Health-related quality of life after aneurysmal subarachnoid hemorrhage: impacts of bleeding severity, computerized tomography findings, surgery, vasospasm, and neurological grade

Bacterial Meningitis Following Aneurysmal Subarachnoid Hemorrhage and Its Association with Cerebral Vasospasm

Aneurysmal subarachnoid hemorrhage (aSAH) is a critical condition with high in-hospital mortality rates. Delayed cerebral ischemia (DCI), a secondary complication associated with aSAH, can also contribute to morbidity and mortality. Although draining the hematoma from the subarachnoid space has been considered effective in preventing DCI, the placement of a drainage system could increase the risk of bacterial meningitis and ventriculitis. This study aimed to examine the association between meningitis following aSAH and the occurrence of DCI, focusing on the role of cerebral vasospasm. Patients who underwent endovascular coiling or surgical clipping for aSAH from April 2001 to March 2022 were included in this study, while those who did not undergo postoperative drainage were excluded. The patient's clinical characteristics, treatment modalities, and outcomes were then analyzed, after which logistic regression was used to assess the odds ratios (OR) for DCI. A total of 810 patients with aSAH were included in this study. Meningitis following aSAH was identified as an independent factor associated with DCI (odds ratio 5.0 [95% confidence intervals (CI) 2.3-11]). Other significant factors were female sex (odds ratio 1.5 [95% CI 0.89-2.5]) and surgical clipping (odds ratio 2.1 [95% CI 1.3-3.4]). This study demonstrated a significant association between meningitis following aSAH and the development of DCI, suggesting that the inflammatory environment associated with meningitis may contribute to cerebral vasospasm. Early recognition and treatment of meningitis in patients with aSAH could reduce the risk of DCI and improve patient outcomes.

Health-related quality of life of patients with aneurysmal subarachnoid hemorrhage who were classified as having "good outcomes"

BACKGROUND

This study aimed to understand the health-related quality of life (HRQoL) of patients with aneurysmal subarachnoid hemorrhage (aSAH) classified as having "good outcomes" and determine associated sociodemographic, psychological, and clinical factors.

METHODS

Participants were 86 patients with aSAH with modified Rankin Scale (mRS) scores of 0-2 in our hospital between February 2003 and April 2014. Participants completed self-report questionnaires examining sociodemographic characteristics and the following self-rating scales: the hospital anxiety and depression scale, Pittsburgh sleep quality index, and EuroQoL-5 Dimension Index (EQ-5D). Further, we retrospectively reviewed clinical data from medical records and radiologic images. Average EQ-5D scores for each variable were compared using Student's t-test and analysis of variance. Correlations between EQ-5D and continuous variables were examined using Pearson correlation analysis. Factors associated with EQ-5D were then examined using univariate and stepwise multivariate analyses through simple and multiple regression.

RESULTS

The mean age of the 86 participants was 56.87 ± 10.28 years (range: 29-79 years), while the mean EQ-5D value was 0.738 ± 0.169. There were 54 women (62.8 %) and 33 men (37.2 %). The participants had depressive symptoms (30.2 %), anxiety (10.5 %), and sleep problems (51.2 %). Regarding sociodemographic variables, educational level (p = 0.017) and monthly income (p = 0.037) were positively correlated with HRQoL. Depressive symptoms (r = -0.505, p < 0.001), anxiety (r = -0.498, p < 0.001), sleep problems (r = -0.265, p = 017), and mRS (r = -0.352, p = 0.001) were negatively correlated with HRQoL. Depressive symptoms, diabetes mellitus, and past psychiatric history explained 48.8 % of the variance in HRQoL in good outcome aSAH according to stepwise multiple regression analysis.

CONCLUSIONS

Patients with good outcome aSAH had low EQ-5D values, which were negatively correlated with depressive symptoms, anxiety, and sleep problems. In addition, HRQoL in good outcome aSAH is associated with depressive symptoms, diabetes mellitus, and past psychiatric disease history. Depressive symptoms, anxiety, and sleep problems are frequent in patients with good outcome aSAH, and mediation of these factors may help improve HRQoL.

The survival and outcome of older patients with primary aneurysmal subarachnoid haemorrhage: a 2-year follow-up, multi-centre, observational study

BACKGROUND AND PURPOSE

The management of older aneurysmal subarachnoid haemorrhage (aSAH) cases is a clinical challenge. This study aimed to analyse the survival and functional outcomes in older aSAH patients (age ≥ 70 years) to provide evidence for making treatment decisions for such patients.

METHODS

We performed a 2-year follow-up analysis of the Chinese Multi-Centre Cerebral Aneurysm Database for older patients suffering from aSAH from 2017 to 2020. A survival analysis was used to investigate the mean survival and hazard ratios for death. Binary logarithmic regression was performed to investigate the odds ratio for independent survival and dependent survival.

RESULTS

A total of 1,136 consecutive older patients with aSAH were assessed in this study, and 944 patients (83.1%) were followed up. The overall mean survival was 37.79 ± 1.04 months. A total of 380 (40.25%) patients died within 2 years after aSAH. In survival analysis, the predictors of mortality were older age, intracerebral haemorrhage (ICH) history, Hunt-Hess (H-H) grade, World Federation of Neurosurgical Societies (WFNS) grade and operative treatment decreased the risk of mortality compared to conservative treatment. In binary logarithmic regression, the predictors of dependent survival were hypertension, diabetes, WFNS grade.

CONCLUSIONS

The risk for 2-year mortality after aSAH increases markedly with older age, ICH history, H-H grade and WFNS grade. Risk factors for 2-year dependent survival were associated with hypertension, diabetes and WFNS grade in older patients with aSAH. Operative treatment markedly decreased mortality but did not significantly decrease the morbidity of dependent survival compared to conservative treatment.

Microsurgery versus embolization: different risk factors for short- and longterm outcomes of patients with ruptured aneurysms

PURPOSE

To evaluate the risk factors for poor outcomes after surgical and endovascular treatment of aneurysmal subarachnoid hemorrhage (aSAH).

METHODS

Patients with ≥ 18-years of age and aSAH were included, while patients who died within 12 h of admission or lost follow-up were excluded. All participants underwent standardized clinical and radiological assessment on admission and were reassessed at discharge and at 6-months follow-up using the Glasgow Outcome Scale (GOS).

RESULTS

Death at discharge was associated with female gender, anterior communication artery (ACoA) aneurysm location and presence of atherosclerotic plaque in the surgical group, and with age in the endovascular group. Both groups had clinical condition on follow-up associated with mFisher score on admission and hypertension. GOS on follow-up was also associated with presence of atherosclerotic plaque and multiple aneurysms in surgical group, and with age in endovascular group.

CONCLUSIONS

Subjects treated surgically are prone to unfavorable outcomes if atherosclerotic plaques and multiple aneurysms are present. In patients with endovascular treatment, age was the main predictor of clinical outcome.

Investigating Recovery After Subarachnoid Hemorrhage With the Imaging, Cognition and Outcome of Neuropsychological Functioning After Subarachnoid Hemorrhage (ICONS) Study: Protocol for a Longitudinal, Prospective Cohort Study

Background

A subarachnoid hemorrhage is a hemorrhage in the subarachnoid space that is often caused by the rupture of an aneurysm. Patients who survive a subarachnoid hemorrhage have a high risk of complications and a negative long-term outcome.

