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Lauzier DC, Athiraman U. Role of microglia after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2024; 44:841-856. [PMID: 38415607 DOI: 10.1177/0271678x241237070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
Subarachnoid hemorrhage is a devastating sequela of aneurysm rupture. Because it disproportionately affects younger patients, the population impact of hemorrhagic stroke from subarachnoid hemorrhage is substantial. Secondary brain injury is a significant contributor to morbidity after subarachnoid hemorrhage. Initial hemorrhage causes intracranial pressure elevations, disrupted cerebral perfusion pressure, global ischemia, and systemic dysfunction. These initial events are followed by two characterized timespans of secondary brain injury: the early brain injury period and the delayed cerebral ischemia period. The identification of varying microglial phenotypes across phases of secondary brain injury paired with the functions of microglia during each phase provides a basis for microglia serving a critical role in both promoting and attenuating subarachnoid hemorrhage-induced morbidity. The duality of microglial effects on outcomes following SAH is highlighted by the pleiotropic features of these cells. Here, we provide an overview of the key role of microglia in subarachnoid hemorrhage-induced secondary brain injury as both cytotoxic and restorative effectors. We first describe the ontogeny of microglial populations that respond to subarachnoid hemorrhage. We then correlate the phenotypic development of secondary brain injury after subarachnoid hemorrhage to microglial functions, synthesizing experimental data in this area.
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Affiliation(s)
- David C Lauzier
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Umeshkumar Athiraman
- Department of Anesthesiology, Washington University School of Medicine, St. Louis, MO, USA
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Germans MR, Tjerkstra MA, Post R, Brenner A, Vergouwen MDI, Rinkel GJ, Roos YB, van den Berg R, Coert BA, Vandertop WP, Verbaan D. Impact of time to start of tranexamic acid treatment on rebleed risk and outcome in aneurysmal subarachnoid hemorrhage. Eur Stroke J 2024:23969873241246591. [PMID: 38606724 DOI: 10.1177/23969873241246591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/13/2024] Open
Abstract
INTRODUCTION The ULTRA-trial investigated effectiveness of ultra-early administration of tranexamic acid (TXA) in subarachnoid hemorrhage (SAH) and showed that TXA reduces the risk of rebleeding without concurrent improvement in clinical outcome. Previous trials in bleeding conditions, distinct from SAH, have shown that time to start of antifibrinolytic treatment influences outcome. This post-hoc analysis of the ULTRA-trial investigates whether the interval between hemorrhage and start of TXA impacts the effect of TXA on rebleeding and functional outcome following aneurysmal SAH. PATIENTS AND METHODS A post-hoc comparative analysis was conducted between aneurysmal SAH patients of the ULTRA-trial, receiving TXA and usual care to those receiving usual care only. We assessed confounders, hazard ratio (HR) of rebleeding and odds ratio (OR) of good outcome (modified Rankin Scale 0-3) at 6 months, and investigated the impact of time between hemorrhage and start of TXA on the treatment effect, stratified into time categories (0-3, 3-6 and >6 h). RESULTS Sixty-four of 394 patients (16.2%) in the TXA group experienced a rebleeding, compared to 83 of 413 patients (19.9%) with usual care only (HR 0.86, 95% confidence interval (CI): 0.62-1.19). Time to start of TXA modifies the effect of TXA on rebleeding rate (p < 0.001), with a clinically non-relevant reduction observed only when TXA was initiated after 6 h (absolute rate reduction 1.4%). Tranexamic acid treatment showed no effect on good outcome (OR 0.96, 95% CI: 0.72-1.27) with no evidence of effect modification on the time to start of TXA (p = 0.53). DISCUSSION AND CONCLUSIONS This study suggests that the effect of TXA on rebleeding is modified by time to treatment, providing a protective, albeit clinically non-relevant, effect only when started after 6 h. No difference in functional outcome was seen. Routine TXA treatment in the aneurysmal SAH population, even within a specified time frame, is not recommended to improve functional outcome.
