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Bhargava Odak D, Saffwan M, Hanif S, Visca A, Eldridge P. Management of poor grade sub-arachnoid haemorrhage - clinical judgement v/s a formal model. Br J Neurosurg 2024; 38:433-438. [PMID: 33650920 DOI: 10.1080/02688697.2021.1885621] [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: 12/24/2019] [Revised: 08/13/2020] [Accepted: 01/28/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The poor grade subarachnoid haemorrhage patients represent a unique cohort with lack of clear treatment protocol. Most neurosurgical units in the UK will manage them at local hospital until they make a significant recovery, this period can put them at higher risk of rebleed while with aggressive treatment a significant subset can achieve a favourable outcome. Identification of this subset is difficult and decision to treat them is associated with significant commitment of neurosurgical and ITU resources. Recent paper by Szklener has come up with a scale for prognostication in this subgroup of patients. We wanted to check the validity of this scale in our patient population and see if this scale can be used to guide early patient transfer and aggressive management at the Neurosurgical unit. METHODS We retrospectively reviewed our referral database for all poor grade subarachnoid patients referred over 2 years. Demographic information, Fisher and WFNS scores, admitting leucocyte count and outcome information as per MRS were obtained. These were scored as per the scale suggested by Szklener. RESULTS A total of 115 poor grade subarachnoid patients were referred over the study time frame. 47 of them were accepted for admission . 18/47 patients achieved a favourable outcome (GOS4-5). Only 1 patient managed in peripheral hospital had a good outcome. There was a significant association between Szklener's score and achieving a favourable outcome p = 0.002. CONCLUSION A selective admission policy could work specially with current economic climate, achieving outcomes comparable to admit-all. However, to optimise outcomes for all patients an aggressive standardised management at peripheral hospitals and a uniform admission policy assisted by Szklener score may be adopted. Szklener's model predicts the outcome better than WFNS and age but more validation is needed.
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Affiliation(s)
- Deepti Bhargava Odak
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Mohamed Saffwan
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Shahid Hanif
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Anna Visca
- Department of Neurosurgery, Walton Centre for Neurology and Neurosurgery, Liverpool, UK
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O'Donohoe TJ, Ovenden C, Bouras G, Chidambaram S, Plummer S, Davidson AS, Kleinig T, Abou-Hamden A. The role of decompressive craniectomy following microsurgical repair of a ruptured aneurysm: Analysis of a South Australian cerebrovascular registry. J Clin Neurosci 2024; 121:67-74. [PMID: 38364728 DOI: 10.1016/j.jocn.2024.01.020] [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: 12/16/2023] [Revised: 01/08/2024] [Accepted: 01/17/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVE Decompressive craniectomy (DC) remains a controversial intervention for intracranial hypertension among patients with aneurysmal subarachnoid haemorrhage (aSAH). METHODS We identified aSAH patients who underwent DC following microsurgical aneurysm repair from a prospectively maintained registry and compared their outcomes with a propensity-matched cohort who did not. Logistic regression was used to identify predictors of undergoing decompressive surgery and post-operative outcome. Outcomes of interest were inpatient mortality, unfavourable outcome, NIS-Subarachnoid Hemorrhage Outcome Measure and modified Rankin Score (mRS). RESULTS A total of 246 patients with aSAH underwent clipping of the culprit aneurysm between 01/09/2011 and 20/07/2020. Of these, 46 underwent DC and were included in the final analysis. Unsurprisingly, DC patients had a greater chance of unfavourable outcome (p < 0.001) and higher median mRS (p < 0.001) at final follow-up. Despite this, almost two-thirds (64.1 %) of DC patients had a favourable outcome at this time-point. When compared with a propensity-matched cohort who did not, patients treated with DC fared worse at all endpoints. Multivariable logistic regression revealed that the presence of intracerebral haemorrhage and increased pre-operative mid-line shift were predictive of undergoing DC, and WFNS grade ≥ 4 and a delayed ischaemic neurological deficit requiring endovascular angioplasty were associated with an unfavourable outcome. CONCLUSIONS Our data suggest that DC can be performed with acceptable rates of morbidity and mortality. Further research is required to determine the superiority, or otherwise, of DC compared with structured medical management of intracranial hypertension in this context, and to identify predictors of requiring decompressive surgery and patient outcome.
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Affiliation(s)
- Tom J O'Donohoe
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia; University of Adelaide, South Australia, Australia.
| | - Christopher Ovenden
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia
| | | | | | - Stephanie Plummer
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia
| | - Andrew S Davidson
- Department of Neurosurgery, Royal Melbourne Hospital, Victoria, Australia
| | - Timothy Kleinig
- University of Adelaide, South Australia, Australia; Stroke Unit, Royal Adelaide Hospital, South Australia, Australia
| | - Amal Abou-Hamden
- Department of Neurosurgery, Royal Adelaide Hospital, South Australia, Australia; University of Adelaide, South Australia, Australia
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Hamming AL, van Dijck JTJM, Visser T, Baarse M, Verbaan D, Schenck H, Haeren RHL, Fakhry R, Dammers R, Aquarius R, Boogaarts JHD, Peul WC, Moojen WA. Study on prognosis of acutely ruptured intracranial aneurysms (SPARTA): a protocol for a multicentre prospective cohort study. BMC Neurol 2024; 24:68. [PMID: 38368355 PMCID: PMC10873988 DOI: 10.1186/s12883-024-03567-6] [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] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 02/12/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND Ruptured intracranial aneurysms resulting in subarachnoid haemorrhage can be treated by open surgical or endovascular treatment. Despite multiple previous studies, uncertainties on the optimal treatment practice still exists. The resulting treatment variation may result in a variable, potentially worse, patient outcome. To better inform future treatment strategies, this study aims to identify the effectiveness of different treatment strategies in patients with ruptured intracranial aneurysms by investigating long-term functional outcome, complications and cost-effectiveness. An explorative analysis of the diagnostic and prognostic value of radiological imaging will also be performed. METHODS This multi-centre observational prospective cohort study will have a follow-up of 10 years. A total of 880 adult patients with a subarachnoid haemorrhage caused by a ruptured intracranial aneurysm will be included. Calculation of sample size (N = 880) was performed to show non-inferiority of clip-reconstruction compared to endovascular treatment on 1 year outcome, assessed by using the ordinal modified Rankin Scale. The primary endpoint is the modified Rankin Scale score and mortality at 1 year after the initial subarachnoid haemorrhage. Patients will receive 'non-experimental' regular care during their hospital stay. For this study, health questionnaires and functional outcome will be assessed at baseline, before discharge and at follow-up visits. DISCUSSION Despite the major healthcare and societal burden, the optimal treatment strategy for patients with subarachnoid haemorrhage caused by ruptured intracranial aneurysms is yet to be determined. Findings of this comparative effectiveness study, in which in-between centre variation in practice and patient outcome are investigated, will provide evidence on the effectiveness of treatment strategies, hopefully contributing to future high value treatment standardisation. TRIAL REGISTRATION NUMBER NCT05851989 DATE OF REGISTRATION: May 10th, 2023.