Objective

The aim of the Imaging, Cognition and Outcome of Neuropsychological functioning after Subarachnoid hemorrhage (ICONS) study is to investigate whether and to what extent deficits exist in multiple domains after subarachnoid hemorrhage, including cognition, emotion and behavior, and to investigate whether brain damage can be detected in patients with subarachnoid hemorrhage. We aim to determine which early measures of cognition, emotion and behavior, and brain damage in the subacute stage play a role in long-term recovery after subarachnoid hemorrhage. Recovery is defined as functioning at a societal participation level, with a focus on resuming and maintaining work, leisure activities, and social relationships over the long term.

Methods

The ICONS study is an observational, prospective, single-center cohort study. The study includes patients with subarachnoid hemorrhage admitted to the Neurosurgery Unit of the University Medical Centre Groningen in the Netherlands. The inclusion criteria include diagnosis of an aneurysmal subarachnoid hemorrhage or an angiographically negative subarachnoid hemorrhage, sufficient ability in the Dutch language, and age older than 18 years. Patients will undergo neuropsychological assessment and magnetic resonance imaging 6 months after the subarachnoid hemorrhage. Furthermore, patients will be asked to fill in questionnaires on multiple psychosocial measures and undergo a structured interview at 6 months, 1 year, and 2 years after the subarachnoid hemorrhage. The primary outcome measure of the ICONS study is societal participation 1 year after the subarachnoid hemorrhage, measured with the Dutch version of the Impact on Participation and Autonomy questionnaire.

Results

The study was launched in December 2019 and recruitment is expected to continue until June 2023. At the time of the acceptance of this paper, 76 patients and 69 healthy controls have been included. The first results are expected in early 2023.

Conclusions

The ICONS study is the first to collect and combine data after subarachnoid hemorrhage in a variety of domains, including cognition, emotion and behavior, and brain damage. The results will contribute to a more comprehensive understanding of the consequences of both aneurysmal subarachnoid hemorrhage and angiographically negative subarachnoid hemorrhage, which may ultimately optimize timely treatment for this patient group by setting realistic and attainable goals to improve daily functioning.

Trial Registration

Netherlands Trial Register NL7803; https://trialsearch.who.int/Trial2.aspx?TrialID=NL7803

International Registered Report Identifier (IRRID)

DERR1-10.2196/38190

Factors Influencing 1-year Functional Outcome after Surgery in Aneurysmal Subarachnoid Hemorrhage Patients: A Single-center Series

Objective:

The objective of the study was to evaluate the outcome and related factors in patients with aneurysmal subarachnoid hemorrhage (aSAH).

Materials and Methods:

Clinical data of 221 patients who were diagnosed with spontaneous SAH due to ruptured intracranial aneurysm and surgically treated at Vajira Hospital between January 2013 and May 2016 were retrospectively reviewed. Patient and aneurysm characteristics, clinical status at presentation, treatment, and status at discharge and 1 year after discharge were recorded. Outcomes 1 year after surgery were assessed using the Glasgow Outcome Scale (GOS). Patients were divided into two groups according to the GOS score: the favorable outcome group (GOS scores 4 and 5) and unfavorable outcome group (GOS scores 1–3).

Results:

Among the 221 study patients, 158 were classified in the favorable outcome group and 63 in the unfavorable outcome group. Patient age, Hunt and Hess grade, aneurysm size, use of Vitamin C solution irrigation in the subarachnoid space, and GOS score 1 year after surgery significantly differed between the two groups.

Conclusions:

Numerous factors analyzed in this study were significantly associated with 1-year outcome in surgically treated aSAH patients, including subarachnoid Vitamin C irrigation. Further study of subarachnoid Vitamin C irrigation is warranted.

An evaluation of the SAFIRE grading scale as a predictor of long-term outcomes for patients in the Barrow Ruptured Aneurysm Trial

OBJECTIVE

The SAFIRE grading scale is a novel, computable scale that predicts the outcome of aneurysmal subarachnoid hemorrhage (aSAH) patients in acute follow-up. However, this scale also may have prognostic significance in long-term follow-up and help guide further management.

METHODS

The records of all patients enrolled in the Barrow Ruptured Aneurysm Trial (BRAT) were retrospectively reviewed, and the patients were assigned SAFIRE grades. Outcomes at 1 year and 6 years post-aSAH were analyzed for each SAFIRE grade level, with a poor outcome defined as a modified Rankin Scale score > 2. Univariate analysis was performed for patients with a high SAFIRE grade (IV or V) for odds of poor outcome at the 1- and 6-year follow-ups.

RESULTS

A total of 405 patients with confirmed aSAH enrolled in the BRAT were analyzed; 357 patients had 1-year follow-up, and 333 patients had 6-year follow-up data available. Generally, as the SAFIRE grade increased, so did the proportion of patients with poor outcomes. At the 1-year follow-up, 18% (17/93) of grade I patients, 22% (20/92) of grade II patients, 32% (26/80) of grade III patients, 43% (38/88) of grade IV patients, and 75% (3/4) of grade V patients were found to have poor outcomes. At the 6-year follow-up, 29% (23/79) of grade I patients, 24% (21/89) of grade II patients, 38% (29/77) of grade III patients, 60% (50/84) of grade IV patients, and 100% (4/4) of grade V patients were found to have poor outcomes. Univariate analysis showed that a SAFIRE grade of IV or V was associated with a significantly increased risk of a poor outcome at both the 1-year (OR 2.5, 95% CI 1.5-4.2; p < 0.001) and 6-year (OR 3.7, 95% CI 2.2-6.2; p < 0.001) follow-ups.

CONCLUSIONS

High SAFIRE grades are associated with an increased risk of a poor recovery at late follow-up.

Neurocritical care complications and interventions influence the outcome in aneurysmal subarachnoid hemorrhage

Background

This observational study was performed to show the impact of complications and interventions during neurocritical care on the outcome after aneurysmal subarachnoid hemorrhage (SAH).

Methods

We analyzed 203 cases treated for ruptured intracranial aneurysms, which were classified regarding clinical outcome after one year according to the modified Rankin Scale (mRS). We reviewed the data with reference to the occurrence of typical complications and interventions in neurocritical care units.

Results

Decompressive craniectomy (odds ratio 21.77 / 6.17 ; p < 0.0001 / p = 0.013), sepsis (odds ratio 14.67 / 6.08 ; p = 0.037 / 0.033) and hydrocephalus (odds ratio 3.71 / 6.46 ; p = 0.010 / 0.00095) were significant predictors for poor outcome and death after one year beside “World Federation of Neurosurgical Societies” (WFNS) grade (odds ratio 3.86 / 4.67 ; p < 0.0001 / p < 0.0001) and age (odds ratio 1.06 / 1.10 ; p = 0.0030 / p < 0.0001) in our multivariate analysis (binary logistic regression model).

Conclusions

In summary, decompressive craniectomy, sepsis and hydrocephalus significantly influence the outcome and occurrence of death after aneurysmal SAH.

