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Rao D, Yang L, Enxi X, Siyuan L, Yu Q, Zheng L, Zhou Z, Yerong C, Bo C, Xiuhong S, Eryi S. A predictive model in patients with chronic hydrocephalus following aneurysmal subarachnoid hemorrhage: a retrospective cohort study. Front Neurol 2024; 15:1366306. [PMID: 38817542 PMCID: PMC11137279 DOI: 10.3389/fneur.2024.1366306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 05/07/2024] [Indexed: 06/01/2024] Open
Abstract
Objective Our aim was to develop a nomogram that integrates clinical and radiological data obtained from computed tomography (CT) scans, enabling the prediction of chronic hydrocephalus in patients with aneurysmal subarachnoid hemorrhage (aSAH). Method A total of 318 patients diagnosed with subarachnoid hemorrhage (SAH) and admitted to the Department of Neurosurgery at the Affiliated People's Hospital of Jiangsu University between January 2020 and December 2022 were enrolled in our study. We collected clinical characteristics from the hospital's medical record system. To identify risk factors associated with chronic hydrocephalus, we conducted both univariate and LASSO regression models on these clinical characteristics and radiological features, accompanied with penalty parameter adjustments conducted through tenfold cross-validation. All features were then incorporated into multivariate logistic regression analyses. Based on these findings, we developed a clinical-radiological nomogram. To evaluate its discrimination performance, we conducted Receiver Operating Characteristic (ROC) curve analysis and calculated the Area Under the Curve (AUC). Additionally, we employed calibration curves, and utilized Brier scores as an indicator of concordance. Additionally, Decision Curve Analysis (DCA) was performed to determine the clinical utility of our models by estimating net benefits at various threshold probabilities for both training and testing groups. Results The study included 181 patients, with a determined chronic hydrocephalus prevalence of 17.7%. Univariate logistic regression analysis identified 11 potential risk factors, while LASSO regression identified 7 significant risk factors associated with chronic hydrocephalus. Multivariate logistic regression analysis revealed three independent predictors for chronic hydrocephalus following aSAH: Periventricular white matter changes, External lumbar drainage, and Modified Fisher Grade. A nomogram incorporating these factors accurately predicted the risk of chronic hydrocephalus in both the training and testing cohorts. The AUC values were calculated as 0.810 and 0.811 for each cohort respectively, indicating good discriminative ability of the nomogram model. Calibration curves along with Hosmer-Lemeshow tests demonstrated excellent agreement between predicted probabilities and observed outcomes in both cohorts. Furthermore, Brier scores (0.127 for the training and 0.09 for testing groups) further validated the predictive performance of our nomogram model. The DCA confirmed that this nomogram provides superior net benefit across various risk thresholds when predicting chronic hydrocephalus. The decision curve demonstrated that when an individual's threshold probability ranged from 5 to 62%, this model is more effective in predicting the occurrence of chronic hydrocephalus after aSAH. Conclusion A clinical-radiological nomogram was developed to combine clinical characteristics and radiological features from CT scans, aiming to enhance the accuracy of predicting chronic hydrocephalus in patients with aSAH. This innovative nomogram shows promising potential in assisting clinicians to create personalized and optimal treatment plans by providing precise predictions of chronic hydrocephalus among aSAH patients.