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Affiliation(s)
- Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Zurich, Switzerland
| | - Maud A Tjerkstra
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - René Post
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Amy Brenner
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Mervyn DI Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriël Je Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Yvo Bwem Roos
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers location University of Amsterdam, Amsterdam, The Netherlands
| | - René van den Berg
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bert A Coert
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centers Location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Neuroscience, Neurovascular Disorders, Amsterdam, The Netherlands
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Doherty RJ, Henry J, Brennan D, Javadpour M. Predictive factors for pre-intervention rebleeding in aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 46:24. [PMID: 36562905 DOI: 10.1007/s10143-022-01930-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/24/2022]
Abstract
Rebleeding before intervention is a devastating complication of aneurysmal subarachnoid haemorrhage (aSAH). It often occurs early and is associated with poor outcomes. We present a systematic review and meta-analysis to identify potential predictors of rebleeding in aSAH. A database search identified studies detailing the occurrence of pre-intervention rebleeding in aSAH, and 809 studies were screened. The association between rebleeding and a variety of demographic, clinical, and radiological factors was examined using random effects meta-analyses. Fifty-six studies totalling 33,268 patients were included. Rebleeding occurred in 3,223/33,268 patients (11.1%, 95%CI 9.4-13), with risk decreasing by approximately 0.2% per year since 1981. Systolic blood pressure (SBP) during admission was higher in patients who rebled compared with those who did not (MD 7.4 mmHg, 95%CI 2.2 - 12.7), with increased risk in cohorts with SBP > 160 mmHg (RR 2.12, 95%CI 1.35-3.34), but not SBP > 140 mmHg. WFNS Grades IV-V (RR 2.05, 95%CI 1.13-3.74) and Hunt-Hess grades III-V (RR 2.12, 95%CI 1.38-3.28) were strongly associated with rebleeding. Fisher grades IV (RR 2.24, 95%CI 1.45-3.49) and III-IV (RR 2.05, 95%CI 1.17-3.6) were also associated with an increased risk. Awareness of potential risk factors for rebleeding is important when assessing patients with aSAH to ensure timely management in high-risk cases. Increased SBP during admission, especially > 160 mmHg, poorer clinical grades, and higher radiological grades are associated with an increased risk. These results may also aid in designing future studies assessing interventions aimed at reducing the risk of rebleeding.
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Affiliation(s)
- Ronan J Doherty
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - Jack Henry
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland
| | - David Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Mohsen Javadpour
- National Centre for Neurosurgery, Beaumont Hospital, Dublin, Ireland.
- Royal College of Surgeons in Ireland, St. Stephen's Green, Dublin, Ireland.
- School of Medicine, Trinity College Dublin, Dublin, Ireland.
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Tetinou F, Kanmounye US, Sadler S, Nitcheu I, Oriaku AJ, Ndajiwo AB, Bankole NDA. Cerebral aneurysms in Africa: A scoping review. Interdisciplinary Neurosurgery 2021. [DOI: 10.1016/j.inat.2021.101291] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
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Sonne A, Andersen JB, Eskesen V, Lippert F, Waldorff FB, Siersma V, Lohse N, Rasmussen LS. Neurosurgical Admission Later Than 4 h After the Emergency Call Does Not Result in Worse Long-Term Outcome in Subarachnoid Haemorrhage. Front Neurol 2021; 12:739020. [PMID: 34777206 PMCID: PMC8581136 DOI: 10.3389/fneur.2021.739020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 09/23/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Few studies have investigated the importance of the time interval between contact to the emergency medical service and neurosurgical admission in patients with spontaneous subarachnoid haemorrhage. We hypothesised that longer time to treatment would be associated with an increased risk of death or early retirement. Methods: This was a retrospective observational study with 4 years follow-up. Those who reached a neurosurgical department in fewer than 4 h were compared with those who reached it in more than 4 h. Individual level data were merged from the Danish National Patient Register, medical records, the Copenhagen Emergency Medical Dispatch Centre, the Civil Registration System, and the Ministry of Employment and Statistics Denmark. Patients were ≥18 years and had a verified diagnosis of spontaneous subarachnoid haemorrhage. The primary outcome was death or early retirement after 4 years. Results: Two hundred sixty-two patients admitted within a three-and-a-half-year time period were identified. Data were available in 124 patients, and 61 of them were in their working age. Four-year all-cause mortality was 25.8%. No significant association was found between time to neurosurgical admission and risk of death or early retirement (OR = 0.35, 95% confidence interval [CI]: 0.10–1.23, p = 0.10). Conclusion: We did not find an association between the time from emergency telephone call to neurosurgical admission and the risk of death or early retirement.
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Affiliation(s)
- Asger Sonne
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Jesper B Andersen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Freddy Lippert
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Copenhagen Emergency Medical Services, Copenhagen, Denmark
| | - Frans B Waldorff
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Lohse
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.,Department of Emergency Medicine, Copenhagen University Hospital Nordsjællands Hospital, Hillerød, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Sonne A, Egholm S, Elgaard L, Breindahl N, Jensen AH, Eskesen V, Lippert F, Waldorff FB, Lohse N, Rasmussen LS. Symptoms presented during emergency telephone calls for patients with spontaneous subarachnoid haemorrhage. Scand J Trauma Resusc Emerg Med 2021; 29:118. [PMID: 34399811 PMCID: PMC8365904 DOI: 10.1186/s13049-021-00934-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/09/2021] [Indexed: 11/10/2022] Open
Abstract
Background A spontaneous subarachnoid haemorrhage (SAH) is one of the most critical neurological emergencies a dispatcher can face in an emergency telephone call. No study has yet investigated which symptoms are presented in emergency telephone calls for these patients. We aimed to identify symptoms indicative of SAH and to determine the sensitivity of these and their association (odds ratio, OR) with SAH. Methods This was a nested case–control study based on all telephone calls to the medical dispatch center of Copenhagen Emergency Medical Services in a 4-year time period. Patients with SAH were identified in the Danish National Patient Register; diagnoses were verified by medical record review and their emergency telephone call audio files were extracted. Audio files were replayed, and symptoms extracted in a standardized manner. Audio files of a control group were replayed and assessed as well. Results We included 224 SAH patients and 609 controls. Cardiac arrest and persisting unconsciousness were reported in 5.8% and 14.7% of SAH patients, respectively. The highest sensitivity was found for headache (58.9%), nausea/vomiting (46.9%) and neck pain (32.6%). Among conscious SAH patients these symptoms were found to have the strongest association with SAH (OR 27.0, 8.41 and 34.0, respectively). Inability to stand up, speech difficulty, or sweating were reported in 24.6%, 24.2%, and 22.8%. The most frequent combination of symptoms was headache and nausea/vomiting, which was reported in 41.6% of SAH patients. More than 90% of headaches were severe, but headache was not reported in 29.7% of conscious SAH patients. In these, syncope was described by 49.1% and nausea/vomiting by 37.7%. Conclusion Headache, nausea/vomiting, and neck pain had the highest sensitivity and strongest association with SAH in emergency telephone calls. Unspecific symptoms such as inability to stand up, speech difficulty or sweating were reported in 1 out of 5 calls. Interestingly, 1 in 3 conscious SAH patients did not report headache. Trial registration NCT03980613 (www.clinicaltrials.gov).