Qualitative and Quantitative Wall Enhancement Analyses in Unruptured Aneurysms Are Associated With an Increased Risk of Aneurysm Instability

Objective

Intracranial aneurysm wall enhancement (AWE) is independently associated with unstable aneurysms. However, a quantitative analysis of wall enhancement is lacking. This study aims to investigate the relationship between qualitative and quantitative wall enhancement indices (WEIs), traditional risk factors for aneurysms, and clinical ELAPSS/PHASES scores in a large cohort of intracranial saccular aneurysms.

Materials and Methods

In this cross-sectional study, a total of 174 patients (mean age 60.4 ± 9.5 years; 53% women) with 248 asymptomatic unruptured intracranial aneurysms underwent pre- and post-contrast black-blood magnetic resonance imaging (MRI). The extent of AWE was defined as non-AWE (pattern 0), focal AWE (pattern 1), or circumferential AWE (pattern 2). WEI was calculated using wall signal intensities on pre- and post-contrast images. Predicted 3- and 5-year growth risk and 5-year rupture risk were obtained from ELAPSS and PHASES scores, respectively. Uni- and multivariate analyses were conducted to explore the relationship between AWE characteristics, risk-related factors, and aneurysm instability.

Results

Aneurysm size [odds ratio (OR), 1.3; 95% confidence interval (CI), 1.2-1.4; P < 0.001], non-internal carotid artery/middle cerebral artery location (OR, 1.9; 95% CI, 1.0-3.6; P = 0.045), and irregular shape (OR, 2.4; 95% CI, 1.2-4.5; P = 0.009) were independently associated with AWE. For aneurysms with AWE, the estimated 3- and 5-year growth risk (25.3 ± 13.0% and 38.0 ± 17.4%) and the 5-year rupture risk (3.9 ± 5.2%) were 1.9-3.3 times higher than those for aneurysms without AWE (12.8 ± 9.1%, 20.3 ± 13.0%, and 1.2 ± 1.6%, respectively; all P < 0.001). Larger areas and higher WEIs of enhancement positively correlated with aneurysm size (r = 0.43 and 0.38, respectively), 3- and 5-year growth risk, and 5-year rupture risk (r = 0.49 and 0.40, r = 0.49 and 0.40, r = 0.36 and 0.24, respectively; all P < 0.001). In sum, a larger aneurysm size, non-internal carotid artery/middle cerebral artery location, and irregular shape were independently associated with AWE. Larger areas and higher WEIs were associated with an increased risk of aneurysm growth and rupture. These findings suggest that quantitative AWE metrics should be considered in future large-scale longitudinal studies to evaluate their value in aneurysm risk management.

Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS)

OBJECTIVE

The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort.

METHODS

The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined.

RESULTS

Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676).

CONCLUSIONS

Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.

The relationship between liver cyst volume and QOL in Japanese ADPKD patients

BACKGROUND

Although it is widely accepted that the autosomal dominant polycystic kidney disease (ADPKD) patients with large liver cysts have a significant decrement in quality of life (QOL), there is insufficient evidence that clearly demonstrates the relationship between the size of the liver cysts and QOL. Therefore, we started this prospective longitudinal study to investigate the impact of liver cysts on QOL.

METHODS

We grouped the 111 included ADPKD patients into 4 groups (control group A; < 25%, group B; 25-49%, group C; 50-75%, group D; > 75%) according to liver cysts-parenchyma ratio (CPR). QOL was measured by FANLTC + FACT-Hep scores. We compared QOL scores and several clinical parameters amongst these groups for 3 years.

RESULTS

The number of patients in group A, B, C, and D was 31, 14, 14, and 23, respectively. Although there were no significant differences in AST (p = 0.107), ALT (p = 0.925), and serum albumin (p = 0.212) between the four groups, platelet count was significantly decreased along with the extension of cyst volume (p = 0.030). Overall, the mean FANLTC and FACT-Hep scores were 71.8 ± 12.5, and 32.4 ± 5.8, respectively. FANLTC (p = 0.017) and FACT-Hep scores (p = 0.003) were significantly decreased with increasing cyst volume. From the data collected at the time of registration, multivariate linear regression analysis demonstrated that the CPR had a significant influence on FANLTC and FACT-Hep scores.

CONCLUSION

In this cross-sectional and prospective longitudinal study, we demonstrate the relationship between liver cyst volume and QOL in ADPKD patients. We hope to establish the long-term influence on QOL in this ongoing prospective longitudinal study.

Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Risk Factors Affecting Clinical Outcomes in Intracranial Aneurysm Patients in a Multi-Center Study

Objective: Patients with poor-grade aneurysm subarachnoid hemorrhage (SAH) have commonly been considered to have a poor prognosis. The objective of this study was to investigate the independent risk factors affecting clinical outcomes in intracranial aneurysm patients with poor-grade aneurysm subarachnoid hemorrhage (aSAH) underwent different intervention therapies. Methods: A multicenter observational registry of 324 poor-grade aSAH patients treated at tertiary referral centers from October 2010 to March 2012 were enrolled in this study. The clinical data including patient characteristics on admission and during treatment course, treatment modality, aneurysm size and location, radiologic features, signs of cerebral herniation (dilated pupils), and functional neurologic outcome were collected. Clinical outcomes were assessed via a modified Rankin Scale at 12 months. Multivariate logistic regression models were used to develop prognostic models. The area under the receiver operator characteristic curves (AUC) and Hosmer-Lemeshow tests were used to assess discrimination and calibration. WAP score was developed to predict risk of poor outcome. Results: Older age, female gender, ventilated breathing status, non-reactive pupil response, pupil dilation, lower GCS score, a WFNS grade of V, intraventricular hemorrhage, a higher Fisher grade, a higher modified Fisher grade, and conservative treatment were calculated to be associated with a relatively poor outcome. Multivariate analyses revealed that older age, lower Glasgow coma scale score (GCS), the absence of pupillary reactivity, higher modified Fisher grade, and conservative treatment were independent predictors of poor outcome, showed good discrimination and calibration. Patients with WFNS grade V, older age and non-reactive pupillary reactivity were predicted to have a poor outcome by WAP risk score. Conclusions: A simple WAP risk score had good discrimination and calibration in the prediction of outcome. The risk score can be easily measured and may complement treatment decision-making.

Clinical Outcomes After Endovascular Coiling in High-Grade Aneurysmal Hemorrhage

Object:

Our experience in Calgary was reviewed to determine the safety and clinical effectiveness of coiling in patients with high-grade aneurysmal subarachnoid hemorrhage (SAH).

Methods:

Patients with Hunt-Hess grades IV and V aneurysmal subarachnoid hemorrhage who underwent endovascular coiling between January 1999 and April 2009 at Foothills Medical Centre, Calgary, Alberta, Canada were reviewed. The primary outcome measure was the Modified Rankin Score after at least six months. Secondary outcome measures included extent of aneurysm occlusion and peri-procedural complications. In patients with favourable functional outcomes, Barthel's Index (BI), Re-integration to normal living index (RINL), and Zung depression scale (ZDS) were determined.

Results:

Thirty-three patients were identified (median age of 57 years; 73% female) and 69% were Hunt-Hess grade IV subarachnoid hemorrhage and 22 % were grade V Endovascular coiling resulted in absence of residual flow into the aneurysm fundus in 91%. Only seven procedure-related complications occurred with no deaths attributed to the procedure. Vasospasm, hydrocephalus, and pneumonia were the most common non-procedural complications. Average follow-up was 27 +/- 17 months. Overall mortality was 32%, but 53% of patients had good functional outcome (mRS<3). Nine patients completed the BI, RINL, and ZDS with average BI 99 +/- 2, RINL 89 +/- 14, ZDS 33 +/-11, suggesting minimal deficits in function and mood.