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Affiliation(s)
- Dai Rao
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Li Yang
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Xu Enxi
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Lu Siyuan
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Qian Yu
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Li Zheng
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Zhou Zhou
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chen Yerong
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Chen Bo
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Shan Xiuhong
- Department of Radiology, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
| | - Sun Eryi
- Department of Neurosurgery, Affiliated People’s Hospital of Jiangsu University, Zhenjiang, Jiangsu, China
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Dissanayake AS, Burrows E, Ho KM, Phillips TJ, Honeybul S, Hankey GJ. Rebleeding following aneurysmal subarachnoid hemorrhage before 'endovascular first' treatment: a retrospective case-control study of published scoring systems. J Neurointerv Surg 2024; 16:498-505. [PMID: 37316197 DOI: 10.1136/jnis-2023-020390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Pre-treatment re-bleeding following aneurysmal subarachnoid hemorrhage (aSAH) affects up to 7.2% of patients even with ultra-early treatment within 24 hours. We retrospectively compared the utility of three published re-bleed prediction models and individual predictors between cases who re-bled matched to controls using size and parent vessel location from a cohort of patients treated in an ultra-early, 'endovascular first' manner. METHODS On retrospective analysis of our 9-year cohort of 707 patients suffering 710 episodes of aSAH, there were 53 episodes of pre-treatment re-bleeding (7.5%). Forty-seven cases who had a single culprit aneurysm were matched to 141 controls. Demographic, clinical and radiological data were extracted and predictive scores calculated. Univariate, multivariate, area under the receiver operator characteristic curve (AUROCC) and Kaplan-Meier (KM) survival curve analyses were performed. RESULTS The majority of patients (84%) were treated using endovascular techniques at a median 14.5 hours post-diagnosis. On AUROCC analysis the score of Liu et al. had minimal utility (C-statistic 0.553, 95% confidence interval (CI) 0.463 to 0.643) while the risk score of Oppong et al. (C-statistic 0.645 95% CI 0.558 to 0.732) and the ARISE-extended score of van Lieshout et al. (C-statistic 0.53 95% CI 0.562 to 0.744) had moderate utility. On multivariate modeling, the World Federation of Neurosurgical Societies (WFNS) grade was the most parsimonious predictor of re-bleeding (C-statistic 0.740, 95% CI 0.664 to 0.816). CONCLUSIONS For aSAH patients treated in an ultra-early timeframe matched on size and parent vessel location, WFNS grade was superior to three published models for re-bleed prediction. Future re-bleed prediction models should incorporate the WFNS grade.
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Affiliation(s)
- Arosha S Dissanayake
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Emalee Burrows
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Kwok M Ho
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Timothy J Phillips
- Neurological Intervention and Imaging Service of Western Australia, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
| | - Stephen Honeybul
- Department of Neurosurgery, Sir Charles Gairdner Hospital, Nedlands, Perth, Western Australia, Australia
| | - Graeme J Hankey
- School of Medicine, The University of Western Australia, Perth, Western Australia, Australia
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Panni P, Riccio L, Cao R, Pedicelli A, Marchese E, Caricato A, Feletti A, Testa M, Zanatta P, Gitti N, Piva S, Mardighian D, Semeraro V, Nardin G, Lozupone E, Paiano G, Picetti E, Montanaro V, Petranca M, Bortolotti C, Scibilia A, Cirillo L, Lanterna AL, Ambrosi A, Mortini P, Beretta L, Falini A. Clinical Impact and Predictors of Aneurysmal Rebleeding in Poor-Grade Subarachnoid Hemorrhage: Results From the National POGASH Registry. Neurosurgery 2023; 93:636-645. [PMID: 37010298 DOI: 10.1227/neu.0000000000002467] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 01/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Scarce data are available regarding rebleeding predictors in poor-grade aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVES To investigate predictors and clinical impact of rebleeding in a national multicentric poor-grade aSAH. METHODS Retrospective analysis of prospectively collected data from the multicentric Poor Grade Aneurysmal Subarachnoid Hemorrhage Study Group (POGASH) registry of consecutive patients treated from January 1, 2015, to June 