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Affiliation(s)
- Asger Sonne
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.
| | - Sarita Egholm
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Laurits Elgaard
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Niklas Breindahl
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Alice Herrlin Jensen
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark
| | - Vagn Eskesen
- Department of Neurosurgery, The Neuroscience Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Freddy Lippert
- Copenhagen Emergency Medical Services, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Frans Boch Waldorff
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Odense, Denmark.,The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Nicolai Lohse
- Department of Emergency Medicine, Copenhagen University Hospital - Nordsjællands Hospital, Hillerød, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars Simon Rasmussen
- Department of Anaesthesia, section 6011, Center of Head and Orthopaedics, Rigshospitalet, Inge Lehmanns Vej 6, 2100, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Dokponou YCH, Kotecha J, Bandyopadhyay S, Erhabor J, Ooi SZY, Egiz A, Boutarbouch M, Dalle DU, Higginbotham G, Thioub M, Sichimba D, Bankole NDA, Kanmounye US. Continental Survey of Access to Diagnostic Tools and Endovascular Management of Aneurysmal Subarachnoid Hemorrhage in Africa. Front Surg 2021; 8:690714. [PMID: 34355014 PMCID: PMC8329527 DOI: 10.3389/fsurg.2021.690714] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 06/14/2021] [Indexed: 11/18/2022] Open
Abstract
Rationale: Interventional neurovascular procedures are effective in lowering the burden of mortality and complications resulting from aneurysmal subarachnoid hemorrhage (aSAH). Despite the wide uptake of interventional neurovascular procedures in high-income countries, access to care in low- and middle-income countries remains limited, and little is known about accessibility in Africa. In this survey, we decided to assess access to diagnostic tools and treatment of aSAH in Africa. Methodology: A Google form e-survey was distributed to African neurosurgery centers accepting responses from January 4th to March 21st 2021. Data on accessibility to diagnostic tools, treatment methodologies, and interventional neuroradiology personnel in African centers were collected. Ninety five percent confidence intervals were computed for each variable. Results: Data was received from 36 neurosurgical centers in 16 African countries (16/54, 30%). Most centers were public institutions. Ninety four percent of the centers had the necessary resources for a lumbar puncture (LP) and a laboratory for the diagnosis of aSAH. Most centers had at least one computed tomography (CT) scanner, 81% of the centers had access to CT angiography and some had access to conventional angiography. Forty seven percent of the centers could obtain a head CT within 2 h of presentation in an emergency. Sixty one percent of centers provided clipping of intracranial aneurysms whilst only 22% of centers could perform the endovascular treatment. Sixty four percent of centers did not have an endovascular specialist. Conclusion: This survey highlights health inequity in access to endovascular treatment for aSAH. Lack of diagnostic tools to identify an aneurysm and a shortfall of qualified endovascular specialists are prime reasons for this. Our findings can inform health system strengthening policies including the acquisition of equipment and capacity building in Africa.
