Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Five-Year Functional Outcomes Among Patients Surviving Aneurysmal Subarachnoid Hemorrhage

Importance

Longitudinal changes in functional levels can provide valuable information about disability. However, longitudinal outcomes in aneurysmal subarachnoid hemorrhage (aSAH) have not been well reported, which could provide insight into appropriate management and information for patients experiencing disability.

Objective

To investigate the 5-year prognosis and functional outcomes of patients with aSAH.

Design, Setting, and Participants

This retrospective cohort study used data of patients with aSAH from the Korean Stroke Cohort for Functioning and Rehabilitation study up to 5 years after onset. Data were collected from August 2012 through May 2015 in 9 different hospitals in Korea. Data were analyzed from September 2023 through January 2024.

Exposure

Patients with aSAH surviving at least 7 days after onset.

Main Outcomes and Measures

Assessments were performed serially from 7 days to 5 years after onset. Prognosis, measured by the modified Rankin scale (mRS) in terms of positive outcome (mRS score of 0 or 1), and mortality were analyzed. In addition, sequential functional outcomes were assessed using the Functional Independence Measure (FIM) in survivors of aSAH at 5 years after onset. Multiple imputation method was used to handle missing data. Wilcoxon signed-rank test and paired t test were used to analyze differences in functional measurements between each follow-up period. Additionally, a generalized mixed-effects model was used to analyze the longitudinal trajectory of the FIM.

Results

A total of 338 patients with aSAH (mean [SD] age, 56.3 [13.0] years; 207 female [61.2%]) were included. Among survivors of aSAH at 7 days, the 5-year mortality rate was 8.3% (28 participants). The distribution of mRS significantly improved until 4 years and then plateaued, with 180 (53.3%) and 77 (22.8%) patients reporting an mRS score of 0 and 1, respectively. FIM showed a significant improvement up to 4 years (mean [SD] score, 118.9 [18.7]) and then plateaued.

Conclusions and Relevance

In this cohort study, the functional outcomes in patients with aSAH continued to improve up to 4 years after onset, with the majority of participants showing favorable outcomes without significant disability, suggesting that proper long-term assessment is needed and appropriate management should be emphasized to maximize potential outcomes of patients with aSAH.

The Effectiveness of Target Temperature Management on Poor-Grade Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

The effectiveness of target temperature management (TTM) in poor-grade aneurysmal subarachnoid hemorrhage (aSAH) remains a topic of debate. In order to assess the clinical efficacy of TTM in patients with poor-grade aSAH, we conducted a systematic review and meta-analysis. This research was registered in PROSPERO (CRD42023445582) and included all relevant publications up until October 2023. We compared the TTM groups with the control groups in terms of unfavorable outcomes (modified Rankin scale [mRS] score > 3), mortality, delayed cerebral ischemia (DCI), cerebral vasospasm (CVS), and specific complications. Subgroup analyses were performed based on country, study type, follow-up time, TTM method, cooling maintenance period, and rewarming rate. Effect sizes were calculated as relative risk (RR) using random-effect or fixed-effect models. The quality of the articles was assessed using the methodological index for non-randomized studies scale. Our analysis included a total of 5 clinical studies (including 1 randomized controlled trial) and 219 patients (85 in the TTM group and 134 in the control group). Most of the studies were of moderate quality. TTM was found to be associated with a statistically significant improvement in mortality (mRS score 6) rates compared with the control group (RR = 0.61, 95% confidence interval [CI]: 0.40-0.94, p = 0.026). However, there was no statistically significant difference in unfavorable outcomes (mRS 4-6) between the TTM and control groups (RR = 0.94, 95% CI: 0.71-1.26, p = 0.702). The incidence of adverse events, including DCI, CVS, pneumonia, cardiac complications, and electrolyte imbalance, did not significantly differ between the two groups. In conclusion, our overall results suggest that TTM does not significantly reduce unfavorable outcomes in poor-grade aSAH patients. However, TTM may decrease mortality rates. Preoperative TTM may cause patients to miss the opportunity for surgery, although it temporarily protects the brain. Furthermore, the incidence of adverse events was similar between the TTM and control groups.

Long-term functional outcomes among patients surviving aneurysmal subarachnoid hemorrhage: The KOSCO study

BACKGROUND AND OBJECTIVES

Aneurysmal subarachnoid hemorrhage (aSAH) remains a significant global health concern, and therefore, understanding their functional outcomes is essential. The aim of this study was to investigate the 1-year functional outcomes of patients with aSAH.

METHODS

We retrospectively analyzed data of patients with aSAH from the Korean Stroke Cohort for Functioning and Rehabilitation study, up to 1 year post-onset. The cohort data were collected twice. The first data was collected from August 2012 through May 2015, and the second data was collected from January to December in 2020, from nine different hospitals. Assessments were performed from 7 days to 1 year. Disability, measured by modified Rankin Scale (mRS), was analyzed in terms of good outcome (mRS 0 or 1) and mortality. In addition, functional level was further assessed using Functional Independence Measure (FIM) in aSAH survivors at 1 year post-onset. A subgroup analysis was conducted, with participants further classified into two groups: one with mild-to-moderate disability (mRS 0-3) and another with severe disability (mRS 4 or 5), as reported 7 days after onset. Multiple imputation method was used to handle missing data. In addition, mixed-effects model was used to analyze the trajectory of FIM.

RESULTS

A total of 517 patients with aSAH were included. Of these, 246 (47.6%) showed mild-to-moderate disability and 271 (52.4%) showed severe disability at 7 days. At 1 year after onset, the mortality rate was 6.0% and the good outcome was reported in 76.2% of patients. In aSAH survivors at 1 year, FIM showed a significant improvement over time, with a significant difference demonstrated between the subgroups. Age, initial clinical severity, and cognitive function at 7 days were also identified as significant covariates.

CONCLUSIONS

The majority of patients reporting mild-to-moderate disability at 7 days exhibited good functional outcome, and even among those with severe disability, there was a favorable outcome with continuous improvement in their functional levels. Therefore, proper assessments and effective management should be employed to achieve favorable functional outcomes among aSAH survivors.

Safety and effectiveness of Neuroform Atlas stent-assisted coil embolization for ruptured intracranial aneurysms

OBJECTIVE

The treatment outcomes of ruptured intracranial aneurysms using the Neuroform Atlas stent were evaluated.

METHODS

This study represents a retrospective review that included patients who underwent endovascular treatment for ruptured aneurysms at a single institution. Between January 2018 and September 2022, endovascular treatments including simple coiling or Neuroform Atlas stent-assisted coil embolization were performed in 191 patients with ruptured intracranial aneurysms.

