The value of computed tomography perfusion & transcranial Doppler in early diagnosis of cerebral vasospasm in aneurysmal & traumatic subarachnoid hemorrhage

Microsurgery Treatment as an Optimal Management of Posterior Cerebral Artery Aneurysms: A Systematic Review and Meta-Analysis

The choice of treatment of two modalities, open surgical or endovascular, in posterior cerebral artery (PCA) intracranial aneurysms must be taken based on their special characteristics. The objective of this study is to assess the potential superiority in outcomes, operative mortality, and clinical improvement after microsurgical and endovascular management repair in PCA intracranial aneurysms. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we created this study, performing a systematic investigation on the PubMed database, with the last search carried out on June 12, 2016. The eligibility limitations were that only full text was used in the English language, and double-checking was applied. Extracted data was organized on a standard table form, including first author, publication year, general number of patients and patients at follow-up, mortality rate (with 30 days from the selecting treatment), improvement (showing postoperatively at the clinical progress (muscle strength, thinking ability, and disorientation, due to ischemic infarctions following parent vessel occlusion) for the patients of both modalities. There were eight articles that matched our study criteria. The total study population included 8,863 patients with an aneurysm, 184 (2.07%) of which had an aneurysm at the different segments of the PCA. The pooled results revealed no statistically significant difference between the two groups, in terms of mortality, but with substantial statistical results concerning clinical improvement. We concluded that the aneurysmal site and size do not influence the treatment outcome. However, clinical improvement was a statistically significant factor, demonstrating the superiority of open surgical management over endovascular treatment (EVT) for PCA aneurysms. The selection of the appropriate procedure for every case must be done based on its special characteristics.

The Outcome after Surgical Management of Ruptured Versus Unruptured Anterior Circulation Aneurysms

OBJECTIVES

The present article aimed to review the safety and the clinical and radiological outcomes of clipped ruptured and unruptured anterior circulation aneurysms.

MATERIALS AND METHODS

The study investigated the relative articles involving the outcome after surgical management of ruptures versus unruptured anterior circulation aneurysms through electronic databases from January 1980 to January 2023. The primary outcomes were mortality and modified Rankin scale (mRS) >3.

RESULTS

Information on mRS >3 was found in six articles totalizing 2096 patients, of whom 130 subjects had ruptured and unruptured aneurysms. Data about mortality was provided by eight studies totalizing 2454 participants, of whom 140 subjects had ruptured and unruptured aneurysms.

CONCLUSIONS

The current meta-analysis indicates that surgical clipping is a safe procedure for both ruptured and unruptured aneurysms of anterior circulation.

Effect of circulating miR‑126 levels on intracranial aneurysms and their predictive value for the rupture of aneurysms: A systematic review and meta‑analysis

Intracranial aneurysm (IA) is a common cerebrovascular disease with a high risk of rupture. At present, the mechanisms underlying the formation and rupture of IAs is not clinically clear. MicroRNAs (miRNAs/miRs) are involved in the development of IAs. The present study aimed to determine the efficacy of circulating miRNA-126 (miR-126) levels as potential biomarkers for predicting aneurysmal ruptures. The present study searched comparative articles involving circulating miR-126 levels and intracranial aneurysms through electronic databases from 1980 to February, 2023. Collected variables included the first author's name, covered study period, publication year, total number of patients and age, and number of males. We collected information about the expression levels of circulating miR-126 in serum. Three articles met the eligibility criteria. The total number of patients was 379 [226 with IA rupture and 153 with non-rupture or/+ controls (healthy)]. The circulating miR-126 can be used as a biomarker for predicting aneurysmal rupture. Interestingly, an aneurysmal size >10 mm was associated with an IA rupture.

Value of sildenafil treatment for the prevention of vasospasm‑related delayed ischemic neurological deficits and delayed brain infarction following aneurysmal subarachnoid hemorrhage

Cerebral vasospasm (CV) or delayed cerebral ischemia (DCI) constitutes the main reason for the unfavorable outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). The present retrospective cohort study, through an evaluation with computed tomography (CT) perfusion (CTP), aimed to examine the utility of an intravenous or oral administration of sildenafil in preventing DCI that develops due to vasospasm in these patients. A retrospective cohort study was conducted, which included 34 patients in a tertiary care hospital. Of these patients, 18 were males (52.9%), and the median age was 54.4 years. Of these patients, 18 (52.9%) had undergone surgery, and 16 (47.1%) had an endovascular procedure. CTP was performed on the 3rd to the 6th day. The clinical outcome was documented at 30 days using a CT scan and a complete neurological evaluation, including the Glasgow Coma Scale assessment. There was a statistically significant difference in the number of patients who developed an ischemic event at 1 month between those who did not receive sildenafil compared to those who received sildenafil (P<0.05). In addition, the multivariate analysis revealed that cerebral blood flow was an independent factor for detecting an ischemic event in 1 month (P=0.001). On the whole, the findings of the present study indicate that the intravenous or oral administration of sildenafil may be beneficial for the prevention of DCI.