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Affiliation(s)
- Alexander L Hamming
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
| | - Jeroen T J M van Dijck
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Tjitske Visser
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Martine Baarse
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Dagmar Verbaan
- Department of Neurosurgery, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Hanna Schenck
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Roel H L Haeren
- Department of Neurosurgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Rahman Fakhry
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Stroke Centre, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - René Aquarius
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jeroen H D Boogaarts
- Department of Neurosurgery, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Wilco C Peul
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands
| | - Wouter A Moojen
- University Neurosurgical Centre Holland, Leiden University Medical Centre, Haaglanden Medical Centre and Haga Hospital, Leiden and The Hague, Lijnbaanweg 32, The Hague, 2512 VA, The Netherlands.
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Hofmann BB, Gundlach EP, Fischer I, Muhammad S, Kram R, Beseoglu K, Cornelius JF. Evaluation of FRESH scores in predicting outcome and quality of life after aneurysmal subarachnoid haemorrhage in a European patient cohort. Acta Neurochir (Wien) 2024; 166:29. [PMID: 38261024 PMCID: PMC10806023 DOI: 10.1007/s00701-024-05909-2] [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] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Accepted: 11/14/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Despite aneurysmal subarachnoid haemorrhage (aSAH) patients often experiencing physical and mental disabilities impacting their quality of life (QoL), routine assessment of long-term QoL data and predictive tools are limited. This study evaluates the newly developed "functional recovery expected after subarachnoid haemorrhage" (FRESH) scores with long-term outcomes and QoL in European aSAH patients. METHODS FRESH, FRESH-cog, and FRESH-quol scores were retrospectively obtained from aSAH patients. Patients were contacted, and the modified Rankin Scale (mRS), extended short form-36 (SF-36), and telephone interview for cognitive status (TICS) were collected and performed. The prognostic and empirical outcomes were compared. RESULTS Out of 374 patients, 171 patients (54.1%) completed the SF-36, and 154 patients completed the TICS. The SF-36 analysis showed that 32.7% had below-average physical component summary (PCS) scores, and 39.8% had below-average mental component summary (MCS) scores. There was no significant correlation between the FRESH score and PCS (p = 0.09736), MCS (p = 0.1796), TICS (p = 0.7484), or mRS 10-82 months (average 46 months) post bleeding (p = 0.024), respectively. There was also no significant correlation found for "FRESH-cog vs. TICS" (p = 0.0311), "FRESH-quol vs. PCS" (p = 0.0204), "FRESH-quol vs. MCS" (p = 0.1361) and "FRESH-quol vs. TICS" (p = 0.1608). CONCLUSIONS This study found no correlation between FRESH scores and validated QoL tools in a European population of aSAH patients. The study highlights the complexity of reliable long-term QoL prognostication in aSAH patients and emphasises the need for further prospective research to also focus on QoL as an important outcome parameter.
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Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Evgenia P Gundlach
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Igor Fischer
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Sajjad Muhammad
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Rainer Kram
- Department of Anesthesiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jan F Cornelius
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Capion T, Lilja-Cyron A, Olsen MH, Møller K, Juhler M, Mathiesen T. Predictors of shunt insertion in patients with aneurysmal subarachnoid haemorrhage-a single-centre retrospective analysis. Acta Neurochir (Wien) 2024; 166:24. [PMID: 38240848 PMCID: PMC10799140 DOI: 10.1007/s00701-024-05926-1] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/23/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND No standard has been established regarding timing and choice of strategy for discontinuation of external ventricular drainage (EVD) in patients with aneurysmal subarachnoid haemorrhage (aSAH), and little is known about the importance of clinical variables. A proportion of the patients who initially pass their discontinuation attempt return with delayed hydrocephalus and the need of a permanent shunt. Early differentiation between patients who need a shunt and those who do not would facilitate care. We conducted a retrospective analysis on patients with aSAH and an EVD to search significant differences in treatment and clinical variables between patients who received a permanent shunt during initial hospitalization or after readmission, and those who never received a shunt. METHODS We included 183 patients with aSAH who received an EVD over a 4-year period between 2015 and 2018 and divided them into three groups: those who received a shunt during primary admission, those who were readmitted for delayed hydrocephalus and received a shunt, and those who never needed a shunt. Between these groups, we compared selected clinical variables as well as outcome at discharge and after 6 months. Additionally, we assessed the ability of a shunt dependency score (SDASH) to predict the need for permanent drainage in the patients. RESULTS Of 183 included patients, 108 (59%) ultimately received a ventriculoperitoneal (VP) shunt. Of these, 89 (82%) failed discontinuation during the primary admission and received a permanent shunt before discharge from the neurosurgical department. The remaining 19 (18%) were discharged after successful discontinuation, but subsequently developed delayed hydrocephalus and were admitted for shunt placement a median of 39 (range: 18-235) days after ictus. Ninety-four patients were discharged after successful discontinuation of the EVD, consisting of those who never developed the need for a permanent shunt and the 19 who were readmitted with delayed hydrocephalus, corresponding to a 20% (19/94) readmittance rate. Clinical variables such as drainage volume or discontinuation strategy did not differ across the three groups of patients. The SDASH score failed to provide any clinically useful information regarding prediction of shunt placement. CONCLUSION In this study, clinical variables including use of the predictive score SDASH predicted neither the overall need for nor the timing of shunt placement after aSAH. The homogeneous distribution of data between the three different groups renders strong independent clinical predictive factors unlikely. Thus, attempts to predict a permanent shunt requirement from these variables may be futile in these patients.
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Affiliation(s)
- Tenna Capion
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Alexander Lilja-Cyron
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Markus Harboe Olsen
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Tiit Mathiesen
- Department of Neurosurgery, The Neuroscience Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Leung KYQ, Cartoon J, Hammond NE. Depression screening in patients with aneurysmal subarachnoid haemorrhage and their caregivers: A systematic review. Aust Crit Care 2023; 36:1138-1149. [PMID: 36774293 DOI: 10.1016/j.aucc.2022.12.007] [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: 09/09/2022] [Revised: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 02/11/2023] Open
Abstract
BACKGROUND Depression commonly occurs after aneurysmal subarachnoid haemorrhage (aSAH) which can negatively impact patients and their caregivers. Identification and validation of depression screening instruments specifically for patients with aSAH and their caregivers has not been performed. OBJECTIVES The objectives of this study were to identify the common depression screening tools in patients with aSAH and their caregivers and to determine if they are validated for use in these populations. METHODS Medical Subject Headings and keyword search terms were used in five electronic databases to identify randomised controlled, quasi-experimental and observational studies published between 1 January 2010 and 26 June 2022. Screening, data extraction and study quality assessments were conducted by two independent reviewers. RESULTS Of the 3440 identified studies, 61 met inclusion, with 2 of 61 (3%) RCTs, 2 of 61 (3%) quasi-experimental, and 57 of 61 (93%) observational studies included. The majority of studies (58/61 [95%]) reported patient-only depression screening, 1 of 61 (2%) reported both patients' and caregivers' depression screening, and 2 of 61 (3%) reported caregiver-only depression screening. Nine depression screening instruments were identified. The Beck Depression Inventory-II (BDI-II) was the most commonly used (13/59; 22%), followed by the Hospital Anxiety and Depression Scale (HADS) (12/59; 20%). In the ischaemic stroke population, the BDI-II was reported to have excellent sensitivity (0.85) and specificity (0.75); the HADS was also found to have good sensitivity (0.62) and specificity (0.83) in the ischaemic stroke population. Only two depression screening instruments for caregivers were identified: HADS and Goldberg Depression Scale. Both were found to have good sensitivity (>0.80) and specificity (>0.80) in the general population. CONCLUSION The BDI-II and HADS were the most commonly used depression screening instruments in patients with aSAH. Neither of these instruments has been specifically validated in an aSAH population. None of the nine depression instruments were validated for patients with aSAH. Due to an insufficient number of studies in caregivers' population, validity was unable to be determined.