Conclusions:

Endovascular coiling in patients with high-grade subarachnoid hemorrhage is safe. While the morbidity and mortality from high-grade aneurysmal subarachnoid hemorrhage remains significant, favourable radiologic and functional outcomes can be achieved in a significant proportion of these critically ill patients.

LPS Pretreatment Provides Neuroprotective Roles in Rats with Subarachnoid Hemorrhage by Downregulating MMP9 and Caspase3 Associated with TLR4 Signaling Activation

Subarachnoid hemorrhage (SAH), as a severe brain disease, has high morbidity and mortality. SAH usually induced neurological dysfunction or death and the treatment is far from satisfaction. Here, we investigated the effect of low dose of LPS pretreatment and underlying molecular mechanism in rat SAH model. Firstly, SAH model was induced by prechiasmal cistern injection method (SAH1) and common carotid artery-prechiasmal cistern shunt method (SAH2), respectively, to select the more suitable SAH model. At 6, 12, 24, 48, and 72 h after SAH, brain injury including neurological dysfunction, blood-brain barrier disruption, brain edema, and cell apoptosis were detected. And the expression of MMP9, HMGB1/TLR4, and caspase3 in cortex were also explored. Then, SB-3CT, an inhibitor of MMP9, was administrated to investigate the exact function of MMP9 in the brain injury at 24 h after SAH. Moreover, low dose of LPS was used to verify whether it had nerve protection after SAH and the mechanism involving in MMP9 and caspase 3 was investigated. Our results showed SAH1 seems to be the most suitable SAH model. In addition, MMP9 activated by HMGB1/TLR4 may promote or aggravate brain injury, while inhibiting MMP9 via SB-3CT exerted a neuroprotective effect. Moreover, LPS improved the neurological dysfunction, reduced Evans blue extravasation and brain edema, and inhibited cell apoptosis of cortex in rats with brain injury induced by SAH. Importantly, LPS pretreatment increased the expression level of TLR4, and decreased the level of MMP9 and caspase3. Therefore, the present study revealed that low dose of LPS pretreatment could provide neuroprotective effects on brain injury caused by SAH via downregulating MMP9 and caspase3 and activating TLR4 signal pathway.

Long-term reintegration and quality of life in patients with subarachnoid hemorrhage and a good neurological outcome: findings after more than 20 years

OBJECTIVE The goal of this study was to examine long-term quality of life (QOL) and reintegration in patients with good neurological recovery after aneurysmal subarachnoid hemorrhage (aSAH) and SAH of unknown cause (SAH NUD). METHODS A long-term follow-up was performed in an original cohort of 113 individuals who had suffered SAH (93 with aSAH and 20 with SAH NUD) between 1977 and 1984. Self-reporting assessments, performed > 20 years after the bleeding episode, included the Quality of Life Scale (QOLS), Psychological General Well-Being (PGWB) index, and Reintegration to Normal Living (RNL) index, along with information on sleep disturbances and work status. RESULTS Seventy-one survivors were identified. Questionnaires were returned by 67 individuals who had suffered SAH 20-28 years previously. The QOL was rated in the normal range for both the QOLS score (aSAH 90.3 vs SAH NUD 88.6) and the PGWB index (aSAH 105.9 vs SAH NUD 102.8). Ninety percent of patients had returned to their previous employment. Complete RNL was reported by 40% of patients with aSAH and by 46% of patients with SAH NUD; mild to moderate readjustment difficulties by 55% and 38%, respectively; and severe difficulties by 5% of patients with aSAH and 15% of patients with SAH NUD. Self-rated aspects of cognition, mood, and energy resources in addition resulted in a substantial drop in overall reintegration. Sleep disturbances were reported by 26%. CONCLUSIONS More than half of patients with SAH who had early good neurological recovery experienced reintegration difficulties after > 20 years. However, the general QOL was not adversely affected by this impairment. Inability to return to work after SAH was associated with lower QOLS scores. Sleep disturbances were associated with lower PGWB scores.

Associations with health-related quality of life after intracerebral haemorrhage: pooled analysis of INTERACT studies

BACKGROUND AND PURPOSE

Limited data exist on health-related quality of life (HRQoL) after intracerebral haemorrhage (ICH). We aimed to determine baseline factors associated with HRQoL among participants of the pilot and main phases of the Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trials (INTERACT 1 and 2).

METHODS

The INTERACT studies were randomised controlled trials of early intensive blood pressure (BP) lowering in patients with ICH (<6 hours) and elevated systolic BP (150-220 mm Hg). HRQoL was determined using the European Quality of Life Scale (EQ-5D) at 90 days, completed by patients or proxy responders. Binary logistic regression analyses were performed to identify factors associated with poor overall HRQoL.

RESULTS

2756 patients were included. Demographic, clinical and radiological factors associated with lower EQ-5D utility score were age, randomisation outside of China, antithrombotic use, high baseline National Institutes of Health Stroke Scale (NIHSS) score, larger ICH, presence of intraventricular extension and use of proxy responders. High (≥14) NIHSS score, larger ICH and proxy responders were associated with low scores in all five dimensions of the EQ-5D. The NIHSS score had a strong association with poor HRQoL (p<0.001). Female gender and antithrombotic use were associated with decreased scores in dimensions of pain/discomfort and usual activity, respectively.

CONCLUSIONS

Poor HRQoL was associated with age, comorbidities, proxy source of assessment, clinical severity and ICH characteristics. The strongest association was with initial clinical severity defined by high NIHSS score.

TRIAL REGISTRATION NUMBERS

NCT00226096 and NCT00716079; Post-results.

The functional and structural changes in the basilar artery due to overpressure blast injury

Overpressure blast-wave induced brain injury (OBI) leads to progressive pathophysiologic changes resulting in a reduction in brain blood flow, blood brain barrier breakdown, edema, and cerebral ischemia. The aim of this study was to evaluate cerebral vascular function after single and repeated OBI. Male Sprague-Dawley rats were divided into three groups: Control (Naive), single OBI (30 psi peak pressure, 1 to 2 msec duration), and repeated (days 1, 4, and 7) OBI (r-OBI). Rats were killed 24 hours after injury and the basilar artery was isolated, cannulated, and pressurized (90 cm H2O). Vascular responses to potassium chloride (KCl) (30 to 100 mmol/L), endothelin-1 (10(-12) to 10(-7) mol/L), acetylcholine (ACh) (10(-10) to 10(-4) mol/L) and diethylamine-NONO-ate (DEA-NONO-ate) (10(-10) to 10(-4) mol/L) were evaluated. The OBI resulted in an increase in the contractile responses to endothelin and a decrease in the relaxant responses to ACh in both single and r-OBI groups. However, impaired DEA-NONO-ate-induced vasodilation and increased wall thickness to lumen ratio were observed only in the r-OBI group. The endothelin-1 type A (ET(A)) receptor and endothelial nitric oxide synthase (eNOS) immunoreactivity were significantly enhanced by OBI. These findings indicate that both single and r-OBI impairs cerebral vascular endothelium-dependent dilation, potentially a consequence of endothelial dysfunction and/or vascular remodelling in basilar arteries after OBI.