30th, 2021. Grading was defined as pretreatment World Federation of Neurological Surgeons grading scale IV-V. Ultra-early vasospasm (UEV) was defined as luminal narrowing of intracranial arteries not due to intrinsic disease. Rebleeding was defined as clinical deterioration with evidence of increased hemorrhage on subsequent computed tomography scans, fresh blood from the external ventricular drain, or deterioration before neuroradiological evaluation. Outcome was assessed by the modified Rankin Scale. RESULTS Among 443 consecutive World Federation of Neurological Surgeons grades IV-V patients with aSAH treated within a median of 5 (IQR 4-9) hours since onset, rebleeding occurred in 78 (17.6%). UEV (adjusted odds ratio [OR] 6.8, 95% CI 3.2-14.4; P < .001) and presence of dissecting aneurysm (adjusted OR 3.5, 95% CI 1.3-9.3; P = .011) independently predicted rebleeding while history of hypertension (adjusted OR 0.4, 95% CI 0.2-0.8; P = .011) independently reduced its chances. 143 (32.3) patients died during hospitalization. Rebleeding emerged, among others, as an independent predictor of intrahospital mortality (adjusted OR 2.2, 95% CI 1.2-4.1; P = .009). CONCLUSION UEV and presence of dissecting aneurysms are the strongest predictors of aneurysmal rebleeding. Their presence should be carefully evaluated in the acute management of poor-grade aSAH.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Lucia Riccio
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Roberta Cao
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Pedicelli
- Institute of Radiological Sciences, Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Enrico Marchese
- Department of Neurosurgery Fondazione Policlinico Universitario A. Gemelli, IRCCS Catholic University of Rome, Rome, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care Medicine Fondazione Policlinico Universitario A.Gemelli IRCCS Catholic University of Rome, Rome, Italy
| | - Alberto Feletti
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mattia Testa
- Institute of Neurosurgery, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Paolo Zanatta
- Anesthesia and Intensive Care A, Integrated University Hospital, Verona, Italy
| | - Nicola Gitti
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Simone Piva
- Department of Anesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Dikran Mardighian
- Department of Neuroradiology Spedali Civili University Hospital, Brescia, Italy
| | | | - Giordano Nardin
- Department of Critical Care, SS Annunziata Hospital, Taranto, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, Lecce, Italy
| | - Giafranco Paiano
- Department of Anaesthesia and Critical Care, Vito-Fazzi Hospital, Lecce, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Vito Montanaro
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Massimo Petranca
- Department of Anesthesia and Intensive Care, Parma University Hospital, Italy
| | - Carlo Bortolotti
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Antonino Scibilia
- Department of Neurosurgery, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | - Luigi Cirillo
- Department of Neuroradiology, IRCCS Institute of Neurological Sciences "Bellaria", Bologna, Italy
| | | | | | - Pietro Mortini
- Department of Neurosurgery, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Luigi Beretta
- Department of Neurocritical Care San Raffaele University Hospital, Milan, Italy
| | - Andrea Falini
- Department of Neuroradiology, Interventional Neuroradiology Division, San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Vergouwen MDI, Rinkel GJE. Emergency Medical Management of Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:51-58. [PMID: 37344653 PMCID: PMC10499704 DOI: 10.1007/s12028-023-01757-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/08/2023] [Indexed: 06/23/2023]
Abstract
Aneurysmal subarachnoid hemorrhage is a medical emergency that necessitates direct transfer to a tertiary referral center specialized in the diagnosis and treatment of this condition. The initial hours after aneurysmal rupture are critical for patients with aneurysmal subarachnoid hemorrhage, both in terms of rebleeding and combating the effect of early brain injury. No good treatment options are available to reduce the risk of rebleeding before aneurysm occlusion. Lowering the blood pressure may reduce the risk of rebleeding but carries a risk of inducing delayed cerebral ischemia or aggravating the consequences of early brain injury. Early brain injury after aneurysmal rupture has an important effect on final clinical outcome. Proper cerebral perfusion is pivotal in these initial hours after aneurysmal rupture but threatened by complications such as neurogenic pulmonary edema and cardiac stunning, or by acute hydrocephalus, which may necessitate early drainage of cerebrospinal fluid.