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Affiliation(s)
- Yao Christian Hugues Dokponou
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon.,Department of Neurosurgery, Mohammed V University, Rabat, Morocco
| | - Jay Kotecha
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Soham Bandyopadhyay
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Joshua Erhabor
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | - Abdullah Egiz
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | | | - David Ulrich Dalle
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - George Higginbotham
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Mbaye Thioub
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Dawin Sichimba
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon
| | - Nourou Dine Adeniran Bankole
- Research Department, Association of Future African Neurosurgeons, Yaounde, Cameroon.,Department of Neurosurgery, Mohammed V University, Rabat, Morocco
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Sorteberg A, Romundstad L, Sorteberg W. Timelines and rebleeds in patients admitted into neurosurgical care for aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2021; 163:771-781. [PMID: 33409740 PMCID: PMC7886745 DOI: 10.1007/s00701-020-04673-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022]
Abstract
Background Mortality and morbidity of aneurysmal subarachnoid haemorrhage (aSAH) remain high, and prognosis is influenced by multiple non-modifiable factors such as aSAH severity. By analysing the chronology of aSAH management, we aim at identifying modifiable factors with emphasis on the occurrence of rebleeds in a setting with 24/7 surgical and endovascular availability of aneurysm repair and routine administration of tranexamic acid. Methods Retrospective analysis of institutional quality registry data of aSAH cases admitted into neurosurgical care during the time period 01 January 2013–31 December 2017. We registered time and mode of aneurysm repair, haemorrhage patterns, course of treatment, mortality and functional outcome. Rebleeding was scored along the entire timeline from ictus to discharge from the primary stay. Results We included 544 patients (368, 67.6% female), aged 58 ± 14 years (range 1–95 years). Aneurysm repair was performed in 486/544 (89.3%) patients at median 7.4 h after arrival and within 3, 6, 12 and 24 h in 26.8%, 44.7%, 73.0% and 96.1%, respectively. There were circadian variations in time to repair and in rebleeds. Rebleeding prior to aneurysm repair occurred in 9.7% and increased with aSAH severity and often in conjunction with patient relocations or interventions. Rebleeds occurred more often during surgical repair outside regular working hours, whereas rebleeds after repair (1.8%) were linked to endovascular repair. Conclusions The risk of rebleed is imminent throughout the entire timeline of aSAH management even with ultra-early aneurysm repair. Several modifiable factors can be linked to the occurrence of rebleeds and they should be identified and optimised within neurosurgical departments. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-020-04673-3.
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Phuong Nguyen T, Rehman S, Stirling C, Chandra R, Gall S. Time and predictors of time to treatment for aneurysmal subarachnoid haemorrhage (aSAH): a systematic review. Int J Qual Health Care 2021; 33:6127110. [PMID: 33533408 DOI: 10.1093/intqhc/mzab019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/17/2021] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a serious form of stroke, for which rapid access to specialist neurocritical care is associated with better outcomes. Delays in the treatment of aSAH appear to be common and may contribute to poor outcomes. We have a limited understanding of the extent and causes of these delays, which hinders the development of interventions to reduce delays and improve outcomes. The aim of this systematic review was to quantify and identify factors associated with time to treatment in aSAH. METHODS This systematic review was performed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines and was registered in PROSPERO (Reg. No. CRD42019132748). We searched four electronic databases (MEDLINE, EMBASE, Web of Science and Google Scholar) for manuscripts published from January 1998 using pre-designated search terms and search strategy. Main outcomes were duration of delays of time intervals from onset of aSAH to definitive treatment and/or factors related to time to treatment. RESULTS A total of 64 studies with 16 different time intervals in the pathway of aSAH patients were identified. Measures of time to treatment varied between studies (e.g. cut-off timepoints or absolute mean/median duration). Factors associated with time to treatment fell into two categories-individual (n = 9 factors, e.g. age, sex and clinical characteristics) and health system (n = 8 factors, e.g. pre-hospital delay or presentation out-of-hours). Demographic factors were not associated with time to treatment. More severe aSAH reduced treatment delay in most studies. Pre-hospital delays (patients delay, late referral, late arrival of ambulance, being transferred between hospitals or arriving at the hospital outside of office hours) were associated with treatment delay. In-hospital factors (patients with complications, procedure before definitive treatment, slow work-up and type of treatment) were less associated with treatment delay. CONCLUSIONS The pathway from onset to definitive treatment of patients with aSAH consists of multiple stages with multiple influencing factors. This review provides the first comprehensive understanding of extent and factors associated with time to treatment of aSAH. There is an opportunity to target modifiable factors to reduce time to treatment, but further research considering more factors are needed.