Efficacy of combined intravenous plus intrathecal nimodipine administration in patients with severe cerebral vasospasm post‑aneurysmal subarachnoid hemorrhage: A retrospective cohort study

Aneurysmal subarachnoid hemorrhage (aSAH) and the ensuing cerebral vasospasm (CV) and delayed cerebral ischemia (DCI) comprise the main reasons for morbidity and mortality in affected patients. The present study aimed to evaluate the efficacy of the use of combined intravenous (IV) and intrathecal (IT) nimodipine therapy for preventing permanent neurological deterioration and DCI in patients suffering from CV post-hemorrhage. The evaluation was performed using computed tomography perfusion and transcranial doppler ultrasound. The present retrospective cohort study analyzed 14 out of 146 patients diagnosed with vasospasm due to spontaneous or aSAH. These patients were divided into two groups as follows: i) The IV group, which included patients treated with only IV nimodipine; and ii) the IV + IT group, which included patients who received IV nimodipine in combination with IT nimodipine. Of the 14 patients, 7 patients were males (50%), and the mean age was 50.9 years (SD ±19 years). In total, 6 patients [42.8%; 5 (35.7%) from group A and 1 (7.1%) from group B], who experienced clinical symptoms with severe CV, were administered intra-arterial calcium channel therapy or/and IT nimodipine following the early identification of symptomatic vasospasm. The rate of adverse ischemic events was lower with IT nimodipine management during the 1 month of follow-up (6 vs. 2 events; odds ratio, 15.00; 95% confidence interval, 1.03-218.31; P=0.031). On the whole, the findings of the present study suggest that the combined use of IT nimodipine with IV admission for patients post-aSAH who developed severe CV is a safe procedure that may prevent permanent neurological deterioration and delay unfavorable ischemic incidents.

Early diagnosis of cerebral vasospasm associated with cerebral ischemia following subarachnoid hemorrhage: Evaluation of computed tomography perfusion and transcranial doppler as accurate methods

Cerebral vasospasm (CV) constitutes a major post-operative complication and source of morbidity in cases of subarachnoid hemorrhage (SAH). The early detection of CV in SAH may be difficult both clinically and radiographically. The present pilot study thus aimed to evaluate the practicability of the technique in a tertiary healthcare setting and to assess the diagnostic effectiveness of various diagnostic computed tomography (CT) perfusion (CTP) aspects in predicting the clinical outcome of patients with SAH (traumatic and aneurysmal). A retrospective study including 34 patients in a tertiary care hospital was thus conducted. The results revealed that of the 34 patients, 18 (52.9%) were males, and the mean age was 54.4±18.5 years (16-85 years old; range, 69 years). In total, 15 (44.1%) patients had traumatic SAH following traumatic brain injury (TBI), 11 (33.3%) had aneurysmal SAH, and 8 patients (23.6%) presented with TBI without SAH as controls. CTP was performed on the third to the sixth day, and 15-20 min prior to CPT, a transcranial Doppler ultrasound was performed. Clinical outcomes were documented at 30 days using a CT scan and a complete neurological evaluation, including Glasgow Coma Scale assessment. The results of a multivariate analysis revealed that cerebral blood flow (CBF) was an independent factor for detecting an ischemic event in 1 month (P=0.003). On the whole, the present study demonstrates that CTP, and consequently CBF, is a considerable index that may identify the onset of cerebral ischemia in patients with SAH.

Cerebral Perfusion and Functional Outcome in Pediatric Head Injury Patients

OBJECTIVE

To evaluate the usefulness and degree of perfusion abnormalities in pediatric head injury patients by using computed tomography perfusion (CTP) and to assess its co-relation with neurologic outcome based on Glasgow Outcome Scale Extended Pediatric revision (GOSE-P).

METHODS

Prospective evaluation of pediatric head injury patients who were taken for CTP after admission and then on discharge. We evaluated 5 regions of interest: orbitofrontal cortex, internal capsule, thalamus, caudate nucleus, and sensorimotor cortex for cerebral blood perfusion. The patient's clinical and radiologic findings were analyzed, correlated with cerebral blood flow (CBF) and MTT (mean transient time), and the outcome assessed using the GOSE-P scale on 3-month follow-up.

RESULTS

Both CBF and MTT showed a correlation with the GOSE-P scale. In mild head injury patients, the Pearson correlation of GOSE-P with mean CBF and mean MTT was -0.11 and 0.56, respectively (P < 0.05) in the sensorimotor cortex; in moderate head injury patients the Pearson correlation of GOSE-P with mean CBF in the caudate nucleus and mean MTT in the internal capsule was -0.32 and 0.36, respectively (P < 0.05); and in severe head injury patients, the Pearson correlation of GOSE-P with mean CBF and mean MTT was -0.78 and 0.56, respectively (P < 0.05) in the caudate nucleus, which had the highest Pearson co-relation among the regions studied.

CONCLUSIONS

We conclude that CBF and MTT are 2 important radiologic parameters that can be used as prognostic indicators in pediatric head injury patients.

