K, Mei Y, Barrow DL. Aneurysmal Subarachnoid Hemorrhage: Trends, Outcomes, and Predictions From a 15-Year Perspective of a Single Neurocritical Care Unit. Neurosurgery 2021; 88:574-583. [PMID: 33313810 PMCID: PMC8133330 DOI: 10.1093/neuros/nyaa465] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/12/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage (aSAH) is associated with disproportionally high mortality and long-term neurological sequelae. Management of patients with aSAH has changed markedly over the years, leading to improvements in outcome. OBJECTIVE To describe trends in aSAH care and outcome in a high-volume single center 15-yr cohort. METHODS All new admissions diagnosed with subarachnoid hemorrhage (SAH) to our tertiary neuro-intensive care unit between 2002 and 2016 were reviewed. Trend analysis was performed to assess temporal changes and a step-wise regression analysis was done to identify factors associated with outcomes. RESULTS Out of 3970 admissions of patients with SAH, 2475 patients proved to have a ruptured intracranial aneurysm. Over the years of the study, patient acuity increased by Hunt & Hess (H&H) grade and related complications. Endovascular therapies became more prevalent over the years, and were correlated with better outcome. Functional outcome overall improved, yet the main effect was noted in the low- and intermediate-grade patients. Several parameters were associated with poor functional outcome, including long-term mechanical ventilation (odds ratio 11.99, CI 95% [7.15-20.63]), acute kidney injury (3.55 [1.64-8.24]), pneumonia (2.89 [1.89-4.42]), hydrocephalus (1.80 [1.24-2.63]) diabetes mellitus (1.71 [1.04-2.84]), seizures (1.69 [1.07-2.70], H&H (1.67 [1.45-1.94]), and age (1.06 [1.05-1.07]), while endovascular approach to treat the aneurysm, compared with clip-ligation, had a positive effect (0.35 [0.25-0.48]). CONCLUSION This large, single referral center, retrospective analysis reveals important trends in the treatment of aSAH. It also demonstrates that despite improvement in functional outcome over the years, systemic complications remain a significant risk factor for poor prognosis. The historic H&H determination of outcome is less valid with today's improved care.
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Affiliation(s)
- Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and School of Medicine, Atlanta, Georgia
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and School of Medicine, Atlanta, Georgia
| | - Chen Feng
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Kathleen Martin
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University Hospital and School of Medicine, Atlanta, Georgia
| | - Khalid Medani
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, Georgia
| | - Yajun Mei
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Daniel L Barrow
- Department of Neurosurgery, Emory University Hospital and School of Medicine, Atlanta, Georgia
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27
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Maruhashi T, Higashi Y. An overview of pharmacotherapy for cerebral vasospasm and delayed cerebral ischemia after subarachnoid hemorrhage. Expert Opin Pharmacother 2021; 22:1601-1614. [PMID: 33823726 DOI: 10.1080/14656566.2021.1912013] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Introduction: Survival from aneurysmal subarachnoid hemorrhage has increased in the past few decades. However, functional outcome after subarachnoid hemorrhage is still suboptimal. Delayed cerebral ischemia (DCI) is one of the major causes of morbidity.Areas covered: Mechanisms underlying vasospasm and DCI after aneurysmal subarachnoid hemorrhage and pharmacological treatment are summarized in this review.Expert opinion: Oral nimodine, an L-type dihydropyridine calcium channel blocker, is the only FDA-approved drug for the prevention and treatment of neurological deficits after aneurysmal subarachnoid hemorrhage. Fasudil, a potent Rho-kinase inhibitor, has also been shown to improve the clinical outcome and has been approved in some countries for use in patients with aneurysmal subarachnoid hemorrhage. Although other drugs, including nicardipine, cilostazol, statins, clazosentan, magnesium and heparin, have been expected to have beneficial effects on DCI, there has been no convincing evidence supporting the routine use of those drugs in patients with aneurysmal subarachnoid hemorrhage in clinical practice. Further elucidation of the mechanisms underlying DCI and the development of effective therapeutic strategies for DCI, including combination therapy, are necessary to further improve the functional outcome and mortality after subarachnoid hemorrhage.
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Affiliation(s)
- Tatsuya Maruhashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan
| | - Yukihito Higashi
- Department of Cardiovascular Regeneration and Medicine, Research Institute for Radiation Biology and Medicine, Hiroshima University, Hiroshima, Japan.,Division of Regeneration and Medicine, Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
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García-Ballestas E, Florez-Perdomo WA, Starke RM, Joaquim AF, Agrawal A, Keni RR, Moscote-Salazar LR. Risk of Seizures after Endovascular Management of Ruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis. J Epilepsy Res 2021; 10:55-61. [PMID: 33659196 PMCID: PMC7903045 DOI: 10.14581/jer.20009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 11/26/2020] [Accepted: 12/04/2020] [Indexed: 12/26/2022] Open
Abstract
Seizures in aneurysmal subarachnoid haemorrhage (aSAH) have been described secondary to SAH, changes in cortical function, vasospasm and as a result of treatment effects. Seizures are one of the important clinical determinants in neurological outcome of aSAH. Various studies support the notion of less risk of future seizures in endovascular treatment as compared to the microsurgical clipping, yet there is no conclusive evidence in favour or against the seizure occurrence in aSAH patients after endovascular treatment as compared to the microsurgical treatment. To carry out a systematic review and meta-analysis of the risk of seizures after endovascular management (coiling) of ruptured intracranial aneurysms. A literature search was performed in electronic database of PubMed, MEDLINE, Embase, and Scopus from inception to February 2020, using the terms Seizure, Intracranial aneurysms, embolization, with no constraints applied. Data were pooled using a random-effect model, results were abstracted as odds ratios (ORs) and 95% confidence interval (CI), and heterogeneity was reported as Chi-square. Five studies involving 3,077 patients were included in the meta-analysis. After endovascular management of aSAH, seizure risk was increased by a worse clinical severity (World Federation of Neurosurgery scale or Hunt and Hess) (OR, 3.34; 95% CI, 2.69–4.16; p<0.00001), severe vasospasm (OR, 2.20; 95% CI, 1.67–2.92; p<0.00001), cerebral infarction (OR, 5.19; 95% CI, 3.23–8.35; p<0.00001), and cerebral edema (OR, 1.79; 95% CI, 1.37–2.34; p<0.0000). Worse clinical severity, vasospasm, cerebral infarction and cerebral oedema are significant risk factors for the development of seizures after endovascular intervention in aSAH. The mechanism for this correlation is not clear.