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Affiliation(s)
- Kwan Yee Queenie Leung
- Department of Anaesthesia and Pain Management, Royal North Shore Hospital, St Leonards, NSW, Australia.
| | - Jodi Cartoon
- Consultation Liaison Psychiatry, Royal North Shore Hospital, St Leonards, NSW, Australia.
| | - Naomi E Hammond
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, St Leonards, NSW, Australia; Critical Care Program, The George Institute for Global Health, UNSW Sydney, Newtown, NSW, Australia.
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Ojo OA, Bankole OB, Onyia CU, Awofeso O, Dawang Y. Surgical management of Aneurysmal Subarachnoid Haemorrhage in a resource-constrained region: A Nigerian regional experience. Brain Spine 2023; 3:101778. [PMID: 38021009 PMCID: PMC10668055 DOI: 10.1016/j.bas.2023.101778] [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] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Revised: 06/09/2023] [Accepted: 06/30/2023] [Indexed: 12/01/2023]
Abstract
Background Aneurysmal Subarachnoid Haemorrhage (aSAH) is a vascular injury with significantly high mortality, especially when poorly managed. This study seeks to outline the experiences in setting up a neurovascular service in Lagos, Nigeria. Methods A series of 45 patients were operated after aSAH over a period of 10 years. Patients consecutively were recruited following computed tomography angiography (CTA) diagnosis of aSAH. Clinical data were recorded on a predesigned form after obtaining informed consent; aSAH was classified using the WFNS classification, intraoperative findings were documented. Challenges in the management were analysed in a post-operative root cause analysis (RCA) review. Outcomes and factors responsible for the observed outcomes and actions taken were recorded. Results Forty-five patients were operated after aSAH was confirmed; there were 29 females and 16 males. (M:F 1:1.8), the age ranged from 14 to 76 years (mean 49.1±13.58). All the aneurysms were on the anterior circle of Willis, mainly on Anterior Communicating Artery aneurysm (18/48).Thirty-eight patients (84.4%) survived and were discharged within an average of 10 days after surgery. Lower GCS at presentation was associated with poor prognosis (p = 0.026); however, data analysis demonstrated that other factors (financial issues, lack of appropriate instrumentation and equipment, experience of the surgeon) played a significant role in determining the outcome. Conclusions Aneurysmal Subarachnoid Haemorrhage (aSAH) is a challenging pathology and its management may be further burdened in resource constrained countries, as shown by the data analysed in this study from Lagos, Nigeria. Specialized and well-funded Neurovascular centres are needed to overcome the challenges faced and to improve care for aSAH patients in Nigeria.
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Affiliation(s)
| | | | | | | | - Yusuf Dawang
- Department of Surgery, University of Abuja Teaching Hospital, Abuja, FCT, Nigeria
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Ghafaji H, Nordenmark TH, Western E, Sorteberg W, Karic T, Sorteberg A. Coping strategies in patients with good outcome but chronic fatigue after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:1007-1019. [PMID: 36912975 PMCID: PMC10068657 DOI: 10.1007/s00701-023-05549-y] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 02/28/2023] [Indexed: 03/14/2023]
Abstract
BACKGROUND Fatigue is a highly prevalent and debilitating symptom among patients in the chronic phase of aneurysmal subarachnoid haemorrhage (aSAH) with no identified effective treatment. Cognitive therapy has been shown to have moderate effects on fatigue. Delineating the coping strategies used by patients with post-aSAH fatigue and relating them to fatigue severity and emotional symptoms could be a step towards developing a behavioural therapy for post-aSAH fatigue. METHODS Ninety-six good outcome patients with chronic post-aSAH fatigue answered the questionnaires Brief COPE, (a questionnaire defining 14 coping strategies and three Coping Styles), the Fatigue Severity Scale (FSS), Mental Fatigue Scale (MFS), Beck Depression Inventory (BDI-II) and Beck Anxiety Inventory (BAI). The Brief COPE scores were compared with fatigue severity and emotional symptoms of the patients. RESULTS The prevailing coping strategies were "Acceptance", "Emotional Support", "Active Coping" and "Planning". "Acceptance" was the sole coping strategy that was significantly inversely related to levels of fatigue. Patients with the highest scores for mental fatigue and those with clinically significant emotional symptoms applied significantly more maladaptive avoidant strategies. Females and the youngest patients applied more "Problem-Focused" strategies. CONCLUSION A therapeutic behavioural model aiming at furthering "Acceptance" and reducing passivity and "Avoidant" strategies may contribute to alleviate post-aSAH fatigue in good outcome patients. Given the chronic nature of post-aSAH fatigue, neurosurgeons may encourage patients to accept their new situation so that they can start a process of positive reframing instead of being trapped in a spiral of futile loss of energy and secondary increased emotional burden and frustration.
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Affiliation(s)
- Hajar Ghafaji
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway. .,Faculty of MedicineInstitute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Tonje Haug Nordenmark
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Elin Western
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | | | - Tanja Karic
- Department of Physical Medicine and Rehabilitation, Oslo University Hospital, Oslo, Norway
| | - Angelika Sorteberg
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway.,Faculty of MedicineInstitute of Clinical Medicine, University of Oslo, Oslo, Norway
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Hostettler IC, Lange N, Schwendinger N, Ambler G, Hirle T, Frangoulis S, Trost D, Gempt J, Kreiser K, Meyer B, Winter C, Wostrack M. VPS dependency after aneurysmal subarachnoid haemorrhage and influence of admission hyperglycaemia. Eur Stroke J 2023; 8:301-308. [PMID: 37021154 PMCID: PMC10069185 DOI: 10.1177/23969873221147087] [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: 10/08/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction Hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH) is a common complication which may lead to insertion of a ventriculoperitoneal shunt (VPS). Our aim is to evaluate a possible influence of specific clinical and biochemical factors on VPS dependency with special emphasis on hyperglycaemia on admission. Patients and methods Retrospective analysis of a monocentric database of aSAH patients. Using univariable and multivariable logistic regression analysis we evaluated factors influencing VPS dependency, with a special focus on hyperglycaemia on blood sample within 24 h of admission, dichotomised at 126 mg/dl. Factors evaluated in the univariable analysis were age, sex, known diabetes, Hunt and Hess grade, Barrow Neurological Institute scale, treatment modality, extra-ventricular drain (EVD) insertion, complications (rebleeding, vasospasm, infarction, decompressive craniectomy, ventriculitis), outcome variables and laboratory parameters (glucose, C-reactive protein, procalcitonin). Results We included 510 consecutive patients treated with acute aSAH requiring a VPS (mean age 58.2 years, 66% were female). An EVD was inserted in 387 (75.9%) patients. In the univariable analysis, VPS dependency was associated with hyperglycaemia on admission (OR 2.56, 95%CI 1.58-4.14, p < 0.001). In the multivariable regression analysis after stepwise backward regression, factors associated with VPS dependency were hyperglycaemia >126 mg/dl on admission (OR 1.93, 95%CI 1.13-3.30, p = 0.02), ventriculitis (OR 2.33, 95%CI 1.33-4.04, p = 0.003), Hunt and Hess grade (overall p-value 0.02) and decompressive craniectomy (OR 2.68, 95%CI 1.55-4.64, p < 0.001). Conclusion Hyperglycaemia on admission was associated with an increased probability of VPS placement. If confirmed, this finding might facilitate treatment of these patients by accelerating insertion of a permanent draining system.