RESULTS

Intraprocedural rupture was observed in 11 (8.7%) patients in the Simple Coiling (SC) group, which was slightly higher than that in 4 (6.3%) patients in the Neuroform Atlas stent-assisted coiling (NASAC) group (p=0.241). However, Thromboembolic event (TEE) was slightly more prevalent in the NASAC group, with 4 (6.3%) cases as compared to the 5 (3.9%) cases in the SC group (p=0.235). The retreatment rate was slightly higher in the SC group, with 19 (26.4%) patients as compared to the 10 patients (22.2%) in the NASAC group (p=0.342).

CONCLUSIONS

The use of the Neuroform Atlas stent (NAS) for ruptured aneurysms might be safe and effective.

Prevention of deep vein thrombosis in patients with aneurysmal subarachnoid hemorrhage: a best practice implementation project

INTRODUCTION

Deep vein thrombosis (DVT) is a common complication observed in aneurysmal subarachnoid hemorrhage (aSAH) patients, which significantly increases the survival risks and reduces the patient's quality of life. However, preventive clinical measures for DVT have not been standardized; therefore, the scientific basis and effectiveness of these measures require further validation.

OBJECTIVE

This study aims to employ evidence-based practices to effectively prevent the occurrence of DVT in aSAH patients.

METHODS

This study was performed from June 2023 to March 2024 in the neurosurgical intensive care unit of a Grade III Class A general hospital in Nanchang, China. Furthermore, it was based on the healthcare model published by the Joanna Briggs Institute Library (JBI) in 2016, which emphasizes the use of previous evidence-based practices while considering appropriateness, feasibility, clinical significance, and validity. In this research study, 15 review indicators were developed, and baseline assessments on 47 nurses and 49 patients were conducted. Furthermore, factors promoting and obstructing implementation were analyzed, and targeted strategies to address these obstacles were formulated. Moreover, a follow-up audit was performed to identify best practices.

RESULTS

The baseline review results indicated that the incidence of DVT in aSAH patients was 16.3%. Furthermore, the implementation rates of six review indicators (1, 2, 4, 5, 8, 13) were all < 100.0%, with indicators 2, 5, and 8 indicating < 60.0% implementation rates. After the project implementation, a subsequent audit revealed that the best practice initiative yielded significant improvements compared to the baseline data. Moreover, the incidence of lower limb DVT in aSAH patients decreased from 16.3% before the evidence-based practices to 6.1% after their implementation. At the nursing level, the DVT prevention knowledge and practice questionnaire scores increased from 63.62 ± 11.48 to 74.77 ± 9.98 after the evidence-based practices (t = -5.03, p < .001). In addition, the implementation rates of the six review indicators improved to varying degrees after the implementation of evidence-based practices (p < .050).

CONCLUSIONS

This project implemented evidence-based practices and indicated a reduced incidence of lower limb DVT in patients with aSAH. Furthermore, this study improved the knowledge, provided evidence for DVT prevention for the neurosurgical ICU nurses, promoted the implementation rate of review indicators for DVT prevention, standardized the behavior of neurosurgical ICU nurses for preventing DVT in aSAH patients, and ensured the safety of patients.

TRIAL REGISTRATION

This study has been registered at the EvidenceBased Nursing Center of Fudan University in China. Clinical trial number ER20230578.

Diagnosis and endovascular management of vasospasm after aneurysmal subarachnoid hemorrhage - survey of real-life practices

BACKGROUND

Vasospasm and delayed cerebral ischemia (DCI) are the leading causes of morbidity and mortality after intracranial aneurysmal subarachnoid hemorrhage (aSAH). Vasospasm detection, prevention and management, especially endovascular management varies from center to center and lacks standardization. We aimed to evaluate this variability via an international survey of how neurointerventionalists approach vasospasm diagnosis and endovascular management.

METHODS

We designed an anonymous online survey with 100 questions to evaluate practice patterns between December 2021 and September 2022. We contacted endovascular neurosurgeons, neuroradiologists and neurologists via email and via two professional societies - the Society of NeuroInterventional Surgery (SNIS) and the European Society of Minimally Invasive Neurological Therapy (ESMINT). We recorded the physicians' responses to the survey questions.

RESULTS

A total of 201 physicians (25% [50/201] USA and 75% non-USA) completed the survey over 10 months, 42% had >7 years of experience, 92% were male, median age was 40 (IQR 35-46). Both high-volume and low-volume centers were represented. Daily transcranial Doppler was the most common screening method (75%) for vasospasm. In cases of symptomatic vasospasm despite optimal medical management, endovascular treatment was directly considered by 58% of physicians. The most common reason to initiate endovascular treatment was clinical deficits associated with proven vasospasm/DCI in 89%. The choice of endovascular treatment and its efficacy was highly variable. Nimodipine was the most common first-line intra-arterial therapy (40%). Mechanical angioplasty was considered the most effective endovascular treatment by 65% of neurointerventionalists.

CONCLUSION

Our study highlights the considerable heterogeneity among the neurointerventional community regarding vasospasm diagnosis and endovascular management. Randomized trials and guidelines are needed to improve standard of care, determine optimal management approaches and track outcomes.

Treatment of Cerebral Vasospasm Following Aneurysmal Subarachnoid Hemorrhage using the Neurospeed Semi-compliant Balloon

BACKGROUND AND PURPOSE

Cerebral vasospasm (CV) following aneurysmal subarachnoid hemorrhage (aSAH) may lead to morbidity and mortality. Endovascular mechanical angioplasty may be performed if symptomatic CV is refractory to noninvasive medical management. Off-label compliant remodelling balloons tend to conform to the course of the vessel, contrary to noncompliant or semi-compliant balloons. Our objective is to describe our initial experience with the semi-compliant Neurospeed balloon (approved for intracranial stenosis) in cerebral vasospasm treatment following aSAH.

METHODS

All patients included in the prospective observational SAVEBRAIN PWI (NCT05276934 on clinicaltrial.gov) study who underwent cerebral angioplasty using the Neurospeed balloon for the treatment of medically refractory and symptomatic CV after aSAH were identified. Patient demographic information, procedural details and outcomes were obtained from electronic medical records.

RESULTS

Between February 2022 and June 2023, 8 consecutive patients underwent CV treatment with the Neurospeed balloon. Angioplasty of 48 arterial segments (supraclinoid internal carotid artery, A1 and A2 segments of the anterior cerebral artery, M1 and M2 segments of the middle cerebral artery) was attempted and 44/48 (92%) were performed. The vessel diameter significantly improved following angioplasty (+81%), while brain hypoperfusion decreased (-81% of the mean TMax). There was no long-term clinical complication, 4% periprocedural complications occurred.

CONCLUSION

The semi-compliant Neurospeed balloon is effective in the treatment of cerebral vasospasm following aSAH, bringing a new device into the armamentarium of the neurointerventionalist to perform intracranial angioplasty.