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Affiliation(s)
- Thuy Phuong Nguyen
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia
| | - Christine Stirling
- School of Nursing, University of Tasmania, Tasmania 71 Brooker Avenue, Hobart, Tasmania 7001, Australia
| | - Ronil Chandra
- Neuro Interventional Radiology, Monash Health, 246 Clayton Road, Clayton, Victoria 3168, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool Street, Hobart, Tasmania 7000, Australia.,Medicine Monash Health, Monash University, Wellington Rd, Clayton, Victoria 3800, Australia
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Choudhry A, Murray D, Corr P, Nolan D, Coffey D, MacNally S, O'Hare A, Power S, Crockett M, Thornton J, Rawluk D, Brennan P, Javadpour M. Timing of treatment of aneurysmal subarachnoid haemorrhage: are the goals set in international guidelines achievable? Ir J Med Sci 2021; 191:401-406. [PMID: 33599919 DOI: 10.1007/s11845-021-02542-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 02/02/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND AIMS International guidelines emphasise the importance of securing ruptured cerebral aneurysms within 48-72 h of ictus. We assessed the timing of treatment of patients with aneurysmal subarachnoid haemorrhage (aSAH) referred to a national neurosurgical centre. MATERIALS AND METHODS Analysis of a prospective database of patients with aSAH admitted between 1st of February 2016 and 29th of February 2020 was performed. The timing to treatment was expressed in days and analysed in three ways: ictus to treatment, ictus to referral and referral to treatment. ORs with 95% CI were calculated for aneurysm treatment within 24, 48 and 72 h for good grade (WFSN 1-3) and poor grade (WFNS 4-5) cohorts separately. RESULTS Of a total of 538 patients with aSAH, the aneurysm was secured in 312 (58%) within 24 h and in 398 (74%) within 48 h of ictus. Securing the aneurysm within 48 h of ictus was achieved in 89% (395/444) of patients who were referred within 24 h of ictus, but in only 3.2% (3/94) who were referred > 24 h after ictus. Poor grade patients (WFNS 4-5) were more likely than good grade patients (WFNS 1-3) to be referred to neurosurgery within 48 h of ictus (OR 22.87, 95% CI 3.14-166.49, p = 0.0020) and for their aneurysm to be secured within 48 h (OR 1.78, 95% CI 1.06-2.98, p = 0.0297) of ictus. Ictus to referral delay was highest in WFNS grade 1 patients. CONCLUSIONS In centres with 7 day per week provision of interventional neuroradiology and vascular neurosurgery, the majority of patients with aSAH can be treated within the timeframes recommended by international guidelines and this applies to all grades of aSAH. However, delays still occur in a significant proportion of patients and this particularly applies to delays in presentation and diagnosis in good grade patients.
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Affiliation(s)
- Abdurehman Choudhry
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Daniel Murray
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Paula Corr
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Nolan
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Deirdre Coffey
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Stephen MacNally
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Alan O'Hare
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Sarah Power
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - Matthew Crockett
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland
| | - John Thornton
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Daniel Rawluk
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland
| | - Paul Brennan
- Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland.,Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mohsen Javadpour
- National Neurosurgical Centre, Beaumont Hospital, Dublin, Ireland. .,Royal College of Surgeons in Ireland, Dublin, Ireland. .,Trinity College Dublin, Dublin, Ireland.
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11
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Post R, Germans MR, Coert BA, Rinkel GJE, Vandertop WP, Verbaan D. Update of the ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage (ULTRA) trial: statistical analysis plan. Trials 2020; 21:199. [PMID: 32070395 PMCID: PMC7029526 DOI: 10.1186/s13063-020-4118-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2019] [Accepted: 01/29/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recurrent bleeding from an intracranial aneurysm after subarachnoid hemorrhage (SAH) is associated with unfavorable outcome. Recurrent bleeding before aneurysm occlusion can be performed occurs in up to one in five patients and most often happens within the first 6 h after the primary hemorrhage. Reducing the rate of recurrent bleeding could be a major factor in improving clinical outcome after SAH. Tranexamic acid (TXA) reduces the risk of recurrent bleeding but has thus far not been shown to improve functional outcome, probably because of a higher risk of delayed cerebral ischemia (DCI). To reduce the risk of ultraearly recurrent bleeding, TXA should be administered as soon as possible after diagnosis and before transportation to a tertiary care center. If TXA is administered for a short duration (i.e., < 24 h), it may not increase the risk of DCI. The aim of this paper is to present in detail the statistical analysis plan (SAP) of the ULTRA trial (ULtra-early TRranexamic Acid after Subarachnoid Hemorrhage), which is currently enrolling patients and investigating whether ultraearly and short-term TXA treatment in patients with aneurysmal SAH improves clinical outcome at 6 months. METHODS/DESIGN The ULTRA trial is a multicenter, prospective, randomized, open, blinded endpoint, parallel-group trial currently ongoing at 8 tertiary care centers and 16 of their referral centers in the Netherlands. Participants are randomized to standard care or to receive TXA at a loading dose of 1 g, immediately followed by 1 g every 8 h for a maximum of 24 h, in addition to standard care, as soon as SAH is diagnosed. In the TXA group, TXA administration is stopped immediately prior to treatment (coil or clip) of the causative aneurysm. Primary outcome is the modified Rankin Scale (mRS) score at 6 months after SAH, dichotomized into good (mRS 0-3) and poor (mRS 4-6) outcomes, assessed blind to treatment allocation. Secondary outcomes include case fatalities at 30 days and at 6 months and causes of poor clinical outcome. Safety outcomes are recurrent bleeding, DCI, hydrocephalus, per-procedural complications, and other complications such as infections occurring during hospitalization. Data analyses will be according to this prespecified SAP. TRIAL REGISTRATION Netherlands Trial Register, NTR3272. Registered on 25 January 2012. ClinicalTrials.gov, NCT02684812. Registered on 17 February 2016.