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Affiliation(s)
- Ezequiel García-Ballestas
- Latin American Council of Neurocritical Care, Cartagena, Colombia.,Center of Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Bolívar, Colombia
| | - William A Florez-Perdomo
- Latin American Council of Neurocritical Care, Cartagena, Colombia.,Faculty of Medicine, Surcolombian University, Neiva, Colombia
| | - Robert M Starke
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, FL, USA
| | | | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Saket Nagar, Nellore, India
| | | | - Luis-Rafael Moscote-Salazar
- Latin American Council of Neurocritical Care, Cartagena, Colombia.,Center of Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Bolívar, Colombia
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Poor grade subarachnoid hemorrhage: Treatment decisions and timing influence outcome. Should we, and when should we treat these patients? BRAIN HEMORRHAGES 2021. [DOI: 10.1016/j.hest.2020.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Findings Predictive of Poor Outcome in Grade 5 Subarachnoid Hemorrhage: A Cohort Study. Can J Neurol Sci 2021; 48:807-816. [PMID: 33472716 DOI: 10.1017/cjn.2021.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Most patients with World Federation of Neurological Surgeons (WFNS) grade 5 subarachnoid hemorrhage (SAH) have poor outcomes. Accurate assessment of prognosis is important for treatment decisions and conversations with families regarding goals of care. Unjustified pessimism may lead to "self-fulfilling prophecy," where withdrawal of life-sustaining measures (WLSM) is invariably followed by death. METHODS We performed a cohort study involving consecutive patients with WFNS grade 5 SAH to identify variables with >= 90% and >= 95% positive predictive value (PPV) for poor outcome (1-year modified Rankin Score >= 4), as well as findings predictive of WLSM. RESULTS Of 140 patients, 38 (27%) had favorable outcomes. Predictors with >= 95% PPV for poor outcome included unconfounded 72-hour Glasgow Coma Scale motor score <= 4, absence of >= 1 pupillary light reflex (PLR) at 24 hours, and intraventricular hemorrhage (IVH) score of >= 20 (volume >= 54.6 ml). Intracerebral hemorrhage (ICH) volume >= 53 ml had PPV of 92%. Variables associated with WLSM decisions included a poor motor score (p < 0.0001) and radiographic evidence of infarction (p = 0.02). CONCLUSIONS We identified several early predictors with high PPV for poor outcome. Of these, lack of improvement in motor score during the initial 72 hours had the greatest potential for confounding from "self-fulfilling prophecy." Absence of PLR at 24 hours, IVH score >= 20, and ICH volume >= 53 ml predicted poor outcome without a statistically significant effect on WLSM decisions. More research is needed to validate prognostic variables in grade 5 SAH, especially among patients who do not undergo WLSM.
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Impact of smoking on course and outcome of aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2020; 162:3117-3128. [PMID: 32728905 PMCID: PMC7593300 DOI: 10.1007/s00701-020-04506-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 07/17/2020] [Indexed: 01/09/2023]
Abstract
Background While the smoking-related risk of experiencing an aneurysmal subarachnoid hemorrhage (aSAH) is well established, it remains unclear whether smoking has an unexpected “protective effect” in aSAH, or if smokers are more at risk for complications and poor outcomes. Methods Prospective, observational study investigating the course and outcome of aSAH in patients admitted during the years 2011 and 2012. Smoking status at admittance, demographic, medical, and radiological variables were registered along with management, complications, and outcome at 1 year in terms of mortality, modified Rankin score, and Glasgow outcome score extended. We compared current smokers with nonsmokers on group level and by paired analysis matched by aSAH severity, age, and severity of vasospasm. Results We included 237 patients, thereof 138 current smokers (58.2%). Seventy-four smoker/nonsmoker pairs were matched. Smokers presented more often in poor clinical grade, had less subarachnoid blood, and were younger than nonsmokers. Ruptured aneurysms were larger, and multiple aneurysms more common in smokers. Severe multi-vessel vasospasm was less frequent in smokers, whereas all other complications occurred at similar rates. Mortality at 30 days was lower in smokers and functional outcome was similar in smokers and nonsmokers. Poor clinical grade, age, cerebral infarction, and vertebrobasilar aneurysms were independent predictors of 1-year mortality and of poor functional outcome. Serious comorbidity was a predictor of 1-year mortality. Smoking did not predict mortality or poor functional outcome. Conclusions Notwithstanding clinically more severe aSAH, smokers developed less frequently severe vasospasm and had better outcome than expected. The risk for complications after aSAH is not increased in smokers.