Targeted Temperature Management for Poor Grade Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

OBJECTIVE

We assessed the effectiveness and safety of target temperature management (TTM) in treating patients with poor-grade aneurysmal subarachnoid hemorrhage (aSAH). The primary objective was to evaluate the neurological outcome at 3 months. Secondary objectives were to assess mortality, delayed cerebral ischemia, cerebral edema, hydrocephalus, midline shift, and laboratory indicators related to TTM.

METHODS

A single-blind, nonrandomized controlled trial was conducted. After admission, patients with poor-grade aSAH (Hunt-Hess scores IV ∼ V) were assigned to a TTM group or a control group in a 1:1 ratio. TTM with core temperatures ranging from 36°C to 37°C was performed immediately and maintained until microclipping or endovascular embolization. Subsequently, rapid induction to 33°C ∼ 35°C was carried out and maintained for 3 to 5 days. Then, the patients underwent slow rewarming to 36°C ∼ 37°C and maintained at that temperature for a minimum of 48 hours.

RESULTS

Sixty patients (30 treated with TTM and 30 with standard treatment) were included in the study. At 3 months, a favorable prognosis (modified Rankin scale score 0 to 3) was significantly higher in the TTM group than in the control group (n = 14, 46.7% vs. n = 6, 20.0%, P = 0.028). Adjusted multivariate logistics regression analysis indicated that TTM (odds ratio = 0.20, 95% confidence interval: 0.05-0.77, P = 0.019) reduced the number of unfavorable prognoses 3 months after admission.

CONCLUSIONS

This study demonstrated the effectiveness and safety of TTM in patients with poor-grade aSAH, and its implementation improved neurological outcomes. Multicenter randomized controlled studies with a large number of patients are needed to confirm these observations.

Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Pharmacological Prevention of Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Causes of morbidity and mortality following aneurysmal subarachnoid hemorrhage (aSAH) include early brain injury and delayed neurologic deterioration, which may result from delayed cerebral ischemia (DCI). Complex pathophysiological mechanisms underlie DCI, which often includes angiographic vasospasm (aVSP) of cerebral arteries.

METHODS

Despite the study of many pharmacological therapies for the prevention of DCI in aSAH, nimodipine-a dihydropyridine calcium channel blocker-remains the only drug recommended universally in this patient population. A common theme in the research of preventative therapies is the use of promising drugs that have been shown to reduce the occurrence of aVSP but ultimately did not improve functional outcomes in large, randomized studies. An example of this is the endothelin antagonist clazosentan, although this agent was recently approved in Japan.

RESULTS

The use of the only approved drug, nimodipine, is limited in practice by hypotension. The administration of nimodipine and its counterpart nicardipine by alternative routes, such as intrathecally or formulated as prolonged release implants, continues to be a rational area of study. Additional agents approved in other parts of the world include fasudil and tirilazad.

CONCLUSIONS

We provide a brief overview of agents currently being studied for prevention of aVSP and DCI after aSAH. Future studies may need to identify subpopulations of patients who can benefit from these drugs and perhaps redefine acceptable outcomes to demonstrate impact.

Is Thyroid Dysfunction Associated with Unruptured Intracranial Aneurysms? A Population-Based, Nested Case-Control Study from Korea

Background: Few risk factors for the development of intracranial aneurysms (IAs) are known. We investigated the potential role of thyroid diseases in IA development using nationwide real-world data. Methods: A nested case-control study within the National Health Insurance Service-National Sample Cohort data from 2002 to 2019 was performed. A total of 5335 patients with unruptured IA were matched by age and sex with 80,025 controls at a ratio of 1:15. We estimated the odds ratios (ORs) and corresponding confidence intervals [CIs] between thyroid diseases and unruptured IA using a multivariable conditional logistic regression model. Results: Tobacco smoking, use of antihypertensive medication, and hypothyroidism were significantly associated with an elevated risk for unruptured IA in univariate analysis. In multivariable analysis, a history of hypothyroidism was associated with unruptured IA (adjusted OR: 1.46 [CI: 1.26-1.69]). Among patients with hypothyroidism, long-term use of thyroid hormone for >5 years was associated with a reduced risk for unruptured IA (adjusted OR: 0.69 [CI: 0.48-0.99]). A history of hyperthyroidism was associated with a reduced risk for unruptured IAs (adjusted OR: 0.71 [CI: 0.54-0.93]). In secondary analyses of the data according to sex, the respective observed associations between hypothyroidism and hyperthyroidism and the risk of IAs were found to be statistically significant in females but not in males. Conclusions: Hypothyroidism is associated with an increased risk of unruptured IAs, whereas hyperthyroidism is associated with a reduced risk. Overall, the findings suggest that thyroid hormones may play a protective role in the development of unruptured IAs. Further studies are needed to clarify potential direct causality and the biologic mechanisms relating thyroid dysfunction and unruptured IA.

Management of neurological complications related to aneurysmal subarachnoid hemorrhage: A comparison of the bedside therapeutic algorithms

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is of the most serious emergencies in neurosurgical practice and continues to be associated with high morbidity and mortality. Beyond securing the ruptured aneurysm to prevent a rebleed, physicians continue to be concerned about potential complications such as cerebral vasospasm-delayed cerebral ischemia (DCI), an area where management remains highly variable. This study aimed at reviewing the most recent literature and assessing any up-to-date schemes for treating the most common aSAH neurological complications in adults that can be applied in daily clinical practice towards optimising outcomes.

METHODS

A systematic review was performed according to PRISMA guidelines on the management of aSAH neurological complications in adults. The literature surveyed was between 2016 and 2022 inclusive, using the Pubmed search engine. Comparisons between the methods suggested by existing therapeutic algorithms were discussed.

RESULTS

Six stepwise algorithms assisting the decision-making for treating cerebral vasospasm-DCI were recognised and compared. No algorithm was found for the management of any other neurological complications of aSAH. Despite differences in the algorithms, induced hypertension and endovascular therapy were common treatments in all approaches. Controversy in the therapeutic process of these complications surrounds not only the variability of methods but also their optimal application towards clinical outcome optimisation.

CONCLUSIONS

A universal approach to managing aSAH complications is lacking. Despite advances in the techniques to secure a ruptured aneurysm, there persist a high rate of neurological deficit and mortality, and several unanswered questions. More research is required towards stratification of current treatment algorithms as per the quality of their evidence.

Microsurgical and endovascular treatment of posterior inferior cerebellar artery aneurysms: a systematic review and meta-analysis

INTRODUCTION

Posterior inferior cerebellar artery (PICA) aneurysms are uncommon vascular lesions of the posterior fossa. In addition to aneurysmal morphology, structural anatomic considerations may confer additional procedural risk, and as a result there is currently no consensus as to whether a surgical or endovascular approach offers greater safety and efficacy for patients.