Traumatic Subarachnoid Hemorrhage: A Scoping Review

Sixty-nine million people have a traumatic brain injury (TBI) each year, and TBI is the most common cause of subarachnoid hemorrhage (SAH). Traumatic SAH (TSAH) has been described as an adverse prognostic factor leading to progressive neurological deterioration and increased morbidity and mortality. A limited number of studies, however, evaluate recent trends in the diagnosis and management of SAH in the context of trauma. The objective of this scoping review was to understand the extent and type of evidence concerning the diagnostic criteria and management of TSAH. This scoping review was conducted following the Joanna Briggs Institute methodology for scoping reviews. The review included adults with SAH secondary to trauma, where isolated TSAH (iTSAH) refers to the presence of SAH in the absence of any other traumatic radiographic intracranial pathology, and TSAH refers to the presence of SAH with the possibility or presence of additional traumatic radiographic intracranial pathology. Data extracted from each study included study aim, country, methodology, population characteristics, outcome measures, a summary of findings, and future directives. Thirty studies met inclusion criteria. Studies were grouped into five categories by topic: TSAH associated with mild TBI (mTBI), n = 13), and severe TBI (n = 3); clinical management and diagnosis (n = 9); imaging (n = 3); and aneurysmal TSAH (n = 1). Of the 30 studies, two came from a low- and middle-income country (LMIC), excluding China, nearly a high-income country. Patients with TSAH associated with mTBI have a very low risk of clinical deterioration and surgical intervention and should be treated conservatively when considering intensive care unit admission. The Helsinki and Stockholm computed tomography scoring systems, in addition to the American Injury Scale, creatinine level, age decision tree, may be valuable tools to use when predicting outcome and death.

Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Objectives

We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler.

Methods

A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries.

Results

Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05).

Conclusion

Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.

Prediction of Symptomatic Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage Using Early Transcranial Doppler

BACKGROUND

Symptomatic vasospasm (sVSP) is a common complication during the course of aneurysmal subarachnoid hemorrhage (aSAH). We aimed to evaluate the efficacy and accuracy of transcranial Doppler ultrasound (TCD), performed within the first 3 days of aSAH to predict the development of sVSP.

METHODS

We performed a retrospective analysis of our institutional prospectively collected database of patients with aSAH. Patients with aSAH and World Federation of Neurosurgical Societies (WFNS) grades I-III were included in the analysis. A receiver operating characteristic (ROC) curve was generated to determine cut-off values for mean flow velocities (MFVs) in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) bilaterally to predict sVSP.

RESULTS

Fifty-one patients were included in the study. Mean age was 49.8 ± 10.2 years, and 84.3% (43 patients) were women. The accuracy of measured MFVs to predict sVSP was 0.79 [95% confidence interval (CI), 0.69-0.89] and 0.77 (95% CI, 0.64-0.91) for the MCA and the ACA, respectively. In the MCA, an MFV ≥ 74 cm/s was significantly associated with a six-fold increased risk of sVSP, achieving sensitivity greater than 70%. In the ACA, an MFV ≥ 64 cm/s was significantly associated with a nine-fold increased risk of sVSP.

CONCLUSION

Early TCD evaluation of MFVs in the MCA and ACA is a useful tool to predict the development of sVSP in patients with acute aSAH.

Electroacupuncture Improves Cerebral Vasospasm and Functional Outcome of Patients With Aneurysmal Subarachnoid Hemorrhage

Cerebral vasospasm is the major cause of a poor outcome after aneurysmal subarachnoid hemorrhage (aSAH), and effective treatments for vasospasm are limited. The purpose of this study was to research the impact of electroacupuncture (EA) on cerebral vasospasm and the outcomes of patients with aSAH. A total of 60 age- and sex-matched aSAH patients were collected from Ningbo First Hospital between December 2015 and June 2017. All patients were given a basic treatment of nimodipine and randomized into two groups. The study group was treated with EA therapy on the Baihui (GV20) acupoint, and the control group was given mock transcutaneous electrical nerve stimulation. Cerebral vasospasm was measured by computed tomographic perfusion (CTP) and transcranial doppler (TCD). The mean flow velocity (MFV) in the middle cerebral artery (MCA), cerebral blood flow (CBF), cerebral blood volume (CBV), and mean transit time (MTT) of the patients were analyzed. The CBV and MTT exhibited significant differences between the study and control groups on the 1st (p = 0.026 and p = 0.001), 7th (p = 0.020 and p < 0.001), and 14th (p = 0.001 and p < 0.001) day after surgery, whereas CBF exhibited statistical significance only on the 14th day after surgery (p = 0.002). The MFV in MCA were significantly reduced after EA treatment in all patients (all p < 0.001). Additionally, the MFV in the MCA in patients treated with EA were considerably reduced compared with those of the control group (3rd day p = 0.046; 5th day, p = 0.010; 7th day, p < 0.001). Moreover, better outcomes were noted in the EA-treated group for the 1st month (p < 0.001) and 3rd month (p = 0.001) after surgery than in the control group. In conclusion, EA represents a potential method to treat cerebral vasospasm after aSAH and can improve the outcomes of patients with aSAH.