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Suzuki H, Kanamaru H, Kawakita F, Asada R, Fujimoto M, Shiba M. Cerebrovascular pathophysiology of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Histol Histopathol 2020; 36:143-158. [PMID: 32996580 DOI: 10.14670/hh-18-253] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) remains a serious cerebrovascular disease. Even if SAH patients survive the initial insults, delayed cerebral ischemia (DCI) may occur at 4 days or later post-SAH. DCI is characteristics of SAH, and is considered to develop by blood breakdown products and inflammatory reactions, or secondary to early brain injury, acute pathophysiological events that occur in the brain within the first 72 hours of aneurysmal SAH. The pathology underlying DCI may involve large artery vasospasm and/or microcirculatory disturbances by microvasospasm, microthrombosis, dysfunction of venous outflow and compression of microvasculature by vasogenic or cytotoxic tissue edema. Recent clinical evidence has shown that large artery vasospasm is not the only cause of DCI, and that both large artery vasospasm-dependent and -independent cerebral infarction causes poor outcome. Animal studies suggest that mechanisms of vasospasm may differ between large artery and arterioles or capillaries, and that many kinds of cells in the vascular wall and brain parenchyma may be involved in the pathogenesis of microcirculatory disturbances. The impairment of the paravascular and glymphatic systems also may play important roles in the development of DCI. As pathological mediators for DCI, glutamate and several matricellular proteins have been investigated in addition to inflammatory molecules. Glutamate is involved in excitotoxicity contributing to cortical spreading ischemia and epileptic activity-related events. Microvascular dysfunction is an attractive mechanism to explain the cause of poor outcomes independently of large cerebral artery vasospasm, but needs more studies to clarify the pathophysiologies or mechanisms and to develop a novel therapeutic strategy.
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Affiliation(s)
- Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan.
| | - Hideki Kanamaru
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Fumihiro Kawakita
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Reona Asada
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masashi Fujimoto
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
| | - Masato Shiba
- Department of Neurosurgery, Mie University Graduate School of Medicine, Tsu, Japan
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Omoto K, Nakagawa I, Nishimura F, Yamada S, Motoyama Y, Nakase H. Computed tomography perfusion imaging after aneurysmal subarachnoid hemorrhage can detect cerebral vasospasm and predict delayed cerebral ischemia after endovascular treatment. Surg Neurol Int 2020; 11:233. [PMID: 32874736 PMCID: PMC7451166 DOI: 10.25259/sni_14_2020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
Background Endovascular treatment (ET) can improve angiographic cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage, but was unrelated to clinical outcomes in previous analyses. Appropriate detection of CV and precise indications for ET are required. This study investigated whether changes in computed tomography perfusion (CTP) parameter can determine indications for ET in CV and predict its effectiveness. Methods Participants comprised 140 patients who underwent neck clipping or coil embolization. CTP was performed a week after aneurysmal treatment or when clinical deterioration had occurred. Patients were divided into ET and non-ET groups by propensity score matching. In addition, the ET group was divided into subgroups with and without new cerebral infarction (CI). All CTP images in the three groups were retrospectively investigated qualitatively and quantitatively. CI was diagnosed from CT at 3 months postoperatively. Results Of the 121 patients examined, 15 patients (11%) needed ET. In qualitative analysis, all ET group patients displayed extension of time-to-peak (TTP) at the region of vasospastic change, regardless of the presence of CI. Quantitative analysis showed significant decreases in cerebral blood volume (P < 0.01), cerebral blood flow (CBF) (P < 0.001), and extension in TTP (P < 0.01) in the ET group compared with the non-ET group. A significant decrease in CBF (P < 0.001) and extension in mean transit time (P < 0.001) was seen in the ET with CI subgroup compared with the ET without CI subgroup. Conclusion CTP in the vasospastic period may be an indication for ET and predict the effectiveness of ET for CV to improve clinical outcomes.
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Affiliation(s)
- Koji Omoto
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Ichiro Nakagawa
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Fumihiko Nishimura
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Shuichi Yamada
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Yasushi Motoyama
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
| | - Hiroyuki Nakase
- Department of Neurosurgery, Nara Medical University, Kashihara, Nara Prefecture, Japan
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Beynon C, Bernhard M, Brenner T, Dietrich M, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus on neurosurgery : Intensive care studies from 2018-2019]. Anaesthesist 2020; 69:205-210. [PMID: 31440787 DOI: 10.1007/s00101-019-00644-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - D Michalski
- Neurologische Intensivstation und Stroke Unit, Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig AöR, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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Ojha M, Finnis ME, Heckelmann M, Raith EP, Moodie S, Chapman MJ, Reddi B, Maiden MJ. Outcomes following grade V subarachnoid haemorrhage: A single-centre retrospective study. Anaesth Intensive Care 2020; 48:289-296. [PMID: 32659113 DOI: 10.1177/0310057x20927033] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
SummaryGrade V subarachnoid haemorrhage is associated with high mortality and morbidity, yet there are few contemporary reports on the treatment provided and outcomes of these patients. In this single-centre retrospective cohort study, we primarily sought to determine the 12-month mortality of patients admitted to the Royal Adelaide Hospital intensive care unit between 2006 and 2016 with grade V subarachnoid haemorrhage. Secondary objectives were to describe treatments provided, patient destination following hospital discharge, organ donation and hospital financial costs. Over the 11-year study period, there were 139 patients admitted with grade V subarachnoid haemorrhage. The annual number of admissions did not change over time. The median age was 56 (interquartile range 48-70) years, 88 (63%) were female and 77 (55%) had a procedure to isolate an aneurysm. There were 77 (55%) patients who died in the intensive care unit, 87 (63%) died in hospital and 89 (64%) had died at 12 months. Of the 52 patients who survived to hospital discharge, 33 (63%) were transferred to a rehabilitation facility, 17 (33%) to another acute care hospital and two (4%) were discharged. Of the 87 patients who died in hospital, 45 (52%) donated organs. The total hospital cost of managing this cohort was A$8.3 million, with a median cost of A$41,824 (interquartile range A$9,933-A$97,332) per patient. Grade V subarachnoid haemorrhage has a high mortality rate, with one-third of patients alive after one year.