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Affiliation(s)
- Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Yang C, Zhang Z, Liao R, Li Y. Relationship between preoperative external ventricular drainage and preoperative rebleeding in aneurysmal subarachnoid hemorrhage: A meta-analysis. Clin Neurol Neurosurg 2023; 224:107563. [PMID: 36580739 DOI: 10.1016/j.clineuro.2022.107563] [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: 11/04/2022] [Revised: 12/09/2022] [Accepted: 12/16/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To analyze published evidence on the relationship between preoperative external ventricular drainage (preop-EVD) and preoperative rebleeding (preop-rebleeding) in aneurysmal subarachnoid hemorrhage (aSAH). METHOD A comprehensive search of three databases (PubMed, Ovid EMBASE, and The Cochrane Library) was conducted from their commencement to March 31, 2022. We collected studies reporting preop-EVD of rupture aneurysms while preop-rebleeding events were documented in these studies. We also extracted information on risk factors for preop-rebleeding from the studies and used Review Manager version 5.3 software to analyze. RESULTS A total of 3671 cases from 14 articles were enrolled in this meta-analysis. Preop-rebleeding rate was 11.04 % (106/960) and 9.22 % (250/2711) in preop-EVD group and control group, respectively. The study lacked power to conclude a clinically significant increase in preop-rebleeding risk (OR=1.60, 95 %CI:0.82-3.22). Fisher> 2 (OR=1.86), modified Fisher> 2 (OR=7.57), World Federation of Neurological Surgeons (WFNS)> 2 (OR=4.39) and aneurysm size > 1 cm (OR=3.01) were risk factors of preop-rebleeding. Patients with Hunt-Hess (HH)> 2 showed a higher preop-rebleeding trend compared to HH≤ 2, but the result did not reach a statistical difference (OR=6.79, P = 0.06). No difference in preop-rebleeding risk between anterior circulation aneurysms and posterior circulation aneurysms. Hydrocephalus had also been shown to be unrelated to higher preop-rebleeding rate. CONCLUSIONS Current evidence does not support that preop-EVD significantly increases the risk of rebleeding prior to aneurysm repair. Patients with poorer clinical status on admission and aneurysms size > 1 cm are at a higher risk of preop-rebleeding.
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Affiliation(s)
- Cheng Yang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Zhulin Zhang
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Rongjie Liao
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
| | - Yuhong Li
- Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing 400038, China.
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Doherty RJ, Henry J, Brennan D, Javadpour M. Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:24. [PMID: 36562905 DOI: 10.1007/s10143-022-01930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding.
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Affiliation(s)
- Ronan J Doherty
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - Jack Henry
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - David Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Oxidative Stress and Intracranial Hypertension after Aneurysmal Subarachnoid Hemorrhage. Antioxidants (Basel) 2022; 11:antiox11122423. [PMID: 36552631 PMCID: PMC9774559 DOI: 10.3390/antiox11122423] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/25/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Intracranial hypertension is a common phenomenon in patients with aneurysmal subarachnoid hemorrhage (aSAH). Elevated intracranial pressure (ICP) plays an important role in early brain injuries and is associated with unfavorable outcomes. Despite advances in the management of aSAH, there is no consensus about the mechanisms involved in ICP increases after aSAH. Recently, a growing body of evidence suggests that oxidative stress (OS) may play a crucial role in physio-pathological changes following aSAH, which may also contribute to increased ICP. Herein, we discuss a potential relation between increased ICP and OS, and resultantly propose antioxidant mechanisms as a potential therapeutic strategy for the treatment of ICP elevation following aSAH.
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van Lieshout JH, Mijderwijk HJ, Nieboer D, Lingsma HF, Ahmadi SA, Karadag C, Muhammad S, Porčnik A, Wasilewski D, Wessels L, van Donkelaar CE, van Dijk JMC, Hänggi D, Boogaarts HD. Development and Internal Validation of the ARISE Prediction Models for Rebleeding After Aneurysmal Subarachnoid Hemorrhage. Neurosurgery 2022; 91:450-458. [PMID: 35881023 DOI: 10.1227/neu.0000000000002045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Accepted: 04/07/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Aneurysmal rerupture is one of the most important determents for outcome after aneurysmal subarachnoid hemorrhage and still occurs frequently because individual risk assessment is challenging given the heterogeneity in patient characteristics and aneurysm morphology. OBJECTIVE To develop and internally validate a practical prediction model to estimate the risk of aneurysmal rerupture before aneurysm closure. METHODS We designed a multinational cohort study of 2 prospective hospital registries and 3 retrospective observational studies to predict the risk of computed tomography confirmed rebleeding within 24 and 72 hours after ictus. We assessed predictors with Cox proportional hazard regression analysis. RESULTS Rerupture occurred in 269 of 2075 patients. The cumulative incidence equaled 7% and 11% at 24 and 72 hours, respectively. Our base model included hypertension, World Federation of Neurosurgical Societies scale, Fisher grade, aneurysm size, and cerebrospinal fluid drainage before aneurysm closure and showed good discrimination with an optimism corrected c-statistic of 0.77. When we extend the base model with aneurysm irregularity, the optimism-corrected c-statistic increased to 0.79. CONCLUSION Our prediction models reliably estimate the risk of aneurysm rerupture after aneurysmal subarachnoid hemorrhage using predictor variables available upon hospital admission. An online prognostic calculator is accessible at https://www.evidencio.com/models/show/2626 .