EVIDENCE ACQUISITION

We systematically examined peer-reviewed literature describing PICA aneurysm treatment planning from January 2000 to May 2021 using the PRISMA methodology. A meta-analysis of proportions was performed. Certainty of the evidence was assessed using the GRADE approach.

EVIDENCE SYNTHESIS

Fifty-eight studies including 1673 PICA aneurysms were analyzed. Overall treatment occlusion rate was 97% (95% confidence interval [CI]: 93-100%) for surgery and 85% (95% CI: 78-92%) for endovascular therapy. The recurrence rate was 6% in the endovascular group and 1% for surgery. Overall morbidity and mortality were 16% and 7%, respectively. Intraoperative complications occurred in 9% of the surgical patients.

CONCLUSIONS

Despite a large body of literature, analysis indicates that 62% of studies had moderate or serious risk of bias, suggesting very-low certainty results. Therefore, treatment via either approach should be determined on a case-by-case basis and according to institutional experience.

Hemodynamic Management in the Prevention and Treatment of Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

One of the most serious complications after subarachnoid hemorrhage (SAH) is delayed cerebral ischemia, the cause of which is multifactorial. Delayed cerebral ischemia considerably worsens neurological outcome and increases the risk of death. The targets of hemodynamic management of SAH have widely changed over the past 30 years. Hypovolemia and hypotension were favored prior to the era of early aneurysmal surgery but were subsequently replaced by the use of hypervolemia and hypertension. More recently, the concept of goal-directed therapy targeting euvolemia, with or without hypertension, is gaining preference. Despite the evolving concepts and the vast literature, fundamental questions related to hemodynamic optimization and its effects on cerebral perfusion and patient outcomes remain unanswered. In this review, we explain the rationale underlying the approaches to hemodynamic management and provide guidance on contemporary strategies related to fluid administration and blood pressure and cardiac output manipulation in the management of SAH.

The effect of induced hypertension in aneurysmal subarachnoid hemorrhage: A narrative review

Aneurysmal subarachnoid hemorrhage ‎(aSAH) ‎accounts for 2-5% of all strokes, and 10%-15% of ‎aSAH patients will not survive until hospital admission. Induced hypertension (IH) is an emerging therapeutic option being used for the treatment of vasospasm in ‎aSAH. For patients with cerebral vasospasm (CVS) consequent to SAH, IH is implemented to increase systolic blood pressure (SBP) in order to optimize cerebral blood flow (CBF) and prevent delayed cerebral ischemia (DCI). Prophylactic use of IH has been associated with the development of vasospasm and cerebral ischemia in SAH patients. Various trials have defined several different parameters to help clinicians decide when to initiate IH in a SAH patient. However, there is insufficient evidence to recommend therapeutic IH in aSAH due to the possible serious complications like myocardial ischemia, development of posterior reversible encephalopathy syndrome (PRES), pulmonary edema, and even rupture of another unsecured aneurysm. This narrative review showed the favorable impact of IH therapy on aSAH patients; however, it is crucial to conduct further clinical and molecular experiments to shed more light on the effects of IH in aSAH.

Effect of early stellate ganglion block in cerebral vasospasm after aneurysmal subarachnoid hemorrhage (BLOCK-CVS): study protocol for a randomized controlled trial

Introduction

Stellate ganglion block has been reported to expand cerebral vessels and alleviate vasospasm after aneurysmal subarachnoid hemorrhage. However, the causal relationship between early stellate ganglion block and cerebral vasospasm prevention has not yet been established. The purpose of this study was to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment for cerebral vasospasm and delayed cerebral ischemia.

Methods/design

This is a single-center, prospective, randomized, controlled, blinded endpoint assessment superiority trial. A total of 228 patients will be randomized within 48 h of aneurysmal subarachnoid hemorrhage onset in a 1:1 ratio into two groups, one group receiving an additional e-SGB and the other group receiving only a camouflaging action before anesthesia induction in the operating room. The primary outcome is the incidence of symptomatic vasospasm within 14 days after aSAH. Further safety and efficacy parameters include the incidence of radiographic vasospasm, new cerebral infarction, postoperative delirium, and complications up to 90 days after surgery; postoperative cerebral hemodynamics; Mini-Mental State Examination score; modified Rankin scale score; and all-cause mortality up to 90 days after surgery.

Discussion

This is a randomized controlled trial to explore the effectiveness and safety of early stellate ganglion block as a preventive treatment to reduce cerebral vasospasm in patients with aneurysmal subarachnoid hemorrhage. If the results are positive, it may provide a new direction for the prevention and treatment of cerebral vasospasm and delayed cerebral ischemia.

Trial registration

The study was registered on Clincaltrials.gov on December 13, 2020 (NCT04691271).

Ultra-early endovascular treatment improves prognosis in High grade aneurysmal subarachnoid hemorrhage: A single-center retrospective study

Background

The long-term survival prognosis of patients with high-grade (Hunt-Hess grade IV–V or World Federation of Neurosurgical Societies grade IV–V) aneurysmal subarachnoid hemorrhage (aSAH) is generally poor, and the association between endovascular treatment timing and the prognosis of high-grade aSAH has not been explored in depth. This retrospective cohort study aimed to determine whether endovascular treatment within 24 h of high-grade aSAH is associated with a better prognosis.

Methods

We retrospectively analyzed the clinical data of patients with high-grade aSAH who were admitted to our institution between January 2018 and January 2021. The Modified Rankin Scale score was used to assess the 6-month prognosis of patients. Univariate and multivariate logistic regression analyses were used to identify the factors associated with prognosis. The area under the receiver operating characteristic (ROC) curve was used to assess the model's discriminatory ability.

Results

Eighty-six patients were included in the study. In the multivariate analysis, the timing of endovascular treatment (odds ratio = 7.003 [1.800–27.242], P = 0.005) was an independent risk factor for prognosis. The ROC curve showed that the predictive power of the timing of endovascular treatment was 0.744, the best cut-off value was 12.5 h, and the corresponding sensitivity and specificity were 71.4 and 70.5%, respectively. Hydrocephalus (P = 0.005) and pulmonary infection (P = 0.029) were also associated with prognosis. In addition, cerebrospinal fluid drainage immediately after endovascular treatment had a significant effect on reducing hydrocephalus formation.

Conclusions

Endovascular therapy within 24 h is feasible and improves the prognosis of patients with high-grade aSAH.

microRNAs in Subarachnoid Hemorrhage (Review of Literature)

Recently, many studies have shown that microRNAs (miRNAs) in extracellular bioliquids are strongly associated with subarachnoid hemorrhage (SAH) and its complications. The article presents issues related to the occurrence of subarachnoid hemorrhage (epidemiology, symptoms, differential diagnosis, examination, and treatment of the patient) and a review of current research on the correlation between miRNAs and the complications of SAH. The potential use of miRNAs as biomarkers in the treatment of SAH is presented.