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Affiliation(s)
- Minny Ojha
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia
| | - Mark E Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Michael Heckelmann
- Department of Neurosurgery, Royal Adelaide Hospital, Adelaide, Australia
| | - Eamon P Raith
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Stewart Moodie
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Donate Life SA, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia
| | - Matthew J Maiden
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care Unit, Barwon Health, Geelong, Australia
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Low total cholesterol and high density lipoprotein are independent predictors of poor outcomes following aneurysmal subarachnoid hemorrhage: A preliminary report. Clin Neurol Neurosurg 2020; 197:106062. [PMID: 32688095 DOI: 10.1016/j.clineuro.2020.106062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is devastating, with delayed cerebral ischemia (DCI) significantly contributing to the high morbidity and mortality rates. Cholesterol has been studied as a measure of nutritional status in other neurological pathologies, but reports examining cholesterol's effects on aSAH outcomes are sparse. This study aimed to elucidate the effect of low total cholesterol (TC) and high density lipoprotein (HDL) on mortality and DCI following aSAH. METHODS We performed a retrospective cohort study at a quaternary academic medical center between June 2014 and July 2018. All patients had aSAH confirmed by digital subtraction angiography and had TC measured on admission. Primary outcomes were mortality and DCI. Secondary outcome was radiographic vasospasm. Univariate and multivariate logistic regressions were performed. RESULTS There were 75 aSAH patients, with an average age of 58.7 ± 1.7 (range: 14-89) and Hunt & Hess score of 2.8 ± 0.1, included for analysis. Those with a low TC < 160 mg/dL had 3 times increased odds of DCI (OR = 3.4; 95 %CI: 1.3-9.0; p = 0.0175) and a nearly 5 times increased odds of death (OR = 4.9; 95 %CI: 1.1-18.3; p = 0.0339). Low HDL < 40 mg/dL was associated with 12 times increased odds of DCI (OR = 12.3; 95 %CI: 2.7-56.4; p = 0.0003) but no significant differences in death (p = 0.2205). In multivariate analysis, low TC was an independent risk factor for increased mortality (OR = 5.6; 95 %CI: 1.2-27.6; p = 0.0335) while low HDL was associated with increased risk for DCI (OR = 17.9; 95 %CI: 3.1-104.4; p = 0.0013). There was no effect of TC or HDL on radiographic vasospasm. CONCLUSIONS Low TC and HDL are independent predictors of increased mortality and DCI, respectively, following aSAH. Low TC and HDL may be markers of poor overall health, in addition to having some pathophysiological effect on cerebral vasculature. These results may have practical implications for the improvement of aSAH prognostication and management.
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Effect of treatment modality and cerebral vasospasm agent on patient outcomes after aneurysmal subarachnoid hemorrhage in the elderly aged 75 years and older. PLoS One 2020; 15:e0230953. [PMID: 32271814 PMCID: PMC7145106 DOI: 10.1371/journal.pone.0230953] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Accepted: 03/11/2020] [Indexed: 12/14/2022] Open
Abstract
Objective We sought to examine whether the effect of treatment modality and drugs for cerebral vasospasm on clinical outcomes differs between elderly and non-elderly subarachnoid hemorrhage (SAH) patients in Japan. Methods We analyzed the J-ASPECT Study Diagnosis Procedure Combination database (n = 17,343) that underwent clipping or coiling between 2010 and 2014 in 579 hospitals. We stratified patients into two groups according to their age (elderly [≥75 years old], n = 3,885; non-elderly, n = 13,458). We analyzed the effect of treatment modality and anti-vasospasm agents (fasudil hydrochloride, ozagrel sodium, cilostazol, statin, eicosapentaenoic acid [EPA], and edaravone) on in-hospital poor outcomes (mRS 3–6 at discharge) and mortality using multivariable analysis. Results The elderly patients were more likely to be female, have impaired levels of consciousness and comorbidity, and less likely to be treated with clipping and anti-vasospasm agents, except for ozagrel sodium and statin. In-hospital mortality and poor outcomes were higher in the elderly (15.8% vs. 8.5%, 71.7% vs. 36.5%). Coiling was associated with higher mortality (odds ratio 1.43, 95% confidence interval 1.2–1.7) despite a lower proportion of poor outcomes (0.84, 0.75–0.94) in the non-elderly, in contrast to no effect on clinical outcomes in the elderly. A comparable effect of anti-vasospasm agents on mortality was observed between non-elderly and elderly for fasudil hydrochloride (non-elderly: 0.20, 0.17–0.24), statin (0.63, 0.50–0.79), ozagrel sodium (0.72, 0.60–0.86), and cilostazol (0.63, 0.51–0.77). Poor outcomes were inversely associated with fasudil hydrochloride (0.59, 0.51–0.68), statin (0.84, 0.75–0.94), and EPA (0.83, 0.72–0.94) use in the non-elderly. No effect of these agents on poor outcomes was observed in the elderly. Conclusions In contrast to the non-elderly, no effect of treatment modality on clinical outcomes were observed in the elderly. A comparable effect of anti-vasospasm agents was observed on mortality, but not on functional outcomes, between the non-elderly and elderly.