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Affiliation(s)
- Isabel Charlotte Hostettler
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Nicole Lange
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Theresa Hirle
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Samira Frangoulis
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dominik Trost
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Kornelia Kreiser
- Department of Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Christof Winter
- Institute of Clinical Chemistry and Pathobiochemistry, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
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Elledge SR, Shewmaker JW, Yang S, Blunck JR. Fludrocortisone evaluation in aneurysmal subarachnoid hemorrhage patients with cerebral salt wasting (Flush Salt). Clin Neurol Neurosurg 2023; 225:107568. [PMID: 36608470 DOI: 10.1016/j.clineuro.2022.107568] [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: 10/19/2022] [Revised: 11/21/2022] [Accepted: 12/18/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Cerebral salt wasting is a condition that can occur in patients with aneurysmal subarachnoid hemorrhage and is characterized by excessive natriuresis, resulting in hyponatremia and hypovolemia. Fludrocortisone is a mineralocorticoid that facilitates retention of sodium and water. Guideline recommendations are weak regarding fludrocortisone use in this patient population due to mixed clinical effectiveness in prior studies. The purpose of this study was to evaluate the clinical effectiveness of fludrocortisone for cerebral salt wasting in patients with aneurysmal subarachnoid hemorrhage. METHODS This single-site, retrospective study evaluated data from March 29th, 2014 through August 31st, 2021. Patients were included if they were admitted for aneurysmal subarachnoid hemorrhage and received fludrocortisone. Patients were excluded if they were less than 18 years old, pregnant, or received fludrocortisone for less than 48 h. Patients served as their own control and endpoints compared baseline data (24 h prior to fludrocortisone) to a run-in period (0-24-hour post fludrocortisone) and a steady-state period (24-48-hour post fludrocortisone). The primary endpoint was fluid balance, determined by urine output and net daily intake. Secondary endpoints included 3 % hypertonic saline (or equivalent) intake and median serum sodium. RESULTS There were 110 patients included in this study. Daily doses of fludrocortisone over the 48-hour period varied from 100 mcg to 500 mcg, with 48 % of patients receiving between 200 mcg and 300 mcg daily. Median 24-hour urine output was reduced over the course of the study period (8232 mL at baseline, 8464 mL during 24-hour run-in, and 7080 mL during steady-state timeframe); p = 0.014. There was a 18 % reduction in net volume intake (p = 0.001), including a 38 % reduction in 3 % hypertonic saline (or equivalent) required during the study period; p = 0.025). CONCLUSION Fludrocortisone was associated with decreased urine output and subsequently, decreased volume intake, to maintain euvolemia in patients with aneurysmal subarachnoid hemorrhage and cerebral salt wasting.
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Affiliation(s)
- Samantha R Elledge
- Saint Luke's Hospital - Department of Pharmacy, 4401 Wornall Rd, Kansas City, MO 64111, USA
| | - Justin W Shewmaker
- Saint Luke's Hospital - Department of Pharmacy, 4401 Wornall Rd, Kansas City, MO 64111, USA
| | - Sam Yang
- Saint Luke's Hospital - Department of Pharmacy, 4401 Wornall Rd, Kansas City, MO 64111, USA
| | - Joseph R Blunck
- Saint Luke's Hospital - Department of Pharmacy, 4401 Wornall Rd, Kansas City, MO 64111, USA.
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11
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Rehman S, Phan HT, Chandra RV, Gall S. Is sex a predictor for delayed cerebral ischaemia (DCI) and hydrocephalus after aneurysmal subarachnoid haemorrhage (aSAH)? A systematic review and meta-analysis. Acta Neurochir (Wien) 2023; 165:199-210. [PMID: 36333624 PMCID: PMC9840585 DOI: 10.1007/s00701-022-05399-0] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 09/19/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES DCI and hydrocephalus are the most common complications that predict poor outcomes after aSAH. The relationship between sex, DCI and hydrocephalus are not well established; thus, we aimed to examine sex differences in DCI and hydrocephalus following aSAH in a systematic review and meta-analysis. METHODS A systematic search was conducted using the PubMed, Scopus and Medline databases from inception to August 2022 to identify cohort, case control, case series and clinical studies reporting sex and DCI, acute and chronic shunt-dependent hydrocephalus (SDHC). Random-effects meta-analysis was used to pool estimates for available studies. RESULTS There were 56 studies with crude estimates for DCI and meta-analysis showed that women had a greater risk for DCI than men (OR 1.24, 95% CI 1.11-1.39). The meta-analysis for adjusted estimates for 9 studies also showed an association between sex and DCI (OR 1.61, 95% CI 1.27-2.05). For acute hydrocephalus, only 9 studies were included, and meta-analysis of unadjusted estimates showed no association with sex (OR 0.95, 95%CI 0.78-1.16). For SDHC, a meta-analysis of crude estimates from 53 studies showed that women had a somewhat greater risk of developing chronic hydrocephalus compared to men (OR 1.14, 95% CI 0.99-1.31). In meta-analysis for adjusted estimates from 5 studies, no association of sex with SDHC was observed (OR 0.87, 95% CI 0.57-1.33). CONCLUSIONS Female sex is associated with the development of DCI; however, an association between sex and hydrocephalus was not detected. Strategies to target females to reduce the development of DCI may decrease overall morbidity and mortality after aSAH.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Hoang T Phan
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia
| | - Ronil V Chandra
- NeuroInterventional Radiology, Monash Health, Melbourne, VIC, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Seana Gall
- Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS, Australia.
- Monash University, Melbourne, VIC, Australia.