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Affiliation(s)
- René Post
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Menno R Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zurich, Frauenklinikstrasse 10, 8091, Zurich, Switzerland
| | - Bert A Coert
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Gabriël J E Rinkel
- Department of Neurology and Neurosurgery, Rudolf Magnus Institute of Neuroscience, University Medical Center Utrecht, PO Box 85060, Utrecht, 3508 AB, the Netherlands
| | - W Peter Vandertop
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Neurosurgical Center Amsterdam, Amsterdam University Medical Centers, PO Box 22660, Amsterdam, 1100 DD, the Netherlands.
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12
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Post R, Germans MR, Boogaarts HD, Ferreira Dias Xavier B, Van den Berg R, Coert BA, Vandertop WP, Verbaan D. Short-term tranexamic acid treatment reduces in-hospital mortality in aneurysmal sub-arachnoid hemorrhage: A multicenter comparison study. PLoS One 2019; 14:e0211868. [PMID: 30730957 PMCID: PMC6366882 DOI: 10.1371/journal.pone.0211868] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Recurrent bleeding is one of the major causes of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage (aSAH). Antifibrinolytic therapy is known to reduce recurrent bleeding, however, its beneficial effect on outcome remains unclear. The effect of treatment with tranexamic acid (TXA) until aneurysm treatment on clinical outcome is evaluated. Methods Patients with an aSAH from two high-volume tertiary referral treatment centers in the Netherlands, Academic Medical Center (AMC) and Radboud University Medical Center (RUMC), between January 2012 and December 2015 were included. Patients were classified into one of two groups; standard treatment or TXA treatment. Demographic and clinical characteristics, in-hospital complications and clinical outcome were compared between the two groups. Multivariate logistic regression was used to adjust for the influence of treatment center and baseline differences. Results Standard treatment was given in 509 patients, and 119 patients received additional TXA therapy before aneurysm occlusion. Patients treated with TXA did not experience less recurrent bleeding adjusted or unadjusted for treatment center (adjusted odds ratio [aOR] 0.80, 95% confidence interval [95% CI]: 0.37–1.73). In-hospital mortality, was significantly lower in the TXA group than the standard care group (adjusted OR [aOR] 0.42, 95% CI: 0.20–0.85). Poor outcome (mRS 4–6) assessed after six months was not different between treatment groups (aOR 1.05, 95% CI: 0.64–1.74). Conclusions Pooled data from two high-volume treatment centers did not show improved clinical outcome after additional TXA treatment in aSAH patients. However, TXA treatment was associated with a decrease in mortality.
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Affiliation(s)
- R. Post
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - M. R. Germans
- Department of Neurosurgery, Clinical Neuroscience Center, University Hospital Zürich, Zürich, Switzerland
| | - H. D. Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - R. Van den Berg
- Department of Radiology, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - B. A. Coert
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - W. P. Vandertop
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
| | - D. Verbaan
- Neurosurgical Center Amsterdam, Amsterdam UMC, Univ(ersity) of Amsterdam, Amsterdam, the Netherlands
- * E-mail:
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13
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Weyhenmeyer J, Guandique CF, Leibold A, Lehnert S, Parish J, Han W, Tuchek C, Pandya J, Leipzig T, Payner T, DeNardo A, Scott J, Cohen-Gadol AA. Effects of distance and transport method on intervention and mortality in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 128:490-498. [PMID: 28186453 DOI: 10.3171/2016.9.jns16668] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Most patients suffering from aneurysmal subarachnoid hemorrhage (aSAH) initially present to a hospital that lacks a neurosurgical unit. These patients require interhospital transfer (IHT) to tertiary facilities capable of multidisciplinary neurosurgical intervention. Yet, little is known about the effects of IHT on the outcomes of patients suffering from aSAH. In this study, the authors examined the effects of IHT and transport method on the timing of treatment, rebleed rates, and overall outcomes of patients who have experienced aSAH. METHODS A retrospective review of medical records identified all consecutive patients who presented with aSAH at an outside hospital and subsequently underwent IHT to a tertiary aneurysm care center and patients who initially presented directly to a tertiary aneurysm care facility between 2008 and 2015. Demographic, operative, radiological, hospital of initial evaluation, transfer method, and outcome data were retrospectively collected. RESULTS The authors identified 763 consecutive patients who were evaluated for aSAH at a tertiary aneurysm care facility either directly or following IHT. For patients who underwent IHT and after accounting for these patients' clinical variability and dichotomizing the patients into groups transferred less than 20 miles and more than 20 miles, the authors noted a significant increase in mortality rates: 7% (< 20 miles) and 18.8% (> 20 miles) (p = 0.004). The increased mortality rate was partially explained by an increased rate of initial presentation to an accredited stroke center in patients undergoing IHT of less than 20 miles (p = 0.000). The method of transport (ground or air ambulance) was found to have significant effect on the patients' outcomes as measured by the Glasgow Outcome Scale score (p = 0.021); patients who underwent ground transport demonstrated a higher likelihood of discharge to home (p = 0.004). The increased severity of presentation in the patient cohort undergoing IHT by air as defined by the Glasgow Coma Scale score, a need for an external ventricular drain, Hunt and Hess grade, and intubation status at presentation did not result in increased mortality when compared with the ground cohort (p = 0.074). In addition, there was an 8-hour increase in duration of time from admission to treatment for the air cohort as compared with the ground cohort (p = 0.054), indicating a potential for further improvement in the overall outcome of this patient group. CONCLUSIONS Aneurysmal SAH remains a challenging neurosurgical disease process requiring highly coordinated care in tertiary referral centers. In this study, the overall distance traveled and the transport method affected patient outcomes. The time from admission to treatment should continue to improve. Further analysis of IHT with a focus on patient monitoring and treatment during transport is warranted.