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Affiliation(s)
- Jasper Hans van Lieshout
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Hendrik-Jan Mijderwijk
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Daan Nieboer
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC-University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sebastian A Ahmadi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Cihat Karadag
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Andrej Porčnik
- Department of Neurosurgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - David Wasilewski
- Department of Neurosurgery, Charité University Hospital, Berlin, Germany
| | - Lars Wessels
- Department of Neurosurgery, Charité University Hospital, Berlin, Germany
| | - Carlina E van Donkelaar
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Daniel Hänggi
- Department of Neurosurgery, Medical Faculty, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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Siddique HH, Elkambergy H, Bayrlee A, Abulhasan YB, Roser F, Dibu JR. Management of External Ventricular Drains and Related Complications: a Narrative Review. Curr Treat Options Neurol 2022. [DOI: 10.1007/s11940-022-00725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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10
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Rao SS, Chung DY, Wolcott Z, Sheriff F, Khawaja AM, Lee H, Guanci MM, Leslie-Mazwi TM, Kimberly WT, Patel AB, Rordorf GA. Intermittent CSF drainage and rapid EVD weaning approach after subarachnoid hemorrhage: association with fewer VP shunts and shorter length of stay. J Neurosurg 2019; 132:1583-1588. [PMID: 31026832 DOI: 10.3171/2019.1.jns182702] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 01/18/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE There is variability and uncertainty about the optimal approach to the management and discontinuation of an external ventricular drain (EVD) after subarachnoid hemorrhage (SAH). Evidence from single-center randomized trials suggests that intermittent CSF drainage and rapid EVD weans are safe and associated with shorter ICU length of stay (LOS) and fewer EVD complications. However, a recent survey revealed that most neurocritical care units across the United States employ continuous CSF drainage with a gradual wean strategy. Therefore, the authors sought to determine the optimal EVD management approach at their institution. METHODS The authors reviewed records of 200 patients admitted to their institution from 2010 to 2016 with aneurysmal SAH requiring an EVD. In 2014, the neurocritical care unit of the authors' institution revised the internal EVD management guidelines from a continuous CSF drainage with gradual wean approach (continuous/gradual) to an intermittent CSF drainage with rapid EVD wean approach (intermittent/rapid). The authors performed a retrospective multivariable analysis to compare outcomes before and after the guideline change. RESULTS The authors observed a significant reduction in ventriculoperitoneal (VP) shunt rates after changing to an intermittent CSF drainage with rapid EVD wean approach (13% intermittent/rapid vs 35% continuous/gradual, OR 0.21, p = 0.001). There was no increase in delayed VP shunt placement at 3 months (9.3% vs 8.6%, univariate p = 0.41). The intermittent/rapid EVD approach was also associated with a shorter mean EVD duration (10.2 vs 15.6 days, p < 0.001), shorter ICU LOS (14.2 vs 16.9 days, p = 0.001), shorter hospital LOS (18.2 vs 23.7 days, p < 0.0001), and lower incidence of a nonfunctioning EVD (15% vs 30%, OR 0.29, p = 0.006). The authors found no significant differences in the rates of symptomatic vasospasm (24.6% vs 20.2%, p = 0.52) or ventriculostomy-associated infections (1.3% vs 8.8%, OR 0.30, p = 0.315) between the 2 groups. CONCLUSIONS An intermittent CSF drainage with rapid EVD wean approach is associated with fewer VP shunt placements, fewer complications, and shorter LOS compared to a continuous CSF drainage with gradual EVD wean approach. There is a critical need for prospective multicenter studies to determine if the authors' experience is generalizable to other centers.