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Garvayo M, Messerer M, Starnoni D, Puccinelli F, Vandenbulcke A, Daniel RT, Cossu G. The positive impact of cisternostomy with cisternal drainage on delayed hydrocephalus after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2023; 165:187-195. [PMID: 36504078 PMCID: PMC9840569 DOI: 10.1007/s00701-022-05445-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 11/27/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Hydrocephalus is one of the major complications of aneurysmal subarachnoid haemorrhage (aSAH). In the acute setting, an external ventricular drain (EVD) is used for early management. A cisternal drain (CD) coupled with the micro-surgical opening of basal cisterns can be an alternative when the aneurysm is clipped. Chronic hydrocephalus after aSAH is managed with ventriculo-peritoneal (VP) shunt, a procedure associated with a wide range of complications. The aim of this study is to analyse the impact of micro-surgical opening of basal cisterns coupled with CD on the incidence of VP shunt, compared to patients treated with EVD. METHODS The authors conducted a retrospective review of 89 consecutive cases of patients with aSAH treated surgically and endovascularly with either EVD or CD between January 2009 and September 2021. Patients were stratified into two groups: Group 1 included patients with EVD, Group 2 included patients with CD. Subgroup analysis with only patients treated surgically was also performed. We compared their baseline characteristics, clinical outcomes and shunting rates. RESULTS There were no statistically significant differences between the two groups in terms of epidemiological characteristics, WFNS score, Fisher scale, presence of intraventricular hemorrhage (IVH), acute hydrocephalus, postoperative meningitis or of clinical outcomes at last follow-up. Cisternostomy with CD (Group 2) was associated with a statistically significant reduction in VP-shunt compared with the use of an EVD (Group 1) (9.09% vs 53.78%; p < 0.001). This finding was confirmed in our subgroup analysis, as among patients with a surgical clipping, the rate of VP shunt was 43.7% for the EVD group and 9.5% for the CD group (p = 0.02). CONCLUSIONS Cisternostomy with CD may reduce the rate of shunt-dependent hydrocephalus. Cisternostomy allows the removal of subarachnoid blood, thereby reducing arachnoid inflammation and fibrosis. CD may enhance this effect, thus resulting in lower rates of chronic hydrocephalus.
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Affiliation(s)
- Marta Garvayo
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Daniele Starnoni
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Francesco Puccinelli
- Department of Radiology, Section of Neuroradiology, University Hospital of Lausanne, Lausanne, Switzerland
| | - Alberto Vandenbulcke
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
| | - Roy T Daniel
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland.
| | - Giulia Cossu
- Department of Neurosurgery, University Hospital of Lausanne and University of Lausanne, Lausanne, Switzerland
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13
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Hopkins K, Price B, Ziogas J, Adamides A, Mangum J. Comparative proteomic analysis of ventricular and cisternal cerebrospinal fluid in haemorrhagic stroke patients. J Clin Neurosci 2023; 107:84-90. [PMID: 36525746 DOI: 10.1016/j.jocn.2022.11.006] [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: 07/20/2022] [Revised: 11/04/2022] [Accepted: 11/10/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Analysis of cerebrospinal fluid (CSF) using mass spectrometry is a relatively novel analytical tool, and comparisons of ventricular and cisternal proteomes are yet to be performed. This may have implications for clinical medicine, particularly in demonstrating continuity of the ventricular system with preserved flow in the presence of ventricular blood. Other uses include the identification of novel biomarkers, including for diagnosis of subarachnoid haemorrhage and of aetiology. The primary objective was therefore to characterise and compare the proteomes of ventricular and CSF after haemorrhagic stroke. METHODS Paired CSF samples were prospectively collected from the optico-carotid cistern and the frontal horn of the lateral ventricle at the time of craniotomy and clipping in 8 patients with haemorrhagic stroke. Six patients had an aneurysmal subarachnoid haemorrhage (aSAH) from a ruptured saccular aneurysm, one patient had an aSAH after rupture of a mycotic aneurysm and one patient had a spontaneous intracerebral haemorrhage (IPH) with an adjacent unruptured saccular aneurysm. Samples were processed and proteins identified and quantified using data-dependent liquid chromatography tandem mass spectrometry (DDA LC-MSMS). RESULTS There was no systematic difference between the cisternal and ventricular proteomes. However, blinded principal component analysis (PCA) of the cisternal and ventricular samples separated patients according to pathophysiology. Additionally CSF D-Dimer levels were not detected in the IPH patient but were reliably measured in aSAH patients. CONCLUSIONS Ventricular CSF is representative of cisternal CSF after aSAH. CSF proteomic PCA analysis can distinguish between haemorrhage types. CSF D-dimer levels may represent a novel diagnostic marker for aSAH. Label free DDA LC-MSMS CSF analysis may inform possible biomarkers.
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Affiliation(s)
- Katherine Hopkins
- Department of Biochemistry and Pharmacology, The University of Melbourne, Melbourne, VIC, Australia
| | - Benjamin Price
- Department of Biochemistry and Pharmacology, The University of Melbourne, Melbourne, VIC, Australia; Department of Neurosurgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia.
| | - James Ziogas
- Department of Biochemistry and Pharmacology, The University of Melbourne, Melbourne, VIC, Australia
| | - Alexios Adamides
- Department of Neurosurgery, The Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jonathan Mangum
- Department of Biochemistry and Pharmacology, The University of Melbourne, Melbourne, VIC, Australia
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14
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Ahmed A, Ahmed Y, Duah-Asante K, Lawal A, Mohiaddin Z, Nawab H, Tang A, Wang B, Miller G, Malawana J. A cost-utility analysis comparing endovascular coiling to neurosurgical clipping in the treatment of aneurysmal subarachnoid haemorrhage. Neurosurg Rev 2022; 45:3259-3269. [PMID: 36056977 PMCID: PMC9492573 DOI: 10.1007/s10143-022-01854-9] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/19/2022] [Accepted: 08/22/2022] [Indexed: 02/03/2023]
Abstract
Endovascular coiling (EC) has been identified in systematic reviews and meta-analyses to produce more favourable clinical outcomes in comparison to neurosurgical clipping (NC) when surgically treating a subarachnoid haemorrhage from a ruptured aneurysm. Cost-effectiveness analyses between both interventions have been done, but no cost-utility analysis has yet been published. This systematic review aims to perform an economic analysis of the relative utility outcomes and costs from both treatments in the UK. A cost-utility analysis was performed from the perspective of the National Health Service (NHS), over a 1-year analytic horizon. Outcomes were obtained from the randomised International Subarachnoid Aneurysm Trial (ISAT) and measured in terms of the patient's modified Rankin scale (mRS) grade, a 6-point disability scale that aims to quantify a patient's functional outcome following a stroke. The mRS score was weighted against the Euro-QoL 5-dimension (EQ-5D), with each state assigned a weighted utility value which was then converted into quality-adjusted life years (QALYs). A sensitivity analysis using different utility dimensions was performed to identify any variation in incremental cost-effectiveness ratio (ICER) if different input variables were used. Costs were measured in pounds sterling (£) and discounted by 3.5% to 2020/2021 prices. The cost-utility analysis showed an ICER of - £144,004 incurred for every QALY gained when EC was utilised over NC. At NICE's upper willingness-to-pay (WTP) threshold of £30,000, EC offered a monetary net benefit (MNB) of £7934.63 and health net benefit (HNB) of 0.264 higher than NC. At NICE's lower WTP threshold of £20,000, EC offered an MNB of £7478.63 and HNB of 0.374 higher than NC. EC was found to be more 'cost-effective' than NC, with an ICER in the bottom right quadrant of the cost-effectiveness plane-indicating that it offers greater benefits at lower costs. This is supported by the ICER being below the NICE's threshold of £20,000-£30,000 per QALY, and both MNB and HNB having positive values (> 0).