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Lee S, Kim YO, Ryu JA. Clinical usefulness of early serial measurements of C-reactive protein as outcome predictors in patients with subarachnoid hemorrhage. BMC Neurol 2020; 20:112. [PMID: 32220241 PMCID: PMC7099821 DOI: 10.1186/s12883-020-01687-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 03/16/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the role of C-reactive protein (CRP) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). METHODS In this retrospective, observational study of adult patients with SAH treated between January 2012 and June 2017. Initial CRP levels collected within 24 h from the onset of SAH, the follow-up CRP levels were measured. The primary outcome was neurological status at six-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). RESULTS Among 156 patients with SAH, 145 (92.9%) survived until discharge. Of these survivors, 109 (69.9%) manifested favorable neurological outcomes (GOS of 4 or 5). Initial CRP levels on admission and maximal CRP levels within four days were significantly higher in the group with poor neurological outcome compared with those manifesting favorable neurological outcomes (P = 0.022, P < 0.001, respectively). However, the clearance of CRPs did not differ significantly between the two groups (P = 0.785). Analysis of the receiver operating characteristic curve for prediction of poor neurological outcome showed that the performance of the maximal CRP was significantly better compared with the initial CRP or the clearance of CRP (P = 0.007, P < 0.001, respectively). In this study, the effect of CRP on neurological outcomes differed according to surgical clipping. The maximal CRP levels within four days facilitate the prediction of neurological outcomes of SAH patients without surgical clipping (C-statistic: 0.856, 95% confidence interval [CI]: 0.767-0.921). However, they were poorly associated with neurological prognoses in SAH patients who underwent surgical clipping (C-statistic: 0.562, 95% CI: 0.399-0.716). Multivariable logistic regression analysis revealed that age (adjusted odds ratio [OR]: 1.10, 95% CI: 1.052-1.158), initial Glasgow Coma Scale (adjusted OR: 0.74, 95% CI: 0.647-0.837), and maximal CRP without surgical clipping (adjusted OR: 1.27, 95% CI: 1.066-1.516) were significantly associated with poor neurological outcomes in SAH patients. CONCLUSIONS Early serial measurements of CRP may be used to predict neurological outcomes of SAH patients. Furthermore, maximal CRP levels within four days post-SAH are significantly correlated with poor neurological outcomes.
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Affiliation(s)
- Sangkil Lee
- Department of Neurology, ChungBuk National University Hospital, Cheongju, Republic of Korea
| | - Yong Oh Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Eibach M, Won SY, Bruder M, Keil F, Herrmann E, Berkefeld J, Seifert V, Konczalla J. Age dependency and modification of the Subarachnoid Hemorrhage Early Brain Edema Score. J Neurosurg 2020; 134:946-952. [PMID: 32197254 DOI: 10.3171/2019.12.jns192744] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 12/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) system measures cerebral edema on CT and can be used to predict outcome after subarachnoid hemorrhage (SAH). The authors developed a modified SEBES (SEBES 6c) and assessed whether it could predict outcome after SAH better than the SEBES. Furthermore, they verified the age dependency of these scores. METHODS In this retrospective study, all patients with aneurysmal SAH in the period from January 2011 to February 2017 at a single institution were analyzed. The SEBES, which is based on the absence of visible sulci at two defined CT levels (0-4 points), and the SEBES 6c were determined from the initial CT. The SEBES 6c system includes the two levels from the original SEBES and one level located 2 cm below the vertex (0-6 points). The authors investigated whether the various SEBESs are age dependent and if they can predict delayed infarction (DI) and outcome. RESULTS Two hundred sixty-one patients met the study inclusion criteria. The SEBES was an independent predictor for DI (OR 1.6 per 1-point increase) and unfavorable outcome (OR 1.36 per 1-point increase), in accordance with findings in the first publication on SEBES. However, here the authors found that the SEBES was age dependent. In the age group younger than 60 years, the patients with high-grade SEBESs (3-4 points) had DIs and unfavorable outcomes significantly more often than the patients with low-grade scores (0-2 points). In the age groups 60-69 years and ≥ 70 years, no significant differences in DI and outcome were identified between high-grade and low-grade scores, although trends toward DI and unfavorable outcomes among the 60-69 age group were noted in patients with high-grade SEBESs.Receiver operating characteristic curve analysis showed that SEBES 6c had a higher prognostic value in predicting outcome than SEBES (p < 0.001). Furthermore, SEBES 6c predicted an unfavorable outcome (OR 1.31 per 1-point increase) and DI (OR 1.36 per 1-point increase) independent of vasospasms. SEBES 6c showed an age dependency similar to that of SEBES. CONCLUSIONS SEBES 6c is more suitable for predicting outcome after SAH than SEBES. Furthermore, it predicts outcome and DI independently of vasospasm, so it can be used to differentiate between early brain injury- and vasospasm-dependent infarctions and outcome. However, SEBES and SEBES 6c are both age dependent and can be used for patients aged < 60 years and may have limited suitability for patients aged 60-69 years and no suitability for patients aged ≥ 70 years.