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Affiliation(s)
- Jonathan Weyhenmeyer
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | | | - Adam Leibold
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Stephen Lehnert
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Jonathan Parish
- 3Carolina's Medical Center Department of Neurosurgery, Charlotte, North Carolina
| | - Woody Han
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Chad Tuchek
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Janit Pandya
- 2Indiana University School of Medicine, Indianapolis, Indiana; and
| | - Thomas Leipzig
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Troy Payner
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Andrew DeNardo
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - John Scott
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
| | - Aaron A Cohen-Gadol
- 1Goodman Campbell Brain and Spine and Department of Neurosurgery, Indiana University, Indianapolis
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14
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Carpenter CR, Hussain AM, Ward MJ, Zipfel GJ, Fowler S, Pines JM, Sivilotti MLA. Spontaneous Subarachnoid Hemorrhage: A Systematic Review and Meta-analysis Describing the Diagnostic Accuracy of History, Physical Examination, Imaging, and Lumbar Puncture With an Exploration of Test Thresholds. Acad Emerg Med 2016; 23:963-1003. [PMID: 27306497 DOI: 10.1111/acem.12984] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 03/31/2016] [Accepted: 04/02/2016] [Indexed: 01/23/2023]
Abstract
BACKGROUND Spontaneous subarachnoid hemorrhage (SAH) is a rare, but serious etiology of headache. The diagnosis of SAH is especially challenging in alert, neurologically intact patients, as missed or delayed diagnosis can be catastrophic. OBJECTIVES The objective was to perform a diagnostic accuracy systematic review and meta-analysis of history, physical examination, cerebrospinal fluid (CSF) tests, computed tomography (CT), and clinical decision rules for spontaneous SAH. A secondary objective was to delineate probability of disease thresholds for imaging and lumbar puncture (LP). METHODS PubMed, Embase, Scopus, and research meeting abstracts were searched up to June 2015 for studies of emergency department patients with acute headache clinically concerning for spontaneous SAH. QUADAS-2 was used to assess study quality and, when appropriate, meta-analysis was conducted using random effects models. Outcomes were sensitivity, specificity, and positive (LR+) and negative (LR-) likelihood ratios. To identify test and treatment thresholds, we employed the Pauker-Kassirer method with Bernstein test indication curves using the summary estimates of diagnostic accuracy. RESULTS A total of 5,022 publications were identified, of which 122 underwent full-text review; 22 studies were included (average SAH prevalence = 7.5%). Diagnostic studies differed in assessment of history and physical examination findings, CT technology, analytical techniques used to identify xanthochromia, and criterion standards for SAH. Study quality by QUADAS-2 was variable; however, most had a relatively low risk of biases. A history of neck pain (LR+ = 4.1; 95% confidence interval [CI] = 2.2 to 7.6) and neck stiffness on physical examination (LR+ = 6.6; 95% CI = 4.0 to 11.0) were the individual findings most strongly associated with SAH. Combinations of findings may rule out SAH, yet promising clinical decision rules await external validation. Noncontrast cranial CT within 6 hours of headache onset accurately ruled in (LR+ = 230; 95% CI = 6 to 8,700) and ruled out SAH (LR- = 0.01; 95% CI = 0 to 0.04); CT beyond 6 hours had a LR- of 0.07 (95% CI = 0.01 to 0.61). CSF analyses had lower diagnostic accuracy, whether using red blood cell (RBC) count or xanthochromia. At a threshold RBC count of 1,000 × 10(6) /L, the LR+ was 5.7 (95% CI = 1.4 to 23) and LR- was 0.21 (95% CI = 0.03 to 1.7). Using the pooled estimates of diagnostic accuracy and testing risks and benefits, we estimate that LP only benefits CT-negative patients when the pre-LP probability of SAH is on the order of 5%, which corresponds to a pre-CT probability greater than 20%. CONCLUSIONS Less than one in 10 headache patients concerning for SAH are ultimately diagnosed with SAH in recent studies. While certain symptoms and signs increase or decrease the likelihood of SAH, no single characteristic is sufficient to rule in or rule out SAH. Within 6 hours of symptom onset, noncontrast cranial CT is highly accurate, while a negative CT beyond 6 hours substantially reduces the likelihood of SAH. LP appears to benefit relatively few patients within a narrow pretest probability range. With improvements in CT technology and an expanding body of evidence, test thresholds for LP may become more precise, obviating the need for a post-CT LP in more acute headache patients. Existing SAH clinical decision rules await external validation, but offer the potential to identify subsets most likely to benefit from post-CT LP, angiography, or no further testing.