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Affiliation(s)
- Ayla Ahmed
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Yonis Ahmed
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Kwaku Duah-Asante
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Abayomi Lawal
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Zain Mohiaddin
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Hasan Nawab
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Alexis Tang
- Faculty of Medicine, Department of Medicine, Imperial College London, London, UK
| | - Brian Wang
- Department of Metabolism, Digestion and Reproduction, Imperial College Healthcare Trust, London, UK.
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK.
| | - George Miller
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK
| | - Johann Malawana
- Centre for Digital Health and Education Research, School of Medicine, University of Central Lancashire, Preston, UK
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15
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Lannon M, Martyniuk A, Sharma S. Intravenous milrinone for delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage: a systematic review. Br J Neurosurg 2022:1-6. [PMID: 36154769 DOI: 10.1080/02688697.2022.2125160] [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: 06/09/2022] [Accepted: 09/10/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Aneurysmal subarachnoid haemorrhage (aSAH) is a major contributor to mortality worldwide, with delayed cerebral ischaemia (DCI) contributing significantly to morbidity in these patients. There are limited evidence-based therapies for DCI. A 2012 case series first recommended the use of intravenous (IV) milrinone in this patient population, stating the need for formal prospective trials. However, uptake of this therapy into clinical practice has proceeded without adequate studies for efficacy and safety. METHODS We sought to determine the effect of IV milrinone on DCI in patients with aSAH in terms of functional outcome through a systematic review using Embase, MEDLINE, and Cochrane Library databases. Quality assessment was performed using MINORS criteria. RESULTS A total of 2429 studies were screened, with ten studies included in the review. Of these, no randomized trials were identified. Three observational comparative studies were included, and the remaining seven studies were non-comparative in nature, and mainly retrospective. Overall, the quality of evidence for non-comparative studies was poor. CONCLUSIONS This study reveals a paucity of evidence in the literature and highlights the need for high-quality randomized trials to investigate the safety and efficacy of IV milrinone, a commonly utilized treatment in critically ill aSAH patients with DCI. Ultimately, without evidence of efficacy and absence of harm, we caution continued use of intravenous milrinone for the treatment of DCI.
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Affiliation(s)
- Melissa Lannon
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, ON, Canada
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16
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Aso D, Fudaba H, Hisamitsu Y, Kubo T, Fujiki M. Mycotic pseudoaneurysm in the internal carotid artery secondary to cranial base abscess diagnosed with optic neuritis: a case report. Br J Neurosurg 2022:1-4. [PMID: 35748069 DOI: 10.1080/02688697.2022.2090503] [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: 03/24/2021] [Revised: 04/19/2022] [Accepted: 06/10/2022] [Indexed: 11/02/2022]
Abstract
Aspergillus-induced mycotic aneurysm is difficult to treat and often has poor outcomes with severe symptom progression. Early diagnosis is also difficult, and blood and cerebrospinal fluid tests often fail to reveal any findings. A 74-year-old man presented with recurrent nosebleeds in addition to symptoms of left optic neuritis. Contrast-enhanced computed tomography scan revealed a left internal carotid artery pseudoaneurysm protruding into the left Onodi cells, which was identified as the origin of bleeding. Endovascular left internal carotid artery occlusion was performed. One month postoperatively, external ophthalmoplegia and disorientation occurred. Although antibiotic treatment was continued for 1 month, consciousness loss and haematemesis occurred, and a new contralateral right internal carotid artery pseudoaneurysm ruptured, which resulted in death. At autopsy, Aspergillus infection centred on the skull base was pathologically found, although the sinus mucosal surface was normal. This case suggested a mycotic infection secondary to optic neuritis resulted in a left infectious pseudoaneurysm that spreads to the skull base and formed an aneurysm on the contralateral side 4 months thereafter. Therefore, the possibility that features of the Onodi cells contributed to the spread of inflammation inside and outside the skull and were involved in the formation of aneurysms inside and outside the dura mater was considered for the first time.
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Affiliation(s)
- Daigo Aso
- Department of Neurosurgery, Oita University Faculty of Medicine, Oita, Japan
| | - Hirotaka Fudaba
- Department of Neurosurgery, Oita University Faculty of Medicine, Oita, Japan
| | - Yoshinori Hisamitsu
- Department of Neurosurgery, Oita University Faculty of Medicine, Oita, Japan
| | - Takeshi Kubo
- Department of Neurosurgery, Oita University Faculty of Medicine, Oita, Japan
| | - Minoru Fujiki
- Department of Neurosurgery, Oita University Faculty of Medicine, Oita, Japan
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17
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Hostettler IC, Kreiser K, Lange N, Schwendinger N, Trost D, Frangoulis S, Hirle T, Gempt J, Wostrack M, Meyer B. Treatment during cerebral vasospasm phase-complication association and outcome in aneurysmal subarachnoid haemorrhage. J Neurol 2022; 269:5553-5560. [PMID: 35729347 PMCID: PMC9468043 DOI: 10.1007/s00415-022-11212-w] [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: 11/01/2021] [Revised: 02/27/2022] [Accepted: 06/01/2022] [Indexed: 11/28/2022]
Abstract
Background Aneurysm treatment during cerebral vasospasm (CVS) phase is frequently considered as particularly dangerous, mainly because of the risk of cerebral infarct. Objective We aimed to evaluate the risk of aneurysmal subarachnoid haemorrhage (aSAH)-specific complications and functional outcome in patients treated during CVS phase. Methods We retrospectively analysed a large, retro- and prospectively collected database of aSAH patients admitted to our department between March 2006 and March 2020. We conducted a uni- and multivariable logistic regression analysis to evaluate influencing factors on rebleeding, cerebral infarct, Glasgow Outcome Score (GOS) at discharge and mortality and assessed the rate of angiographic vasospasm on admission. Results We included 853 patients. The majority of patients were female (66.6%), mean age was 57.3 years. Out of 853 included patients, 92 (10.8%) were treated during CVS phase, 312 (36.6%) underwent clipping and 541 (63.4%) endovascular treatment. Treatment during CVS phase was significantly associated with cerebral infarct in the multivariable logistic regression analysis, unrelated to the nature of intervention (OR 2.42, 1.29–4.54 95% CI p-value = 0.006). However, patients treated during CVS phase did not have increased risk of unfavourable outcome by GOS on discharge. In addition, they did not have a higher rate of rebleeding or mortality. Conclusions Treatment during CVS phase was significantly associated with a higher rate of cerebral infarct as confirmed by imaging. This did not reflect on GOS on discharge, rebleeding, or mortality. Aneurysm treatment during CVS phase is relatively safe and should not be postponed due to the risk of rebleeding and subsequent devastating deterioration. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-022-11212-w.