Adding eosinophil count to EMERALD rules predicts subarachnoid haemorrhage better in emergency department

BACKGROUND

Subarachnoid haemorrhage (SAH) clinical decision rules can provide successful results in the differential diagnosis of non-traumatic headache.

AIM

The aim of this study is to investigate whether a laboratory parameter that can be added to clinical decision-making rules can better predict subarachnoid haemorrhages in patients presenting to the emergency department with headache.

METHODS

We conducted a retrospective cohort study between March 2017 and March 2019. Patients over the age of 18 who admitted to the emergency department with non-traumatic, acute headache last 14 days before admission and evaluated by imaging and laboratory studies were included in the study.

RESULTS

A total of 867 patients were included and 141 of them had SAH. In detecting the SAH, Ottawa SAH rule sensitivity (85.1%), specificity (47.1%), positive predictive value (PPV) (23.8%) and negative predictive value (NPV) (94.2%), and for EMERALD SAH, rule sensitivity (96.4%), specificity (43.2%), PPV (24.8%) and NPV (98.4%). In the regression analysis, statistically significant result was obtained to exclude the diagnosis of SAH with the decrease in the eosinophil value (cutoff < 0.085 10^3/µL, OR: 0.011, 95% CI: 0.001-0.213, p = 0.003). When eosinophil value was added to EMERALD SAH rule, it provided a 100% of sensitivity, a 38.4% of specificity, a 24% of PPV and a 100% of NPV in detecting the SAH.

CONCLUSIONS

EMERALD SAH rule plus eosinophil, which offers 100% sensitivity and NPV for predicting SAH in adult non-traumatic headaches, may be recommended as a successful and practical decision rule for clinical use according to the Ottawa and EMERALD SAH rule.

Comparison of Stent-Assisted Coil Embolization Versus Coil Embolization Alone for Ruptured Cerebral Aneurysms with Mild Symptoms: A Single-Clinic Experience

Purpose

To evaluate the safety and efficacy of stent-assisted coil embolization (SAC) in acutely ruptured cerebral aneurysms without severe symptoms, and thus, the usefulness of the stent itself in patients with subarachnoid hemorrhages.

Materials and Methods

From January 2017 to June 2019, 118 patients were treated with coil embolization for acutely ruptured cerebral aneurysms without severe symptoms (Hunt & Hess grade ≤ 3). The periprocedural complications, six-month modified Rankin scores (mRS), and six-month radiologic outcomes were compared between 56 patients with SAC and 62 patients without SAC (non-SAC).

Results

The rate of good clinical outcomes (mRS ≤ 2), as well as the rate of hemorrhagic and ischemic complications, showed no significant difference between the SAC and non-SAC groups. Moreover, compared to the non-SAC group, the SAC group showed a lower recanalization rate on the six-month follow-up angiogram (20% vs. 39.3%, p = 0.001).

Conclusion

Although stent use was not significantly associated with clinical outcomes in coil embolization of ruptured cerebral aneurysms with non-severe symptoms (Hunt & Hess grade ≤ 3), it significantly decreased the rate of recanalization on follow-up cerebral angiograms.

Association between time to emergency neurosurgery and clinical outcomes for spontaneous hemorrhagic stroke: A nationwide observational study

Objective

Spontaneous hemorrhagic stroke is a devastating disease with high mortality and grave neurological outcomes worldwide. This study aimed to evaluate the association between the elapsed time from emergency department (ED) visit to emergency neurosurgery and clinical outcomes in patients with spontaneous hemorrhagic stroke.

Methods

A nationwide cross-sectional study was conducted using the nationwide emergency database in Korea. Spontaneous hemorrhagic stroke patients who received neurosurgery within 12 hours of ED visit between January 2018 and December 2019 were enrolled. The main exposure was time to neurosurgery and the primary outcome was in-hospital mortality. Multivariable logistic regression was conducted.

Results

Among 2,602 study populations (incidence rate: 2.5 per 100,000 person-years, 15.8% of SAH, 78.6% of ICH, and 5.6% of mixed type), 525 (20.2%) patients received surgery in the ultra-early (0–2 hours) group, 1,093 (42.0%) in the early (2–4 hours) group, and 984 (37.8%) in the late (4–12 hours) group. The early group showed better survival outcomes than the ultra-early and late group (in-hospital mortality 22.2% vs. 26.5% and 26.1%, p = 0.06). Compared to the late group, adjusted OR (95% CI) for in-hospital mortality was 0.78 (0.63–0.96) for the early group, while there was no significant difference in the ultra-early group (0.90 (0.69–1.16)).

Conclusions

Early neurosurgery within 2–4 hours of the ED visit was associated with favorable survival outcomes in patients with spontaneous hemorrhagic stroke.

A Comparison Between Enteral and Intravenous Nimodipine in Subarachnoid Hemorrhage: A Systematic Review and Network Meta-Analysis

Our objective was to compare the effectiveness of intravenous and enteral nimodipine in preventing poor outcome from delayed cerebral ischemia in patients with subarachnoid hemorrhage. We performed a systematic search and a network meta-analysis using the following databases: PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Google Scholar. Risk of Bias 2 tool was used to assess risk of bias of included studies. A ranking among methods was performed on the basis of the frequentist analog of the surface under the cumulative ranking curve. Published studies that met the following population, intervention, comparison, outcomes and study (PICOS) criteria were included: patients with subarachnoid hemorrhage aged 15 years or older (P); nimodipine, intravenous and oral formulation (I); placebo or no intervention (C); poor outcome measured at 3 months (defined as death, vegetative state, or severe disability), case fatality at 3 months, delayed cerebral ischemia, delayed ischaemic neurologic deficit, and vasospasm measured with transcranial Doppler or digital subtraction angiography (O); and randomized controlled trials (S). No language or publication date restrictions were applied. Ten studies were finally included, with a total of 1527 randomly assigned patients. Oral and intravenous nimodipine were both effective in preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. Neither treatment was effective in improving case fatality. Evolving clinical protocols over a 30-year period and the risk of bias of the included studies may limit the strength of our results. Enteral and intravenous nimodipine may have a similar effectiveness in terms of preventing poor outcome, delayed cerebral ischemia, and delayed ischaemic neurological deficit. More research may be needed to fully establish the role of intravenous nimodipine in current clinical practice.