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Affiliation(s)
- Michael Eibach
- 1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University
| | - Sae-Yeon Won
- 1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University
| | - Markus Bruder
- 1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University
| | - Fee Keil
- 2Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University; and
| | - Eva Herrmann
- 3Institute of Biostatistics and Mathematical Modelling, Goethe-University, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- 2Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University; and
| | - Volker Seifert
- 1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University
| | - Juergen Konczalla
- 1Department of Neurosurgery, University Hospital Frankfurt, Goethe-University
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Survival and outcome in patients with aneurysmal subarachnoid hemorrhage in Glasgow coma score 3-5. Acta Neurochir (Wien) 2020; 162:533-544. [PMID: 31980948 DOI: 10.1007/s00701-019-04190-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Accepted: 12/19/2019] [Indexed: 12/30/2022]
Abstract
BACKGROUND Outcome of early, aggressive management of aneurysmal subarachnoid hemorrhage (aSAH) in patients with Hunt and Hess grade V is hitherto limited, and we therefore present our results. METHODS Retrospective study analyzing the medical data of 228 aSAH patients in Glasgow Coma Score 3-5 admitted to our hospital during the years 2002-2012. Background and treatment variables were registered. Outcome was evaluated after 3 and 12 months. RESULTS We intended to treat 176 (77.2%) patients, but only 146 went on to aneurysm repair. Of 52 patients managed conservatively, 27 had abolished cerebral circulation around arrival and 25 were deemed unsalvageable. One-year overall mortality was 65.8% and most (84.7%) of the fatalities occurred within 30 days. One-year mortality was higher in patients > 70 years. Without aneurysm repair, mortality was 100%. After 1 year, 21.9% of all patients lived independently and 4.8% lived permanently in an institution. Outcome in the 78 survivors (34.2%) was favorable in 64.1% in terms of modified Rankin Scale score 0-2, and 85.9% of survivors were able to live at home. Return to work was low for all 228 patients with 14.0% of those employed prior to the hemorrhage having returned to paid work, and respectively, 26.3% in the subgroup of survivors. CONCLUSIONS Even with aggressive, early treatment, 1-year mortality is high in comatose aSAH patients with 65.8%. A substantial portion of the survivors have a favorable outcome at 1 year (64.1%, corresponding to 21.9% of all patients admitted) and 85.9% of the survivors could live at home alone or aided.
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Cerebral Edema After Cardiopulmonary Resuscitation: A Therapeutic Target Following Cardiac Arrest? Neurocrit Care 2019; 28:276-287. [PMID: 29080068 DOI: 10.1007/s12028-017-0474-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
We sought to review the role that cerebral edema plays in neurologic outcome following cardiac arrest, to understand whether cerebral edema might be an appropriate therapeutic target for neuroprotection in patients who survive cardiopulmonary resuscitation. Articles indexed in PubMed and written in English. Following cardiac arrest, cerebral edema is a cardinal feature of brain injury and is a powerful prognosticator of neurologic outcome. Like other conditions characterized by cerebral ischemia/reperfusion, neuroprotection after cardiac arrest has proven to be difficult to achieve. Neuroprotection after cardiac arrest generally has focused on protecting neurons, not the microvascular endothelium or blood-brain barrier. Limited preclinical data suggest that strategies to reduce cerebral edema may improve neurologic outcome. Ongoing research will be necessary to determine whether targeting cerebral edema will improve patient outcomes after cardiac arrest.
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Predictors for Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage Who Completed In-Hospital Rehabilitation in a Single Institution. J Stroke Cerebrovasc Dis 2019; 28:1943-1950. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.03.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 02/21/2019] [Accepted: 03/16/2019] [Indexed: 11/24/2022] Open
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Hemorrhagic burden in poor-grade aneurysmal subarachnoid hemorrhage: a volumetric analysis of different bleeding distributions. Acta Neurochir (Wien) 2019; 161:791-797. [PMID: 30790092 DOI: 10.1007/s00701-019-03846-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Accepted: 02/12/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Volumetric assessment of aneurysmal bleeding has been evaluated in few studies and emerged as a promising outcome predictor. There is a lack of studies evaluating its impact in the poor-grade population. METHODS Retrospective review of 63 consecutive poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients, defined as grade IV and V according to the World Federation of Neurological Surgeons (WFNS) classifications. Global intracranial bleeding volume was calculated with its subarachnoid, intracerebral (ICH), and intraventricular (IVH) portions by means of analytical software. Univariate and multivariate analyses were performed in order to identify independent predictors of outcome. Good outcome was defined as modified Rankin Scale (mRS) 0-2 and mortality as mRS 6. The cutoff values of bleeding volumes were derived by receiver operating curve (ROC) analysis. RESULTS Mean follow-up was of 12.5 (± 1.5) months. Thirty (47.7%) patients achieved good outcome, whereas 19 (30.2) patients out of 63 died. Global intracranial bleeding resulted as an independent predictor of good outcome (cutoff 24 mL). Furthermore, ICH relative percentage of global volume (10% of total) and pure SAH (64% of total) emerged respectively as independent predictors of worsened and improved outcome. Global bleeding volume (cutoff 51 mL) along with global cerebral edema showed to independently predict mortality in the examined poor-grade aSAH population. CONCLUSIONS Volumetric assessment of aneurysmal bleeding has the potential for identifying cutoff values that independently predict outcome. Further insights into the relative importance of different bleeding volumes may be implicated in better tailoring the management of this dismal aSAH population.