Call for uniform neuropsychological assessment after aneurysmal subarachnoid hemorrhage: Swiss recommendations

BACKGROUND

In a high proportion of patients with favorable outcome after aneurysmal subarachnoid hemorrhage (aSAH), neuropsychological deficits, depression, anxiety, and fatigue are responsible for the inability to return to their regular premorbid life and pursue their professional careers. These problems often remain unrecognized, as no recommendations concerning a standardized comprehensive assessment have yet found entry into clinical routines.

METHODS

To establish a nationwide standard concerning a comprehensive assessment after aSAH, representatives of all neuropsychological and neurosurgical departments of those eight Swiss centers treating acute aSAH have agreed on a common protocol. In addition, a battery of questionnaires and neuropsychological tests was selected, optimally suited to the deficits found most prevalent in aSAH patients that was available in different languages and standardized.

RESULTS

We propose a baseline inpatient neuropsychological screening using the Montreal Cognitive Assessment (MoCA) between days 14 and 28 after aSAH. In an outpatient setting at 3 and 12 months after bleeding, we recommend a neuropsychological examination, testing all relevant domains including attention, speed of information processing, executive functions, verbal and visual learning/memory, language, visuo-perceptual abilities, and premorbid intelligence. In addition, a detailed assessment capturing anxiety, depression, fatigue, symptoms of frontal lobe affection, and quality of life should be performed.

CONCLUSIONS

This standardized neuropsychological assessment will lead to a more comprehensive assessment of the patient, facilitate the detection and subsequent treatment of previously unrecognized but relevant impairments, and help to determine the incidence, characteristics, modifiable risk factors, and the clinical course of these impairments after aSAH.

Fisher Grading Scale Associated with Language Disorders in Patients with Anterior Circulation Aneurysmal Subarachnoid Hemorrhage

OBJECTIVE

To associate the presence of language deficits with varying scores of the Fisher grading scale in patients with subarachnoid hemorrhage in the period preceding the treatment of aneurysm in the anterior circulation, as well as to compare the scores of this scale, identifying the grades more associated with the decline of language.

METHODS

Database analysis of 185 preoperative evaluations of language, through the Montreal Toulouse Protocol Alpha version and verbal fluency through CERAD battery, of patients from "Hospital da Restauração" with aneurysmal subarachnoid hemorrhage, divided according to the Fisher grading scale (Fisher I, II, III, or IV) and compared with a control group of individuals considered normal.

RESULTS

The various scores of the Fisher grading scale have different levels of language deficits, more pronounced as the amount of blood increases. Fisher III and IV scores are most associated with the decline of language.

CONCLUSIONS

Our study made it possible to obtain information not yet available in the literature, by correlating the various scores of the Fisher grading scale with language yet in the period preceding treatment.

Changes in the coagulation and fibrinolytic system of patients with subarachnoid hemorrhage

The aim of this study was to investigate the dynamic changes in the coagulation and fibrinolytic system with subarachnoid hemorrhage. The blood coagulation enzyme-AT complex (TAT), anticoagulant enzyme (AT), tissue plasminogen activator (tPA), plasminogen activin inhibitor (PAI-1), and mean blood flow velocity were measured. The TAT level was significantly higher 6 h after subarachnoid hemorrhage (SAH), whereas AT was significantly lower. These changes were maintained at 12 h to 1 d after SAH, returned to normal at 3 d, significantly changed again at 7 d to 14 d. The tPA level gradually increased after SAH and peaked at 14 d, and then returned to normal at 21 d. The PAI-1 levels were significantly lower than those in the control group 1 d after SAH gradually increased, and returned to normal at 21 d. In the cerebral vasospasm (CVS) groups, the levels of TAT, and AT significantly changed compared to the non-CVS groups after SAH. The PAI-1 levels were higher at 7 d and 14 d, but the changes were not significant. In groups Fisher III and IV as well as Hunt III to V, the TAT, AT, tPA, and PAI-1 levels were significantly higher than those in both Fisher and Hunt I and II 6 h, 12 h, 1 d, 7 d, and 14 d after SAH. The changes in the coagulation and fibrinolytic system of patients with SAH are correlated with the progress and symptoms of SAH as well as the blood content and CVS.

Time course of recovery following poor-grade SAH: the incidence of delayed improvement and implications for SAH outcome study design

OBJECT

Data regarding the time course of recovery after poor-grade subarachnoid hemorrhage (SAH) is lacking. Most SAH studies assess outcome at a single time point, often as early as 3 or 6 months following SAH. The authors hypothesized that recovery following poor-grade SAH is a dynamic process and that early outcomes may not always approximate long-term outcomes. To test this hypothesis, they analyzed long-term outcome data from a cohort of patients with poor-grade aneurysmal SAH to determine the incidence and predictors of early and delayed neurological improvement.

METHODS

The authors reviewed outcome data from 88 poor-grade SAH patients enrolled in a prospective SAH treatment trial (the Barrow Ruptured Aneurysm Trial). They assessed modified Rankin Scale (mRS) scores at discharge, 6 months, 12 months, and 36 months after treatment to determine the incidence and predictors of neurological improvement during each interval.

RESULTS

The mean aggregate mRS scores at 6 months (3.31 ± 2.1), 12 months (3.28 ± 2.2), and 36 months (3.17 ± 2.3) improved significantly compared with the mean score at hospital discharge (4.33 ± 1.3, p < 0.001), but they did not differ significantly among themselves. Between discharge and 6 months, 61% of patients improved on the mRS. The incidence of improvement between 6-12 months and 12-36 months was 18% and 19%, respectively. Hunt and Hess Grade IV versus V (OR 6.20, 95% CI 2.11-18.25, p < 0.001) and the absence of large (> 4 cm) (OR 2.76, 95% CI 1.02-7.55, p = 0.05) or eloquent (OR 5.17, 95% CI 1.89-14.10, p < 0.01) stroke were associated with improvement up to 6 months. Age ≤ 65 years (OR 5.56, 95% CI 1.17-26.42, p = 0.02), Hunt and Hess Grade IV versus V (OR 4.17, 95% CI 1.10-15.85, p = 0.03), and absence of a large (OR 8.97, 95% CI 2.65-30.40, p < 0.001) or eloquent (OR 4.54, 95% CI 1.46-14.08, p = 0.01) stroke were associated with improvement beyond 6 months. Improvement beyond 1 year was most strongly predicted by the absence of a large stroke (OR 7.62, 95% CI 1.55-37.30, p < 0.01).

CONCLUSIONS

A substantial minority of poor-grade SAH patients will experience delayed recovery beyond the point at which most studies assess outcome. Younger patients, those presenting in better clinical condition, and those without CT evidence of large or eloquent stroke demonstrated the highest capacity for delayed recovery.