Methodological assessment of guidelines for the diagnosis and management of cerebral vasospasm using the AGREE-II tool

OBJECTIVE

Rupture of an intracranial aneurysm is the most common cause of spontaneous subarachnoid hemorrhage. Despite the recent advances in its early detection, diagnosis, and proper treatment, the outcome of patients experiencing aneurysmal subarachnoid hemorrhage (aSAH) remains poor. It is well known that cerebral vasospasm is the most troublesome complication of aSAH, while delayed cerebral ischemia related to cerebral vasospasm constitutes the major cause of unfavorable outcomes in patients with aSAH. The need for evidence-based guidelines is of great importance for the prevention, early detection, and efficient management of aSAH-induced vasospasm. Moreover, guidelines provide young physicians with a valuable tool for practicing defensible medicine. However, the methodology, clinical applicability, reporting clarity, and biases of guidelines must be periodically assessed. In this study, the authors sought to assess the reporting clarity and methodological quality of published guidelines and recommendations.

METHODS

A search was performed in the PubMed, Scopus, and Web of Science databases. The search terms used were "clinical practice guidelines," "recommendations," "stroke," "subarachnoid hemorrhage," and "vasospasm" in all possible combinations. The search period extended from 1964 to September 2021 and was limited to literature published in the English language. All published guidelines and recommendations reporting on the diagnosis and management of vasospasm were included. Studies other than those reporting guidelines and recommendations were excluded. The eligible studies were evaluated by three blinded raters, employing the Appraisal of Guidelines for Research & Evaluation II (AGREE-II) analysis tool.

RESULTS

A total of 10 sets of guidelines were evaluated in this study. The American Heart Association/American Stroke Association issued guidelines found to have the highest methodological quality and reporting clarity, followed by the European Stroke Organization guidelines and the English edition of the Japanese guidelines issued by the Japanese Society on Surgery for Cerebral Stroke. The interrater agreement was moderate in the current analysis.

CONCLUSIONS

These findings support the idea that improvement of currently existing guidelines is feasible in the following domains: the rigor of guidelines and recommendations development, clinical applicability, editorial independence, and stakeholder involvement. Furthermore, periodic updating of published guidelines requires improvement in the future.

Treatment outcomes of 1-stage clipping of multiple unruptured intracranial aneurysms via keyhole approaches

OBJECTIVE

Complete exclusion of multiple unruptured intracranial aneurysms (UIAs) in one session of intervention may be ideal. However, such situations are not always feasible in terms of treatment modalities and outcomes. The authors aimed to analyze their experience with 1-stage clipping of multiple UIAs.

METHODS

Medical records between March 2013 and December 2018 were retrospectively reviewed, and 111 1-stage keyhole approaches in 110 patients with 261 multiple UIAs were ultimately included in this study. Clinical and radiological outcomes were analyzed, as well as postoperative complications up to 1 month after the surgery and their risk factors.

RESULTS

Keyhole approaches included unilateral supraorbital in 87 operations (78.4%), bilateral supraorbital in 12 (10.8%), and others in 12. The mean operative duration was 169.6 minutes (range 80-490 minutes). The highest numbers of aneurysms clipped at once were 2 (73.9%) and 3 (18.9%). Complete exclusion and residual neck of the clipped aneurysms were achieved in 89.3% and 7.3%, respectively. There was no significant difference between pre- and postoperative 1-month neurological states (p = 0.14). The permanent morbidity rate was 1.8% (n = 2), and there were no deaths. Postoperative transient neurological deterioration (TND) with no radiological and electrophysiological abnormalities occurred in 8 operations (7.2%). Hypertension was the only significant risk factor for postoperative TND (adjusted odds ratio 17.03, 95% confidence interval 1.99-2232.24, p = 0.01).

CONCLUSIONS

One-stage clipping of multiple UIAs via keyhole approaches showed satisfactory treatment outcomes with a low permanent morbidity. Patients with chronic hypertension had a high risk of postoperative TND.

Association of Plasma Glucose to Potassium Ratio and Mortality After Aneurysmal Subarachnoid Hemorrhage

Objectives: Hyperglycemia and hypokalemia are common problems in patients with aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to determine whether the plasma glucose to potassium ratio (GPR) predicts mortality due to aSAH. Methods: We prospectively recruited aSAH patients and healthy controls between March 2007 and May 2017. Clinical outcomes included mortality and poor outcome (modified Rankin scale score of 3-6) after 3 months. Multivariable analysis was used to determine the association between plasma GPR and 3-month mortality in aSAH patients. Results: A total of 553 patients were recruited, and the mortality rate was 11%. The GPR was significantly elevated in aSAH patients compared with controls, in patients with a poor outcome than with a good outcome and in non-survivals than in survivals. Multivariable analysis showed that the plasma GPR was an independent factor associated with 3-month mortality. The area under the curve of the GPR was 0.747 in predicting 3-month mortality. Conclusion: The plasma GPR on admission has potential as a predictor of 3-month mortality in patients with aSAH.

The Fate of Partially Thrombosed Intracranial Aneurysms Treated with Endovascular Intervention

Objective

The fate of partially thrombosed intracranial aneurysms (PTIAs) is not well known after endovascular treatment. The authors aimed to analyze the treatment outcomes of PTIAs.

Methods

We retrospectively reviewed the medical records of 27 PTIAs treated with endovascular intervention between January 1999 and March 2018. Twenty-one aneurysms were treated with intraluminal embolization (ILE), and six were treated with parent artery occlusion (PAO) with or without bypass surgery. Radiological results, clinical outcomes and risk factors for major recurrence were assessed.

Results

The initial clinical status was similar in both groups; however, the last status was better in the ILE group than in the PAO group (p=0.049). Neurological deterioration resulted from mass effect in one case and rupture in one after ILE, and mass effect in two and perforator infarction in one after PAO. Twenty cases (94.2%) in the ILE group initially achieved complete occlusion or residual neck status. However, 13 cases (61.9%) showed major recurrence, the major causes of which included coil migration or compaction. Seven cases (33.3%) ultimately achieved residual sac status after repeat treatment. In the PAO group, all initially showed complete occlusion or a residual neck, and just one case ultimately had a residual sac. Two cases showed major recurrence, the cause of which was incomplete PAO. Aneurysm wall calcification was the only significantly protective factor against major recurrence (odds ratio, 36.12; 95% confidence interval, 1.85 to 705.18; p=0.018).

Conclusion

Complete PAO of PTIAs is the best option if treatment-related complications can be minimized. Simple fluoroscopy is a useful imaging modality because of the recurrence pattern.

Cognitive deficits among patients surviving aneurysmal subarachnoid hemorrhage. A contemporary systematic review

BACKGROUND

Subarachnoid hemorrhage (SAH) is associated with high rates of morbidity, including neurological and cognitive deficits that may be difficult to identify and quantify. This review provides an update on the cognitive deficits that may result from spontaneous aneurysmal SAH (aSAH) and identifies factors that may help predict and manage these deficits at discharge and thereafter.