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Lee S, Kim YO, Baek JS, Ryu JA. The prognostic value of optic nerve sheath diameter in patients with subarachnoid hemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:65. [PMID: 30808383 PMCID: PMC6390328 DOI: 10.1186/s13054-019-2360-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/14/2019] [Indexed: 11/10/2022]
Abstract
BACKGROUND We evaluated the role of optic nerve sheath diameter (ONSD) using brain computed tomography (CT) in predicting neurological outcomes of patients with subarachnoid hemorrhage (SAH). METHODS This was a retrospective, multicenter, observational study of adult patients with SAH admitted between January 2012 and June 2017. Initial brain CT was performed within 12 h from onset of SAH, and follow-up brain CT was performed within 24 h from treatment of a ruptured aneurysm. Primary outcome was neurological status at 6-month follow-up assessed with the Glasgow Outcome Scale (GOS, 1 to 5). RESULTS Among 223 SAH patients, 202 (90.6%) survived until discharge. Of these survivors, 186 (83.4%) manifested favorable neurological outcomes (GOS of 3, 4, or 5). In this study, the ONSDs in the group of patients with poor neurological outcome were significantly greater than those in the favorable neurological outcome group (all p < 0.01). Intracranial pressure (ICP) was monitored in 21 (9.4%) patients during the follow-up CT. A linear correlation existed between the average ONSD and ICP in simple correlation analysis (r = 0.525, p = 0.036). Analysis of the receiver operating characteristic curve for prediction of poor neurological outcome showed that ONSD had considerable predictive value (C-statistics, 0.735 to 0.812). In addition, the performance of a composite of Hunt and Hess grade and ONSD was increasingly associated with poor neurological outcomes than the use of each marker alone. CONCLUSIONS ONSD measured with CT may be used in combination with clinical grading scales to improve prognostic accuracy in SAH patients.
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Affiliation(s)
- Sangkil Lee
- Department of Neurology, ChungBuk National University Hospital, Cheongju, Republic of Korea
| | - Yong Oh Kim
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Ji Sun Baek
- Department of Ophthalmology, Konyang University, Kim's Eye Hospital, Myung-Gok Eye Research Institute, Seoul, Republic of Korea
| | - Jeong-Am Ryu
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Department of Neurosurgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Combined surgery and embolization to treat ruptured cerebral aneurysms with cerebral hematoma and intracranial hypertension: A retrospective analysis and review of the literature. RADIOLOGIA 2019. [DOI: 10.1016/j.rxeng.2018.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tratamiento combinado, mediante embolización y cirugía, de los aneurismas cerebrales rotos con hematoma cerebral e hipertensión intracraneal: Análisis retrospectivo y revisión de la bibliografía. RADIOLOGIA 2019; 61:42-50. [DOI: 10.1016/j.rx.2018.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2018] [Revised: 07/30/2018] [Accepted: 09/18/2018] [Indexed: 11/21/2022]
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Identification of potential organ donors after aneurysmal subarachnoid hemorrhage in a population-based neurointensive care in Eastern Finland. Acta Neurochir (Wien) 2018; 160:1507-1514. [PMID: 29946966 PMCID: PMC6060906 DOI: 10.1007/s00701-018-3600-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 06/14/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND To analyze the organ donation action in population-based neurointensive care of acute aneurysmal subarachnoid hemorrhage (aSAH) and to seek factors that would improve the identification of potential organ donors (PODs) and increase the donor conversion rate (DCR) after aSAH. METHODS The Kuopio Intracranial Aneurysm Database, prospective since 1995, includes all aSAH patients admitted to the Kuopio University Hospital (KUH) from its defined Eastern Finnish catchment population. We analyzed 769 consecutive acute aSAH patients from 2005 to 2015, including their data from the Finnish Transplantation Unit and the national clinical registries. We analyzed PODs vs. actual donors among the 145 (19%) aSAH patients who died within 14 days of admission. Finland had implemented the national presumed consent (opt-out) within the study period in the end of 2010. RESULTS We retrospectively identified 83 (57%) PODs while only 49 (34%) had become actual donors (total DCR 59%); the causes for non-donorship were 15/34 (44%) refusals of consent, 18/34 (53%) medical contraindications for donation, and 1/34 (3%) failure of recognition. In 2005-2010, there were 11 refusals by near relatives with DCR 52% (29/56) and only three in 2011-2015 with DCR 74% (20/27). Severe condition on admission (Hunt and Hess grade IV or V) independently associated with the eventual POD status. CONCLUSIONS Nearly 20% of all aSAH patients acutely admitted to neurointensive care from a defined catchment population died within 14 days, almost half from cardiopulmonary causes at a median age of 69 years. Of all aSAH patients, 11% were considered as potential organ donors (PODs). Donor conversion rate (DCR) was increased from 52 to 74% after the national presumed consent (opt-out). Implicitly, DCR among aSAH patients could be increased by admitting them to the intensive care regardless of dismal prognosis for the survival, along a dedicated organ donation program for the catchment population.
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Suzuki H, Nakatsuka Y, Yasuda R, Shiba M, Miura Y, Terashima M, Suzuki Y, Hakozaki K, Goto F, Toma N. Dose-Dependent Inhibitory Effects of Cilostazol on Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Transl Stroke Res 2018; 10:381-388. [PMID: 30033486 DOI: 10.1007/s12975-018-0650-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 06/24/2018] [Accepted: 07/16/2018] [Indexed: 12/22/2022]
Abstract
Cilostazol is a selective inhibitor of phosphodiesterase type III that downregulates tenascin-C (TNC), a matricellular protein, which may cause delayed cerebral infarction after aneurysmal subarachnoid hemorrhage (SAH). The authors increased the dosage and evaluated the dose-dependent effects of cilostazol on delayed cerebral infarction and outcomes in SAH patients. This was a retrospective cohort study in a single center. One hundred fifty-six consecutive SAH patients including 67 patients of admission World Federation of Neurological Surgeons grades IV-V who underwent aneurysmal obliteration within 48 h post-SAH from 2007 to 2017 were analyzed. Cilostazol (0 to 300 mg/day) was administered from 1-day post-clipping or post-coiling to day 14 or later. Cilostazol treatment dose-dependently decreased delayed cerebral infarction and tended to improve outcomes, although cilostazol did not affect other outcome measures including angiographic vasospasm. On multivariate analyses, 300 mg/day (100 mg three times) cilostazol independently decreased delayed cerebral infarction and improved 3-month outcomes, but other regimens including 200 mg/day (100 mg twice) cilostazol were not independent prognostic factors. Propensity score-matched analyses showed that the 300 mg/day cilostazol cohort had lower plasma TNC levels and a lower incidence of delayed cerebral infarction associated with better outcomes compared with the non-cilostazol cohort. The 300 mg/day cilostazol may improve post-SAH outcomes by reducing plasma TNC levels and delayed cerebral infarction, but not vasospasm. Further studies are warranted to investigate if 300 mg/day cilostazol is more beneficial to post-SAH outcomes than a usual dose of 200 mg/day cilostazol that was demonstrated to be effective in randomized controlled trials.