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Affiliation(s)
- Shyam S Rao
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - David Y Chung
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Zoe Wolcott
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Faheem Sheriff
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Ayaz M Khawaja
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Hang Lee
- 2Biostatistics Center, Division of Clinical Research, Department of Medicine; and
| | - Mary M Guanci
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Thabele M Leslie-Mazwi
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology.,3Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - W Taylor Kimberly
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
| | - Aman B Patel
- 3Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Guy A Rordorf
- 1Division of Neurocritical Care and Emergency Neurology, Department of Neurology
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11
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Gritti P, Lorini FL, Lanterna LA, Bilotta F. Periprocedural management of patients with subarachnoid hemorrhage. Curr Opin Anaesthesiol 2019; 31:511-519. [PMID: 30020154 DOI: 10.1097/aco.0000000000000627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Anesthesiologists and intensivists may be involved in the management of aneurysmal subarachnoid hemorrhage (aSAH) patients at various stages of care. This article will review the recent advances in the periprocedural management of aSAH patients. RECENT FINDINGS New scoring systems to assess gravity and prognosis of aSAH patients have been evaluated and proposed. Rebleeding still remains, with early aneurysmal treatment, a major challenge in the first hours of aSAH management. In the last decades, the treatment of the aSAH has shifted from clipping to coiling and more recently, the use of flow diversion technique has been introduced in selected patients. Although these improvements allow treatment of more complex aneurysms, they have implications for the anesthesiologist, including requiring the management of anticoagulation with its inherent risks. Even though knowledge, monitoring, and management of postprocedural phase of aSAH patients has improved, vasospasm and cerebral-delayed ischemia still remain the major and devastating complications in the postoperative course of aSAH patients. SUMMARY Despite recent progress in the scoring, diagnosis, and treatment of aSAH patients, the periprocedural management of these patients is still a major challenge for anesthesiologists and intensivists, who are involved from the first phase of the aneurysm rupture through the postoperative phases and vasospasm period.
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Affiliation(s)
- Paolo Gritti
- Department of Anaesthesia and Critical Care Medicine
| | | | - Luigi A Lanterna
- Department of Neurosurgery, Ospedale Papa Giovanni XXIII, Bergamo
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, 'Sapienza' University, Rome, Italy
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Darkwah Oppong M, Gümüs M, Pierscianek D, Herten A, Kneist A, Wrede K, Barthel L, Forsting M, Sure U, Jabbarli R. Aneurysm rebleeding before therapy: a predictable disaster? J Neurosurg 2018; 131:1473-1480. [PMID: 30544356 DOI: 10.3171/2018.7.jns181119] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Accepted: 07/03/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Current guidelines for subarachnoid hemorrhage (SAH) include early aneurysm treatment within 72 hours after ictus. However, aneurysm rebleeding remains a crucial complication of SAH. The aim of this study was to identify independent predictors allowing early stratification of SAH patients for rebleeding risk. METHODS All patients admitted to the authors' institution with ruptured aneurysms during a 14-year period were eligible for this retrospective study. Demographic and radiographic parameters, aneurysm characteristics, medical history, and medications as well as baseline parameters at admission (blood pressure and laboratory parameters) were evaluated in univariate and multivariate analyses. A novel risk score was created using independent risk factors. RESULTS Data from 984 cases could be included into the final analysis. Aneurysm rebleeding occurred in 58 cases (5.9%), and in 48 of these cases (82.8%) rerupture occurred within 24 hours after SAH. Of over 30 tested associations, preexisting arterial hypertension (p = 0.02; adjusted odds ratio [aOR] 2.56, 1 score point), aneurysm location at the basilar artery (p = 0.001, aOR 4.5, 2 score points), sac size ≥ 9 mm (p = 0.04, aOR 1.9, 1 score point), presence of intracerebral hemorrhage (p = 0.001, aOR 4.29, 2 score points), and acute hydrocephalus (p < 0.001, aOR 6.27, 3 score points) independently predicted aneurysm rebleeding. A score built upon these parameters (0-9 points) showed a good diagnostic accuracy (p < 0.001, area under the curve 0.780) for rebleeding prediction. CONCLUSIONS Certain patient-, aneurysm-, and SAH-specific parameters can reliably predict aneurysm rerupture. A score developed according to these parameters might help to identify individuals that would profit from immediate aneurysm occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Michael Forsting
- 2Institute for Diagnostic and Interventional Radiology, University Hospital, University of Duisburg-Essen, Essen, Germany
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