MATERIALS AND METHODS

We conducted a systematic review of PubMed and Google Scholar to identify studies published between 2010 and 2019 that assessed cognitive deficits at discharge and during follow-up in patients with aSAH. Full-text articles were assessed for information regarding cognitive testing and factors that may be associated with functional outcomes in this population.

RESULTS

We reviewed 65 studies published since 2010 that described the cognitive deficits associated with non-traumatic aSAH. Such deficits may impact functional outcomes, quality of life, and return to work and may result in cognitive impairments, such as memory difficulties, speech problems, and psychiatric disorders.

CONCLUSIONS

Patients with aSAH, even those that appear normal at the time of hospital discharge, may harbor cognitive deficits that are difficult to detect, yet can interfere with daily functioning. Further research is needed to provide additional information and to identify stronger correlations to be used in the identification, treatment, and amelioration of long-term cognitive deficits in aSAH patients, including those who are discharged with good clinical outcomes scores.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Lessons from the CONSCIOUS-1 Study

After years of research on treatment of aneurysmal subarachnoid hemorrhage (aSAH), including randomized clinical trials, few treatments have been shown to be efficacious. Nevertheless, reductions in morbidity and mortality have occurred over the last decades. Reasons for the improved outcomes remain unclear. One randomized clinical trial that has been examined in detail with these questions in mind is Clazosentan to Overcome Neurological Ischemia and Infarction Occurring After Subarachnoid Hemorrhage (CONSCIOUS-1). This was a phase-2 trial testing the effect of clazosentan on angiographic vasospasm (aVSP) in patients with aSAH. Clazosentan decreased moderate to severe aVSP. There was no statistically significant effect on the extended Glasgow outcome score (GOS), although the study was not powered for this endpoint. Data from the approximately 400 patients in the study were detailed, rigorously collected and documented and were generously made available to one investigator. Post-hoc analyses were conducted which have expanded our knowledge of the management of aSAH. We review those analyses here.

Management of incidentally found unruptured intracranial aneurysms

Incidentally found unruptured intracranial aneurysms are increasing because of the popularity of medical checkups with cerebrovascular imaging and the recent growing interest in health. Accordingly, surgical or endovascular treatments are also increasing in prevalence to improve aneurysm-related symptoms or prevent the rupture of aneurysms causing devastating conditions. However, treatment plans should be carefully determined based on the natural history of aneurysms, comorbidities of the patients, and institutional situations because of the relatively low risk of rupture, no uncommon treatment-related complications, and considerable economical and psychological burdens. Recently, domestic and international clinical guidelines for unruptured intracranial aneurysms were introduced, and the guidelines have been continuously revised according to advancements in imaging and treatment techniques. Here, this review paper introduces the clinical characteristics of unruptured intracranial aneurysms including the epidemiology, risk factors of development, growth and rupture, natural course, symptoms and signs, imaging tools for diagnosis and follow-up, and treatment methods. This paper also includes recent international prospective trials, analytic reports with big data from national health insurance and health insurance review and assessment services, and the guidelines of Korea and other foreign countries.

Clinical Safety and Effectiveness of Stent-Assisted Coil Embolization with Neuroform Atlas Stent in Intracranial Aneurysm

Objective

Stent-assisted coil embolization (SAC) is commonly used for treating wide-neck intracranial aneurysms. In this study, we aimed to assess the clinical safety and efficacy of the NeuroForm Atlas Stent during SAC of intracranial aneurysms.

Methods

We retrospectively analyzed data from patients with ruptured and unruptured cerebral aneurysms, who underwent SAC using the NeuroForm Atlas between February 2018 and July 2018. Favorable clinical outcomes and degree of aneurysm occlusion were defined as a modified Rankin scale score of ≤2 and a Raymond-Roy occlusion classification (RROC) class I/II during the immediate postoperative period and at the 6-month follow-up, respectively.

Results

Thirty-one consecutive patients with 33 cases, including 11 ruptured and 22 unruptured cases were treated via NeuroForm Atlas SAC. Among the 22 unruptured cases with 24 unruptured aneurysms had favorable clinical outcome. Complete occlusion (RROC I) was achieved in 16 aneurysms (66.7%), while neck remnants (RROC II) were observed in six aneurysms (25%). Among the 11 patients with ruptured aneurysms, two died due to re-bleeding and diabetic ketoacidosis. In ruptured cases, RROC I was observed in eight (72.7%) and RROC II was observed in three cases (27.3%). At the 6-month follow-up, no clinical events were observed in the 22 unruptured cases. In the ruptured nine cases, five patients recovered without neurologic deficits, while four experienced unfavorable outcomes at 6 months. Of the 29 aneurysms examined via angiography at the 6-month follow-up, 19 (65.5%) were RROC I, eight (27.6%) were RROC II and two (6.9%) were RROC III. There were no procedure-related hemorrhagic complications.

Conclusion

In this study, we found that stent-assisted coil embolization with NeuroForm Atlas stent may be safe and effective in the treatment of wide-neck intracranial aneurysms. NeuroForm Atlas SAC is feasible for the treatment of both ruptured and unruptured wide-neck aneurysms.

Characteristics and Treatment Outcome of Intracranial Aneurysms in Children and Adolescents

Objective

Intracranial aneurysms are not common in young age patients. We sought to find the characteristics of the intracranial aneurysms in patients under 20 years of age.

Methods

We reviewed 23 consecutive patients ≤20 years of age treated for their intracranial aneurysms during the period from 1995 to 2017. From medical records and imaging studies, we gathered data on age, sex, presentation, associated medical condition, location and characteristics of aneurysms, treatment and clinical outcomes.

Results

The patients’ ages ranged from 13 months to 20 years (median, 14 years). There were 16 males and seven females (male to female ratio, 2.3 : 1) with 31 aneurysms. Clinical presentations included sudden severe headache in 61%, followed by altered mentality in 17% and seizure in 17%. More than one-fourth patients had specific medical conditions related to the development of the cerebral aneurysms. The majority of aneurysms occurred in the anterior circulation (71%), and were saccular (71%). There were each three patients with false aneurysms (13%) and giant aneurysms (13%), and only one patient with multiple aneurysms (4%). We treated 22 patients : 21 aneurysms with the endovascular methods, three with open surgery, and one with combined treatment. Good functional outcome could be achieved in 86% during the follow-up period.

Conclusion

In this series, the young-age patients with intracranial aneurysms were characterized by male predominance, related specific medical conditions, low incidence of multiple aneurysms, high incidence of giant aneurysms and good functional outcome after treatment.