The role of magnesium in the management of cerebral vasospasm

Subarachnoid hemorrhage (SAH) is characterized by bleeding into the subarachnoid space, often caused by ruptured aneurysm. Aneurysmal rupture occurs in 700,000 individuals per year worldwide, with 40,000 cases taking place in the United States. Beyond the high mortality associated with SAH alone, morbidity and mortality are further increased with the occurrence of cerebral vasospasm, a pathologic constriction of blood vessels that can lead to delayed ischemic neurologic deficits (DIND). Treatment of cerebral vasospasm is a source of contention. One extensively studied therapy is Magnesium (Mg) as both a competitive antagonist of calcium at the N-methyl D-aspartate (NMDA) receptor, and a noncompetitive antagonist of both IP3 and voltage-gated calcium channels, leading to smooth muscle relaxation. In our literature review, several animal and human studies are summarized in addition to two Phase III trials assessing the use of intravenous Mg in the treatment of SAH (IMASH and MASH-2). Though many studies have shown promise for the use of Mg in SAH, there has been inconsistency in study design and outcomes. Furthermore, the results of the recently completed clinical trials have shown no significant benefit from using intravenous Mg as adjuvant therapy in the treatment of cerebral vasospasm.

Blunted serum and enhanced salivary free cortisol concentrations in the chronic phase after aneurysmal subarachnoid haemorrhage--is stress the culprit?

Spontaneous aneurysmal subarachnoid haemorrhage (SAH) is a cause of stroke, which constitutes a severe trauma to the brain and may lead to serious long-term medical, psychosocial and endocrinological sequelae. Adrenocorticotrophic hormone deficiency, which is considered to occur in up to 20% of all survivors, is a possible consequence of bleeding. Moreover, preliminary data suggest that a poor psychosocial outcome in SAH survivors is linked to alterations in cortisol secretion. Despite these findings, investigation of diurnal cortisol profiles and the cortisol awakening response (CAR) in chronic SAH patients has not been done so far. In this study, basal serum cortisol and salivary cortisol concentration profiles were investigated in 31 SAH patients more than 1 year after the acute event and in 25 healthy controls. Additionally, low-dose dexamethasone (DEX) suppression tests were conducted, and sensitivity to stress was measured with a psychometric questionnaire (Neuropattern(TM)). Although significantly higher salivary cortisol concentrations were observed on waking in SAH patients (p = 0.013, ANOVA), without a CAR change, total serum cortisol concentrations were blunted, but only in patients with high levels of perceived stress (SAH high stress: 337 nmol/l, SAH low stress: 442 nmol/l, controls: 467 nmol/l; Controls vs. SAH high stress p = 0.018). DEX suppression of cortisol secretion was not significantly different between patients and controls. The results indicate that total (serum) and free (salivary) cortisol concentrations give different information about cortisol availability in patients after aneurysmal SAH. Enhanced free cortisol concentrations may reflect a meaningful biological coping mechanism in SAH patients.

Health-Related Quality of Life 10 Years After Intracranial Aneurysm Rupture

BACKGROUND:

Experiencing an aneurysmal subarachnoid hemorrhage (SAH) could affect health-related quality of life (HRQoL) several years after the onset. Long-term studies are scarce, and there is a lack of knowledge of whether HRQoL is affected &gt; 5 years after the onset and, if so, in what dimensions. In the general population, HRQoL decreases with age and with the occurrence of a disease and differs between sexes. Factors that may influence HRQoL after aneurysmal SAH include neurological outcome, perceived recovery, aneurysm treatment, and family support.

OBJECTIVE:

To measure HRQoL and to explore factors affecting HRQoL 10 years after aneurysmal SAH.

METHODS:

A consecutive sample of all patients admitted for intracranial aneurysm rupture at a neurosurgical clinic in Stockholm (n = 217, 79.5% of eligible) were followed up from 2007 to 2008, approximately 10 years after aneurysm rupture. HRQoL was measured with EQ-5D, and the results were compared with a general population sample from the Stockholm Public Health Survey 2006 matched by age and sex.

RESULTS:

Compared with the general population, the aneurysm sample reported significantly more problems in 4 of 5 EQ-5D dimensions—mobility, self-care, usual activities, and anxiety/depression—and had significantly lower EQ-5Dindex and EQ visual analog scale values. Within the aneurysm sample, HRQoL was most affected in respondents with worse Glasgow Outcome Scale values at hospital discharge, respondents with comorbidities, and respondents with low perceived recovery.

CONCLUSION:

Aneurysmal SAH affects HRQoL to a large extent, even 10 years after the onset, indicating a need for long-term follow-up and support after the onset.

The quality of life of patients with good outcomes after anterior circulation aneurysm surgery assessed by the world health organization quality of life instrument-korean version

Objective

Even in the patients with neurologically good outcome after intracranial aneurysm surgery, their perception of health is an important outcome issue. This study aimed to investigate the quality of life (QOL) and its predictors of patients who had a good outcome following anterior circulation aneurysm surgery as using the World Health Organization Quality of Life instrument-Korean version.

Methods

We treated 280 patients with 290 intracranial aneurysms for 2 years. This questionnaire was taken and validated by 99 patients whose Glasgow Outcome Scale score was 4 and more and Global deterioration scale 3 and less at 6 months after the operation, and 85 normal persons. Each domain and facet was compared between the two groups, and a subgroup analysis was performed on the QOL values and hospital expenses of the aneurysm patients according to the type of craniotomy, approach, bleeding of the aneurysm and brain injury.

Results

Aneurysm patients showed a lower quality of life compared with control patients in level of independence, psychological, environmental, and spiritual domains. In the environmental domain, there were significant intergroup differences according to the type of craniotomy and the surgical approach used on the patients (p<0.05). The hospital charges were also significantly different according to the type of craniotomy (p<0.05).

Conclusion

Despite good neurological status, patients surgically treated for anterior circulation aneurysm have a low quality of life. The craniotomy size may affect the QOL of patients who underwent an anterior circulation aneurysm surgery and exhibited a good outcome.

Determinants of health-related quality of life after aneurysmal subarachnoid hemorrhage: a systematic review

BACKGROUND AND PURPOSE

Many persons with subarachnoid hemorrhage (SAH) from a ruptured intracranial aneurysm recover to functional independence but nevertheless experience reduced quality of life (QoL). The aim of this study was to summarize the evidence on determinants of reduced QoL in this diagnostic group.

METHODS

Databases PubMed, PsychINFO, and CINAHL were used to identify empirical studies reporting on quantitative relationships between possible determinants and QoL in persons with aneurysmal SAH and published in English. Determinants were classified using the International Classification of Functioning, Disability and Health (ICF).

RESULTS

Twenty studies met the inclusion criteria for this review, in which 13 different HRQoL questionnaires were used. Determinants related to Body Structure & Function (clinical condition at admission, fatigue, and disturbed mood), Activity limitations (physical disability and cognitive complaints), and Personal factors (female gender, higher age, neuroticism, and passive coping) are consistently related to worse HRQoL after aneurysmal SAH. Treatment characteristics were not consistently related to HRQoL.

CONCLUSION

This study identified a broad range of determinants of HRQoL after aneurysmal SAH. The findings provide clues to tailor multidisciplinary rehabilitation programs. Further research is needed on participation, psychological characteristics, and environmental factors as determinants of HRQoL after SAH.