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Affiliation(s)
- Hidenori Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan.
| | - Yoshinari Nakatsuka
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Ryuta Yasuda
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Masato Shiba
- Center for Vessels and Heart, Mie University Hospital, Tsu, Japan
| | - Yoichi Miura
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Mio Terashima
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Yume Suzuki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Koichi Hakozaki
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Fuki Goto
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
| | - Naoki Toma
- Department of Neurosurgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie, 514-8507, Japan
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Li K, Guo Y, Zhao Y, Xu B, Xu K, Yu J. Acute rerupture after coil embolization of ruptured intracranial saccular aneurysms: A literature review. Interv Neuroradiol 2017; 24:117-124. [PMID: 29231793 DOI: 10.1177/1591019917747245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Acute rerupture after coil embolization is defined as rerupture within three days after treatment; its prognosis is worse than that of rebleeding at other time periods. However, to date, little is known about complications during the acute phase. Therefore, we used the PubMed database to perform a review of acute rerupture after coil embolization of ruptured intracranial saccular aneurysms and increase our understanding. After reviewing the complications, we found that the cause of acute rerupture is unclear, but the following risk factors are involved: incomplete occlusion of the initial aneurysm, the presence of a hematoma adjacent to a ruptured aneurysm, an aneurysmal outpouching, poor Hunt-Hess grade at the time of treatment, and the location of the aneurysm in an anterior communicating artery. In addition, intraoperative rupture is a non-negligible cause. Acute rerupture after coil embolization mainly occurs within the first 24 hours after the procedure. Brain computed tomography is the gold standard for diagnosing acute rebleeding of a coiled aneurysm. For acute rerupture after coil embolization, prevention is critical, and complete occlusion of the aneurysm in the first session is the best protection against acute rebleeding. In addition, a restricted postembolization anticoagulation strategy is recommended for patients with high-risk aneurysms. For patients with an adjacent hematoma, surgical clipping is recommended. Most patients present no changes immediately after acute rebleeding because of their poor condition. However, surgical or endovascular treatments can be attempted if the patient is in an acceptable condition. Even so, the outcomes are typically unsatisfactory.
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Affiliation(s)
- Kailing Li
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Yunbao Guo
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Ying Zhao
- 2 Department of Training, The First Hospital of Jilin University, Changchun, China
| | - Baofeng Xu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Kan Xu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jinlu Yu
- 1 Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Konczalla J, Kashefiolasl S, Brawanski N, Bruder M, Gessler F, Senft C, Berkefeld J, Seifert V, Tritt S. Cerebral Vasospasm-Dependent and Cerebral Vasospasm-Independent Cerebral Infarctions Predict Outcome After Nonaneurysmal Subarachnoid Hemorrhage: A Single-Center Series with 250 Patients. World Neurosurg 2017; 106:861-869.e4. [PMID: 28711533 DOI: 10.1016/j.wneu.2017.07.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 06/30/2017] [Accepted: 07/03/2017] [Indexed: 12/28/2022]
Abstract
OBJECTIVE The number of patients with nonaneurysmal subarachnoid hemorrhage (naSAH) has increased during the last decade. Data regarding infarctions in naSAH are still limited. The aim of this study was to identify the rate of cerebral vasospasm (CVS)-dependent and CVS-independent infarctions and their influence on clinical outcomes. METHODS Between 1999 and 2015, 250 patients suffering from naSAH were analyzed retrospectively. A delayed infarction was analyzed whether it was associated with CVS (CVS-dependent infarction) or not (CVS-independent). RESULTS A total of 36 patients (14%) had cerebral infarctions. CVS was detected in 54 patients (22%), and 15 (6%) of them developed infarctions (CVS-dependent). Infarctions without signs of CVS (CVS-independent) occurred in 21 patients (8%). Overall, 86% of the patients had favorable outcome. Patients without cerebral infarctions had the best outcome (91% favorable outcome, 5% mortality rate). Patients with CVS-independent infarctions (57%) as well as patients with CVS-dependent infarctions (53%) had a favorable outcome less often. The mortality rate was also significantly greater in patients with CVS-independent (19%) and CVS-dependent infarctions (33%). A further independent predictor was anticoagulative therapy, which increased during study period and was associated with nonperimesencephalic blood distribution. CONCLUSIONS CVS-dependent and independent infarctions occur in naSAH and contribute to unfavorable outcomes. Whereas CVS-independent infarctions occur in any subgroup, CVS-dependent infarctions seem to be associated with blood pattern (Fisher 3). Anticoagulative therapy seems to be not only a predictor for worse outcome but also for nonperimesencephalic SAH. Accordingly, the proportion of perimesencephalic and nonperimesencephalic SAH changed during the study period (from 2.2:1 to 1:1.7).
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany.
| | - Sepide Kashefiolasl
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Stephanie Tritt
- Institute of Neuroradiology, Goethe-University Hospital, Frankfurt am Main, Germany
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