A hybrid operating room for combined surgical and endovascular procedures for cerebrovascular diseases: a clinical experience at a single centre

Purpose: To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR). Material and methods: A single-plane DSA system with 3-dimensional rotational angiography (3DRA), cone-beam computed tomography, and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of neurovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorised into five subcategorical procedures according to the dominance of surgical and/or endovascular procedures: intraoperative angiographic evaluation, combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, surgical approach for interventional procedure, and frameless stereotaxic operation. Results: Intraoperative angiography revealed unsatisfactory clipping of intracranial aneurysms in 6 (13.6%) patients and remnant AVMs in 1 (16.7%) patient, which were determined as complete surgical outcome via indocyanine green videoangiography. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial haemorrhage (ICH) were treated by partial embolisation and surgical clipping. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolisation. In 1 (0.8%) complicated case of 103 intra-arterial (IA) thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. Direct puncture of the common carotid artery or vertebral artery was performed to achieve interventional access to treat aneurysm or recanalise vessel occlusions in 7 cases. In 27 cases of ICH, frameless stereotaxic haematoma aspiration was performed using XperGuide® system. All procedures were performed in single sessions without any procedural complications. Conclusion: Hybrid OR with a fully equipped DSA system could provide safe and precise treatment for neurovascular diseases. Hybrid procedures for neurovascular diseases in hybrid OR are a promising new trend.

Intraoperative Mannitol Administration Increases the Risk of Postoperative Chronic Subdural Hemorrhage After Unruptured Aneurysm Surgery

OBJECTIVE

Although mannitol is used widely to facilitate brain retraction in cases of ruptured aneurysms, there is no consensus about the intraoperative administration of mannitol in the case of unruptured aneurysms. Accordingly, this study was conducted to identify an intraoperative mannitol administration strategy.

METHODS

Mannitol was administered routinely to patients (n = 90) from January 2015 to April 2016 and not administered to patients (n = 97) from May 2016 to June 2017. The patient groups with and without mannitol administration were then compared based on the patient medical records, radiologic data, and digital recordings from an intraoperative microscope.

RESULTS

The patient groups with and without mannitol administration were comparable regarding patient age, number of elderly patients, sex, and aneurysm locations. No between-group difference was identified in terms of the intradural procedural time, retraction-induced cortical injury, postoperative electrolyte imbalance, symptomatic infarction, and postoperative epidural hematomas. However, the patient group without mannitol administration showed a significantly lower incidence of chronic subdural hematomas (CSDHs) >50 mL (13.3% vs. 3.1%, P = 0.010). Moreover, a multivariate analysis revealed that an advanced age (P = 0.019), male sex (P <0.001), and mannitol administration (P = 0.040) were all statistically significant risk factors for a postoperative CSDH >50 mL following unruptured aneurysm surgery.

CONCLUSIONS

Withholding the administration of mannitol during a pterional or modified procedure for unruptured aneurysms was found to reduce the postoperative occurrence of a CSDH without increasing the operative difficulties or other postoperative complications.

A Review of the Management of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Despite decades of research, cerebral vasospasm (CV) continues to account for high morbidity and mortality in patients who survive their initial aneurysmal subarachnoid hemorrhage.

OBJECTIVE

To define the scope of the problem and review key treatment strategies that have shaped the way CV is managed in the contemporary era.

METHODS

A literature search was performed of CV management after aneurysmal subarachnoid hemorrhage.

RESULTS

Recent advances in neuroimaging have led to improved detection of vasospasm, but established treatment guidelines including hemodynamic augmentation and interventional procedures remain highly variable among neurosurgical centers. Experimental research in subarachnoid hemorrhage continues to identify novel targets for therapy.

CONCLUSIONS

Proactive and preventive strategies such as oral nimodipine and endovascular rescue therapies can reduce the morbidity and mortality associated with CV.

Four-Year Experience Using an Advanced Interdisciplinary Hybrid Operating Room : Potentials in Treatment of Cerebrovascular Disease

Objective

To describe our experiences with a fully equipped high-end digital subtraction angiography (DSA) system within a hybrid operating room (OR).

Methods

A single-plane DSA system with 3-dimensional rotational angiography, cone-beam computed tomography (CBCT), and real-time navigation software was used in our hybrid OR. Between April 2014 and January 2018, 191 sessions of cerebrovascular procedures were performed in our hybrid OR. After the retrospective review of all cases, the procedures were categorized into three subcategorical procedures : combined endovascular and surgical procedure, complementary rescue procedure during intervention and surgery, and frameless stereotaxic operation.

Results

Forty-nine of 191 procedures were performed using hybrid techniques. Four cases of blood blister aneurysms and a ruptured posterior inferior cerebellar artery aneurysm were treated using bypass surgery and endovascular trapping. Eight cases of ruptured aneurysm with intracranial hemorrhage (ICH) were treated by partial embolization and surgical clipping. Six cases of ruptured arteriovenous malformation with ICH were treated by Onyx embolization of nidus and subsequent surgical removal of nidus and ICH. Two (5.4%) of the 37 cases of pre-mature rupture during clipping were secured by endovascular coil embolization. In one (0.8%) complicated case of 103 intra-arterial thrombectomy procedures, emergency surgical embolectomy with bypass surgery was performed. In 27 cases of ICH, frameless stereotaxic hematoma aspiration was performed using XperGuide^® system (Philips Medical Systems, Best, the Netherlands). All procedures were performed in single sessions without any procedural complications.

Conclusion

Hybrid OR with a fully equipped DSA system could provide precise and safe treatment strategies for cerebrovascular diseases. Especially, we could suggest a strategy to cope flexibly in complex lesions or unexpected situations in hybrid OR. CBCT with real-time navigation software could augment the usefulness of hybrid OR.

Positive fluid balance is associated with increased in-hospital mortality in patients with intracerebral hemorrhage

Objective: This study aimed to investigate the association between fluid balance (FB) and in-hospital mortality in patients with intracerebral hemorrhage (ICH).Methods: Data were extracted from the online database Multi-parameter Intelligent Monitoring in Intensive Care III. Patients were divided into two groups according to the FB status at 48 hours after intensive care unit (ICU) admission: negative and positive 48-hour FB groups. The primary outcome was in-hospital mortality.Results: Data of 1407 patients were analyzed. Linear spline function in logistic models showed significant association between the volume of positive FB and in-hospital mortality (odds ratio (OR) 1.006; 95% CI: 1.002-1.010), while the association between the volume of negative FB and in-hospital mortality was non-significant. For interpretation, FB was further divided into four quartiles. Referred to Q1, the OR of in-hospital mortality stepwise increased from Q2 (OR, 1.11; 95% CI: 0.72-1.68) to Q4 (OR, 1.68; 95% CI: 1.13-2.48). A similar association was also found between FB and Glasgow coma scale at ICU discharge.Conclusions: In patients with ICH, increased volume of positive FB was associated with higher in-hospital mortality while the volume of negative FB was not. Whether maintaining a zero FB status is a beneficial strategy needs further investigation.