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Affiliation(s)
- Christopher R. Carpenter
- Division of Emergency Medicine; Washington University in St. Louis School of Medicine; St. Louis MO
| | - Adnan M. Hussain
- Department of Emergency Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
| | - Michael J. Ward
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
| | - Gregory J. Zipfel
- Department of Neurosurgery; Washington University in St. Louis; St. Louis MO
| | - Susan Fowler
- Becker Medical Library; Washington University School of Medicine in St. Louis; St. Louis MO
| | - Jesse M. Pines
- Department of Emergency Medicine and Center for Practice Innovation; George Washington University; Washington DC
| | - Marco L. A. Sivilotti
- Department of Emergency Medicine and Department of Biomedical & Molecular Sciences; Queen's University; Kingston Ontario Canada
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15
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Rivero Rodríguez D, Scherle Matamoros C, Fernández Cúe L, Miranda Hernández JL, Pernas Sánchez Y, Pérez Nellar J. [Re-bleeding predictors in patients with aneurysmal subarachnoid haemorrhage and delayed neurosurgical treatment]. Neurocirugia (Astur) 2015; 27:51-6. [PMID: 26260204 DOI: 10.1016/j.neucir.2015.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2014] [Revised: 03/06/2015] [Accepted: 05/31/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To evaluate the re-bleeding predictors in patients with delayed treatment of aneurysmal subarachnoid hemorrhage. PATIENTS AND METHODS A prospective cohort study enrolled 261 patients with aneurysmal subarachnoid hemorrhage, attending in Hermanos Ameijeiras Hospital from October 2005, and June 2014. RESULTS An increased re-bleeding risk in the multivariate analysis was associated with grade III (OR 2.01; 95% CI; 1.06-3.84) and grade IV (OR 3.84; 95% CI; 2.06-7.31) on World Federation Neurological Surgeon (WFNS) scale; grade III (OR 2.04; 95% CI; 1.01-4.13) and grade IV (OR 2.12, 95% CI; 1.05-4.28) on the Fischer scale, aneurism location in posterior circulation (OR 2.45, 95% CI; 1.33-4.44), and anterior communicant artery (OR 1.57, 95% CI;1.00-2.46). Hypertension history was present in 60.9% (159 patients) and was also associated with risk of re-bleeding (OR 2.70, 95% CI; 1.00-7.30). Blood pressure, haematocrit, glycemic, aneurysm size, multiple aneurysms, and location in the middle cerebral artery, do not show any relationship. CONCLUSION Hypertension history, poor grade (III and IV) on WFNS and Fisher scale and aneurysm location were independent risks factors of re-bleeding in patients with delayed aneurysmal treatment.
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16
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Zhao B, Tan X, Yang H, Zheng K, Li Z, Xiong Y, Zhong M. A Multicenter prospective study of poor-grade aneurysmal subarachnoid hemorrhage (AMPAS): observational registry study. BMC Neurol 2014; 14:86. [PMID: 24742248 PMCID: PMC3997185 DOI: 10.1186/1471-2377-14-86] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 04/16/2014] [Indexed: 11/14/2022] Open
Abstract
Background Poor-grade aneurysmal subarachnoid hemorrhage (aSAH) is associated with very high mortality and morbidity. Our limited knowledge on predictors of long-term outcome in poor-grade patients with aSAH definitively managed comes from retrospective and prospective studies of small case series of patients in single center. The purpose of the AMPAS is to determine the long-term outcomes in poor-grade patients with different managements within different time after aSAH, and identify the independent predictors of the outcome that help guide the decision on definitive management. Methods/design The AMPAS study is a prospective, multicenter, observational registry of consecutive hospitalized patients with poor grade aSAH (WFNS grade IV and V). The aim is to enroll at least 226 poor-grade patients in 11 high-volume medical centers (eg, >150 aSAH cases per year) affiliated to different universities in China. This study will describe poor grade patients and aneurysm characteristics, treatment strategies (modality and time of definitive management), hospitalization complications and outcomes evolve over time. The definitive management is ruptured aneurysm treatment. Outcomes at 3, 6, 12 months after the management were measured using the Glasgow Outcome Scale and the Modified Rankin Scale. Discussion The AMPAS is the first prospective, multicenter, observational registry of poor grade aSAH with any management. This study will contribute to a better understanding of significant predictors of outcome in poor grade patients and help guide future treatment of the worst patients after aSAH. Trial registration Chinese Clinical Trial Registry: ChiCTR-TNRC-10001041.
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Affiliation(s)
| | | | | | | | | | | | - Ming Zhong
- Department of Neurosurgery, The first affiliated hospital of Wenzhou Medical University, Wenzhou, China.
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