The importance of early brain injury after subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) is a medical emergency that accounts for 5% of all stroke cases. Individuals affected are typically in the prime of their lives (mean age 50 years). Approximately 12% of patients die before receiving medical attention, 33% within 48 h and 50% within 30 days of aSAH. Of the survivors 50% suffer from permanent disability with an estimated lifetime cost more than double that of an ischemic stroke. Traditionally, spasm that develops in large cerebral arteries 3-7 days after aneurysm rupture is considered the most important determinant of brain injury and outcome after aSAH. However, recent studies show that prevention of delayed vasospasm does not improve outcome in aSAH patients. This finding has finally brought in focus the influence of early brain injury on outcome of aSAH. A substantial amount of evidence indicates that brain injury begins at the aneurysm rupture, evolves with time and plays an important role in patients' outcome. In this manuscript we review early brain injury after aSAH. Due to the early nature, most of the information on this injury comes from animals and few only from autopsy of patients who died within days after aSAH. Consequently, we began with a review of animal models of early brain injury, next we review the mechanisms of brain injury according to the sequence of their temporal appearance and finally we discuss the failure of clinical translation of therapies successful in animal models of aSAH.

Triggers for aggressive interventions in subarachnoid hemorrhage

Ischemia is a common cause of secondary neuronal injury after aneurysmal subarachnoid hemorrhage. An electronic literature search was conducted to identify clinical signs and laboratory data that could serve as predictors for delayed cerebral ischemia and define triggers for additional diagnostic testing or more aggressive intervention. Fifteen articles describing original research that included some discussion of triggers were identified and reviewed. Quality of evidence was considered very low to moderate for included studies. Using data from these studies and expert opinion, a variety of clinical signs and monitoring data were identified as potentially useful triggers for additional tests or aggressive treatments. These data were used to develop a sequence that might be employed in the clinical management of subarachnoid hemorrhage to determine which patients need additional attention, testing, or interventions to reduce/prevent ischemia caused by vasospasm.

Health-related quality of life after aneurysmal subarachnoid hemorrhage: profile and clinical factors

BACKGROUND

Health-related quality of life has recently been suggested as a supplement to the traditional neurological outcome measures from the patient's perspective according to the World Health Organization model and may capture the effects of other factors such as posttraumatic stress disorder and neuroendocrine dysfunction.

OBJECTIVE

To explore the profile and clinical factors of quality of life after aneurysmal subarachnoid hemorrhage using the data we obtained from the recently completed Intravenous Magnesium Sulphate After Aneurysmal Subarachnoid Hemorrhage (IMASH) trial.

METHODS

This study was registered at www.strokecenter.org/trials and www.ClinicalTrials.gov (NCT00124150). Data from a patient cohort obtained with the Short Form-36 questionnaire completed at 6 months were used for analysis.

RESULTS

Patients with aneurysmal subarachnoid hemorrhage demonstrated a decrease in quality of life according to the Short Form-36 at 6 months. The physical and mental health scores correlated with the Extended Glasgow Outcome Scale and had the potential to avoid the ceiling effect. Multiple regression analyses showed that the physical component scores were related to age, World Federation of Neurological Surgeons grade, and chronic hydrocephalus and that the mental component scores were not related to the traditional prognostic factors.

CONCLUSION

Subarachnoid hemorrhage caused a decrease in quality of life. Chronic hydrocephalus is related to a decrease in physical health quality of life.

Immunological response in early brain injury after SAH

This study summarized the role of inflammation in the early brain injury after subarachnoid hemorrhage. Elevation of cytokines, activation of MMPs and phosphorylation of MAPK contributes to neuronal apoptosis and brain edema. Anti-inflammation may be potential strategy for the prevention and suppression of early brain injury after subarachnoid hemorrhage.

Intraventricular hemorrhage volume predicts poor outcomes but not delayed ischemic neurological deficits among patients with ruptured cerebral aneurysms

BACKGROUND

Intraventricular hemorrhage (IVH) predicts worse outcomes following aneurysmal subarachnoid hemorrhage (SAH). One potential mechanism is that IVH predisposes to the development of delayed ischemic neurological deficits (DINDs). No previous studies have evaluated the association between IVH volume (in milliliters) and subsequent development of DINDs or poor outcomes.

OBJECTIVE

To assess the association between the volume of IVH and the subsequent development of DINDs, delayed cerebral infarction, death, and poor neurological outcomes, specifically among patients with concomitant SAH and IVH.

METHODS

We performed a cohort study involving 152 consecutive patients with concomitant SAH and IVH. To determine volume of IVH, we used the IVH Score, shown to correlate well with computerized volumetric assessment. To determine the relative quantity of subarachnoid blood, we applied the SAH Sum Score. Multivariate logistic regression was used to adjust for potential confounders.

RESULTS

There was no significant association between IVH volume and the development of DINDs or delayed infarction. In contrast, patients with poor neurological outcomes had significantly larger baseline IVH volume (mean, 11.8 mL vs 3.8 mL, P = .001). In the multivariate analysis, IVH volume was an independent predictor of poor outcomes (OR per mL: 1.11 [1.04-1.18]). Patients in the highest quartile for IVH volume were far more likely to progress to poor outcome compared with those in the lowest quartile (OR 4.09 [1.32-12.65]). Interobserver agreement in the determination of IVH Score was moderate to good.

CONCLUSIONS

IVH volume is an independent predictor of poor neurological outcomes, even after adjusting for the amount of subarachnoid blood. The pathophysiology of this association does not appear to involve an increased risk of DINDs or delayed infarction. Measures aimed at accelerating IVH clearance, such as intraventricular thrombolysis, merit further evaluation.

Preoperative assessment and preparation of patients with diseases affecting the central nervous system

PURPOSE OF REVIEW

This review will examine the most important issues of preoperative evaluation and preparation in relation to patients with deseases affecting the central nervous system. Those patients may undergo various forms of surgery unrelated to the central nervous system disease. We discuss the effect of physiologic and pharmacological factors on cerebral autoregulation and control of intracranial pressure alongside its clinical relevance with the help of new evidence.

RECENT FINDINGS

Regardless of the reason for surgery, coexisting diseases of brain often have important implications when selecting anesthetic drugs, procedures and monitoring techniques. Suppression of cerebral metabolic rate is not the sole mechanism for the neuroprotective effect of anaesthetic agents. There are certain general principles, but also some specific circumstances, when we are talking about optimal anesthetic procedure for a patient with coexisting brain disease. Intravenous anesthesia, such as combination of propofol and remifentanil, provides best preservation of autoregulation. Among inhaled agents isoflurane and sevoflurane appear to preserve autoregulation at all doses, whereas with other agents autoregulation is impaired in a dose-related manner. During maintenance of anesthesia the patient is ventilated by intermittent positive pressure ventilation, at intermediate hyperventilation (PaCO2 25-30 mmHg).

SUMMARY

Intraoperative cerebral autoregulation monitoring is an important consideration for the patients with coexisting neurological disease. Transcranial Doppler based static autoregulation measurements appears to be the most robust bedside method for this purpose.