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Affiliation(s)
- Isabel C Hostettler
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany. .,Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.
| | - Kornelia Kreiser
- Department of Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Nicole Lange
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Nina Schwendinger
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Dominik Trost
- Department of Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Samira Frangoulis
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Theresa Hirle
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Jens Gempt
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Maria Wostrack
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum Rechts Der Isar, Technical University Munich, Ismaningerstrasse 22, 81675, Munich, Germany
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Schmitt E, Meybohm P, Neef V, Baumgarten P, Bayer A, Choorapoikayil S, Friederich P, Friedrich J, Geisen C, Güresir E, Grünewald M, Gutjahr M, Helmer P, Herrmann E, Müller M, Narita D, Raadts A, Schwendner K, Seifried E, Stark P, Steinbicker AU, Thoma J, Velten M, Weigt H, Wiesenack C, Wittmann M, Zacharowski K, Piekarski F. Preoperative anaemia and red blood cell transfusion in patients with aneurysmal subarachnoid and intracerebral haemorrhage - a multicentre subanalysis of the German PBM Network Registry. Acta Neurochir (Wien) 2022; 164:985-999. [PMID: 35220460 PMCID: PMC8967742 DOI: 10.1007/s00701-022-05144-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 10/21/2021] [Accepted: 01/11/2022] [Indexed: 11/07/2022]
Abstract
Purpose Anaemia is common in patients presenting with aneurysmal subarachnoid (aSAH) and intracerebral haemorrhage (ICH). In surgical patients, anaemia was identified as an idenpendent risk factor for postoperative mortality, prolonged hospital length of stay (LOS) and increased risk of red blood cell (RBC) transfusion. This multicentre cohort observation study describes the incidence and effects of preoperative anaemia in this critical patient collective for a 10-year period. Methods This multicentre observational study included adult in-hospital surgical patients diagnosed with aSAH or ICH of 21 German hospitals (discharged from 1 January 2010 to 30 September 2020). Descriptive, univariate and multivariate analyses were performed to investigate the incidence and association of preoperative anaemia with RBC transfusion, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Results A total of n = 9081 patients were analysed (aSAH n = 5008; ICH n = 4073). Preoperative anaemia was present at 28.3% in aSAH and 40.9% in ICH. RBC transfusion rates were 29.9% in aSAH and 29.3% in ICH. Multivariate analysis revealed that preoperative anaemia is associated with a higher risk for RBC transfusion (OR = 3.25 in aSAH, OR = 4.16 in ICH, p < 0.001), for in-hospital mortality (OR = 1.48 in aSAH, OR = 1.53 in ICH, p < 0.001) and for several postoperative complications. Conclusions Preoperative anaemia is associated with increased RBC transfusion rates, in-hospital mortality and postoperative complications in patients with aSAH and ICH. Trial registration ClinicalTrials.gov, NCT02147795, https://clinicaltrials.gov/ct2/show/NCT02147795 Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05144-7.
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19
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Supriya M, Christopher R, Devi BI, Bhat DI, Shukla D, Kalpana SR. Altered MicroRNA Expression in Intracranial Aneurysmal Tissues: Possible Role in TGF-β Signaling Pathway. Cell Mol Neurobiol 2021. [PMID: 34185228 DOI: 10.1007/s10571-021-01121-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 06/21/2021] [Indexed: 12/23/2022]
Abstract
The molecular mechanisms behind the rupture of intracranial aneurysms remain obscure. MiRNAs are key regulators of a wide array of biological processes altering protein synthesis by binding to target mRNAs. However, variations in miRNA levels in ruptured aneurysmal wall have not been completely examined. We hypothesized that altered miRNA signature in aneurysmal tissues could potentially provide insight into aneurysm pathophysiology. Using a high-throughput miRNA microarray screening approach, we compared the miRNA expression pattern in aneurysm tissues obtained during surgery from patients with aneurysmal subarachnoid hemorrhage (aSAH) with control tissues (GEO accession number GSE161870). We found that the expression of 70 miRNAs was altered. Expressions of the top 10 miRNA were validated, by qRT-PCR and results were correlated with clinical characteristics of aSAH patients. The level of 10 miRNAs (miR-24-3p, miR-26b-5p, miR-27b-3p, miR-125b-5p, miR-143-3p, miR-145-5p, miR-193a-3p, miR-199a-5p, miR-365a-3p/365b-3p, and miR-497-5p) was significantly decreased in patients compared to controls. Expression of miR-125b-5p, miR-143-3p and miR-199a-5p was significantly decreased in patients with poor prognosis and vasospasm. The target genes of few miRNAs were enriched in Transforming growth factor-beta (TGF-β) and Mitogen-activated protein kinases (MAPK) pathways. We found significant negative correlation between the miRNA and mRNA expression (TGF-β1, TGF-β2, SMAD family member 2 (SMAD2), SMAD family member 4 (SMAD4), MAPK1 and MAPK3) in aneurysm tissues. We suggest that miR-26b, miR-199a, miR-497and miR-365, could target multiple genes in TGF-β and MAPK signaling cascades to influence inflammatory processes, extracellular matrix and vascular smooth muscle cell degradation and apoptosis, and ultimately cause vessel wall degradation and rupture.
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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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Yan Y, Hu J, Fang X, Zhen Y, Feng L, Zhang X, Zheng Y, Zhou B, An Q, Leng B. Predicting the Poor Recovery Risk of Aneurysmal Subarachnoid Hemorrhage: Clinical Evaluation and Management Based on a New Predictive Nomogram. Clin Neurol Neurosurg 2021; 200:106302. [PMID: 33092930 DOI: 10.1016/j.clineuro.2020.106302] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 09/20/2020] [Accepted: 10/11/2020] [Indexed: 11/20/2022]
Abstract
PURPOSE To develop and validate a model for identifying the risk factors of poor recovery in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A prediction model was developed using training data obtained from 1577 aSAH patients from multiple centers. The patients were followed for 6 months on average and assessed using the modified Rankin Scale; patient information was collected with a prospective case report form. The least absolute shrinkage and selection operator regression were applied to optimize factor selection for the poor recovery risk model. Multivariable logistic regression, incorporating the factors selected in the previous step, was used for model predictions. Predictive ability and clinical effectiveness of the model were evaluated using C-index, receiver operating characteristic curve, and decision curve analysis. Internal validation was performed using the C-index, taking advantage of bootstrapping validation. RESULTS The predictors included household income per capita, hypertension, smoking, migraine within a week before onset, Glasgow Coma Scale at admission, average blood pressure at admission, modified Fisher score at admission, treatment method, and complications. Our newly developed model made satisfactory predictions; it had a C-index of 0.796 and an area under the receiver operating characteristic curve of 0.784. The decision curve analysis showed that the poor recovery nomogram was of clinical benefit when an intervention was decided at a poor recovery threshold between 2% and 50%. Internal validation revealed a C-index of 0.760. CONCLUSION Our findings indicate that the novel poor recovery nomogram may be conveniently used for risk prediction in aSAH patients. For patients with intracranial aneurysms, migraine needs to be vigilant. Quitting smoking and blood pressure management are also beneficial.