The anti-inflammatory and neuroprotective effects of ghrelin in subarachnoid hemorrhage-induced oxidative brain damage in rats

To elucidate the putative neuroprotective effects of ghrelin in subarachnoid hemorrhage (SAH)-induced brain injury, Wistar albino rats (n = 54) were divided into sham-operated control, saline-treated SAH, and ghrelin-treated (10 microg/kg/d IP) SAH groups. The rats were injected with blood (0.3 mL) into the cisterna magna to induce SAH, and were sacrificed 48 h after the neurological examination scores were recorded. In plasma samples, neuron-specific enolase (NSE), S-100beta protein, TNF-alpha, and IL-1beta levels were evaluated, while forebrain tissue samples were taken for the measurement of malondialdehyde (MDA), glutathione (GSH), reactive oxygen species levels, myeloperoxidase (MPO), Na(+)-K(+)-ATPase activity, and DNA fragmentation ratio. Brain tissue samples containing the basilar arteries were obtained for histological examination, while cerebrum and cerebellum were removed for the measurement of blood-brain barrier (BBB) permeability and brain water content. The neurological scores were impaired at 48 h after SAH induction, and SAH caused significant decreases in brain GSH content and Na(+)-K(+)-ATPase activity, and increases in chemiluminescence, MDA levels, and MPO activity. Compared with the control group, the protein levels of NSE, S-100beta, TNF-alpha, and IL-1beta in plasma were also increased, while ghrelin treatment prevented all SAH-induced alterations observed both biochemically and histopathologically. The results demonstrate that ghrelin alleviates SAH-induced oxidative brain damage, and exerts neuroprotection by maintaining a balance in oxidant-antioxidant status, by inhibiting proinflammatory mediators, and preventing the depletion of endogenous antioxidants evoked by SAH.

Which variables help explain the poor health-related quality of life after subarachnoid hemorrhage? A meta-analysis

OBJECTIVE

Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.

METHODS

Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.

RESULTS

Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.

CONCLUSION

Studies need to turn to new factors to account for poor patient outcome.

Cognitive Functioning and Health-Related Quality of Life 1 Year After Aneurysmal Subarachnoid Hemorrhage in Preoperative Comatose Patients (Hunt and Hess Grade V Patients)

OBJECTIVE

The objective of this study was to determine cognitive functioning and health-related quality of life 1 year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients (Hunt and Hess Grade V patients).

METHODS

Patients who were comatose at hospital arrival and thereafter were investigated for 1 year using a comprehensive neuropsychological test battery and 2 HRQOL questionnaires.

RESULTS

Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged, one (n = 14) with good cognitive function, having mild deficits only, and the other (n = 12) with poor cognitive and poor motor function. Patients performing poorly were older (P = .04), had fewer years of education (P = .005) and larger preoperative ventricular scores, and were more often shunted (P = .02). There were also differences between the 2 groups in the Glasgow Outcome Scale (P = .001), the modified Rankin Scale (P = .001), and employment status. HRQOL was more reduced in patients with poor cognitive function.

CONCLUSION

A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V) recover to good physical and cognitive function, enabling them to live a normal life.

Comparison of postoperative cognitive function in patients undergoing surgery for ruptured and unruptured intracranial aneurysm

BACKGROUND

Patients with SAH often experience cognitive decline. Previous studies used normal volunteers, published normal test values, and orthopedic patients as controls to identify factors for postoperative cognitive decline. The present study excluded the effects of surgery by comparing cognitive function after surgical repair in patients with aneurysmal SAH and patients with unruptured intracranial aneurysm.

METHODS

This study recruited 117 patients with SAH due to ruptured aneurysm and 39 patients with incidentally found unruptured intracranial aneurysms. The cognitive test battery consisted of the Japanese translation of the WAIS-R, the Japanese translation of the WMS, and the recall trial of the ROCF. Postoperative neuropsychological test scores for the patients with SAH and control subjects were compared using group-rate and event-rate analysis. The relationship between clinical variable and postoperative cognitive decline in the patients with SAH was evaluated by univariate analysis using the Mann-Whitney U test or chi(2) test.

RESULTS

Group-rate analysis showed that the WAIS-R and ROCF scores were significantly lower in the SAH group than in the control group. Event-rate analysis demonstrated that the incidence of cognitive decline in the patients with SAH (73 [62.4%] of the 117 patients) was significantly higher than that in the control subjects (12 [30.8%] of 39 patients). The Hunt and Hess grade was significantly higher in patients with postoperative cognitive decline.

CONCLUSION

The cognitive function after SAH was significantly correlated with Hunt and Hess grade on admission when using patients with postoperative unruptured intracranial aneurysm as the control group.

Simvastatin activates Akt/glycogen synthase kinase-3beta signal and inhibits caspase-3 activation after experimental subarachnoid hemorrhage

This study was designed to explore the role of simvastatin and its effects on the Akt/GSK3beta survival signal and apoptosis pathway after experimental subarachnoid hemorrhage (SAH). SAH was induced by blood injection into the cisterna magna in New Zealand white rabbits. Increased expression of phospho-Akt and phospho-GSK3beta was observed in brain tissue after SAH. Apoptosis and related proteins, including P53, apoptosis-inducing factor (AIF), cytochrome C, and cleaved caspase-3, were also activated. Simvastatin, at both low dose (10 mg/kg) and high dose (40 mg/kg), further increased expression of phospho-Akt and phospho-GSK3beta, decreased activation of caspase-3, and inhibited apoptosis. Preserved blood-brain barrier and attenuated brain edema were observed following simvastatin treatment. In addition, the neuroprotective effects of simvastatin were blocked by wortmannin (2.5 microg/kg/min), an irreversible PIK3 inhibitor. P53, AIF, and cytochrome C were not affected by simvastatin treatment. Findings from the present study suggest that simvastatin ameliorates acute brain injury after SAH. The potential mechanisms of action include activation of the Akt/GSK3beta survival signal and inhibition of caspase-dependent apoptosis pathway.

Comparison of experimental rat models of early brain injury after subarachnoid hemorrhage

OBJECTIVE

To investigate acute pathophysiological changes after subarachnoid hemorrhage (SAH) in rats and compare endovascular perforation and double blood injection models for studies of early brain injury after SAH.

METHODS

Rat SAH was induced by endovascular perforation of the internal carotid artery (n = 41) or double injection of autologous blood into the cisterna magna (n = 23). Effects of SAH on arterial blood pressure, intracranial pressure, cerebral artery dimensions, and cerebral blood flow were measured. Neuronal death was assessed 24 hours after SAH.

RESULTS

SAH was more severe in the endovascular perforation model (4-fold greater hemoglobin content on the basal brain surface), and mortality was greater (47%) than in the blood injection model (0%). Intracranial pressure increases were faster and greater in the perforation model. Correspondingly, cerebral blood flow reductions were greater after perforation than in the blood injection model, particularly in middle cerebral artery-supplied regions (32 +/- 16 versus 65 +/- 18 mL/100 g/min, P < 0.01). Diffuse neuronal death occurred in all rats in the perforation model but more seldom after blood injection. Anterior cerebral artery diameter and cross sectional area were significantly decreased on day 1 after SAH induction (52 +/- 21% and 22 +/- 16% of control values; P < 0.001) in the perforation model but not after blood injection.

CONCLUSION

The perforation model produced more severe pathophysiological changes than the double blood injection, and it mimics human SAH in having an injured blood vessel and direct hemorrhagic brain lesion under arterial blood pressure. Therefore, endovascular perforation seems more suitable for study of acute SAH sequelae. However, further model refinement is required to reduce the high mortality rate.