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Jayamanoharan S, Mangum JE, Stylli S, Ziogas J, Adamides AA. Association between elevated cerebrospinal fluid D-dimer levels and delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage. J Clin Neurosci 2020; 76:177-182. [PMID: 32321663 DOI: 10.1016/j.jocn.2020.04.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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: 01/13/2020] [Accepted: 04/04/2020] [Indexed: 11/17/2022]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major contributor to morbidity and mortality. It is currently not possible to reliably predict patients at risk of DCI after aSAH. The aim of this study was to quantify cerebrospinal fluid (CSF) D-Dimer and plasminogen levels and to investigate any association with development of DCI. Cerebrospinal fluid (CSF) samples collected from 30 patients within 72 h post-aSAH (n = 13 DCI and n = 17 non-DCI patients) were analysed. DCI was diagnosed when angiographic vasospasm was detected in the presence of new onset neurological deficit. Enzyme-linked immunosorbent assays were used to quantify D-dimer concentrations while western blotting was used to quantify plasminogen levels. Significant differences in CSF proteins between DCI and non-DCI cohorts were verified using Mann-Whitney test. Sensitivity and specificity of these proteins for detecting DCI was examined using a ROC curve and verified with a Fischer's exact test. CSF levels of D-dimer within 72 h post aSAH were significantly elevated in DCI patients (54.29 ng/ml, 25.35-105.88 ng/ml) compared to non-DCI patients (26.75 ng/ml, 6.9-45.08 ng/ml) [p = 0.03]. In our sample population, D-dimer levels above 41.1 ng/ml had a sensitivity of 69.2% and specificity of 75% for predicting DCI. CSF levels of plasminogen (DCI: 0.50 signal-intensity/μl, 0.20-0.73 signal-intensity/μl, non-DCI: 0.28 signal-intensity/μl, 0.22-0.54 signal-intensity/μl) did not differ between the DCI and non-DCI cohort (p > 0.05). Our study suggests that elevated D-dimer in the first 72 h after aSAH may be a potential predictive biomarker for DCI.
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Affiliation(s)
| | - Jonathan E Mangum
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Stanley Stylli
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria 3010, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, Victoria 3010, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, VIC 3050, Australia; Department of Surgery, University of Melbourne, Parkville, Victoria 3010, Australia.
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Wąsik N, Sokół B, Hołysz M, Mańko W, Juszkat R, Jagodziński PP, Jankowski R. Serum myelin basic protein as a marker of brain injury in aneurysmal subarachnoid haemorrhage. Acta Neurochir (Wien) 2020; 162:545-552. [PMID: 31915942 PMCID: PMC7046567 DOI: 10.1007/s00701-019-04185-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 12/16/2019] [Indexed: 11/25/2022]
Abstract
Background Myelin basic protein (MBP) is the second most abundant protein in central nervous system myelin. Since the 1980s, it has been regarded as a marker of brain tissue injury in both trauma and disease. There have been no recent reports regarding MBP in aneurysmal subarachnoid haemorrhage (SAH). Methods One hundred four SAH patients with ruptured aneurysms underwent endovascular treatment within 24 h of rupture, and 156 blood samples were collected: 104 on days 0–3, 32 on days 4–6 and 20 on days 9–12 post-SAH. MBP levels were assayed using ELISA and compared with the clinical status on admission, laboratory results, imaging findings and treatment outcome at 3 months. Results MBP levels on days 0–3 post-SAH were significantly higher among poor outcome patients (p < 0.001), non-survivors (p = 0.005), patients who underwent intracranial intervention (p < 0.001) and patients with intracerebral haemorrhage (ICH; p < 0.001). On days 4–6 post-SAH, significantly higher levels were found following intracranial intervention (p = 0.009) and ICH (p = 0.039). There was clinically relevant correlation between MBP levels on days 0–3 post-SAH and 3-month Glasgow Outcome Scale (cc = − 0.42) and also ICH volume (cc = 0.48). All patients who made a full recovery had MBP levels below detection limit on days 0–3 post-SAH. Following endovascular aneurysm occlusion, there was no increase in MBP in 86 of the 104 patients investigated (83%). Conclusions The concentration of MBP in peripheral blood after intracranial aneurysm rupture reflects the severity of the brain tissue injury (due to surgery or ICH) and correlates with the treatment outcome. Endovascular aneurysm occlusion was not followed by a rise in MBP in most cases, suggesting the safety of this technique.
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Affiliation(s)
- Norbert Wąsik
- Department of Neurosurgery, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355, Poznan, Poland.
| | - Bartosz Sokół
- Department of Neurosurgery, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355, Poznan, Poland
| | - Marcin Hołysz
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, Poznan, Poland
| | - Witold Mańko
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Robert Juszkat
- Department of Neurosurgery, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355, Poznan, Poland
- Department of General and Interventional Radiology, Poznan University of Medical Sciences, Poznan, Poland
| | - Piotr Paweł Jagodziński
- Department of Biochemistry and Molecular Biology, Poznan University of Medical Sciences, Poznan, Poland
| | - Roman Jankowski
- Department of Neurosurgery, Poznan University of Medical Sciences, 49 Przybyszewskiego Street, 60-355, Poznan, Poland
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Fadelalla M, Kanodia A, Elsheikh M, Ellis J, Smith V, Hossain-Ibrahim K. A case of aneurysmal subarchnoid haemorrhage and superficial siderosis complicated by prospagnosia, simultagnosia and alexia without agraphia. Br J Neurosurg 2019:1-4. [PMID: 31790281 DOI: 10.1080/02688697.2019.1687848] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/06/2023]
Abstract
A 42-year-old lady presented with acute aneurysmal subarachnoid haemorrhage and developed difficulty recognising faces (prosopagnosia), inability to process visual information in busy environments (simultagnosia) and difficulty to read (alexia). She was subsequently found to have superficial siderosis on MRI.
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Affiliation(s)
| | - Avinash Kanodia
- Department of Radiology, NHS Tayside, Dundee, United Kingdom
| | | | - John Ellis
- Department of Ophthalmology, NHS Tayside, Dundee, United Kingdom
| | - Vivien Smith
- Department of Clinical Neuropsychology, NHS Tayside, Dundee, United Kingdom
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Griffiths S, Clark J, Adamides AA, Ziogas J. The role of haptoglobin and hemopexin in the prevention of delayed cerebral ischaemia after aneurysmal subarachnoid haemorrhage: a review of current literature. Neurosurg Rev 2019; 43:1273-1288. [PMID: 31493061 DOI: 10.1007/s10143-019-01169-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 03/13/2019] [Revised: 07/23/2019] [Accepted: 08/26/2019] [Indexed: 01/01/2023]
Abstract
Delayed cerebral ischaemia (DCI) after aneurysmal subarachnoid haemorrhage (aSAH) is a major cause of mortality and morbidity. The pathophysiology of DCI after aSAH is thought to involve toxic mediators released from lysis of red blood cells within the subarachnoid space, including free haemoglobin and haem. Haptoglobin and hemopexin are endogenously produced acute phase proteins that are involved in the clearance of these toxic mediators. The aim of this review is to investigate the pathophysiological mechanisms involved in DCI and the role of both endogenous as well as exogenously administered haptoglobin and hemopexin in the prevention of DCI.
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Affiliation(s)
- Sean Griffiths
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia. .,Western Hospital, 160 Gordon St, Footscray, 3011, Australia.
| | - Jeremy Clark
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - Alexios A Adamides
- Department of Neurosurgery, Royal Melbourne Hospital, 300 Grattan St, Parkville, 3050, Australia
| | - James Ziogas
- Department of Pharmacology and Therapeutics, University of Melbourne, Parkville, 3010, Australia
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Placek MM, Smielewski P, Wachel P, Budohoski KP, Czosnyka M, Kasprowicz M. Can interhemispheric desynchronization of cerebral blood flow anticipate upcoming vasospasm in aneurysmal subarachnoid haemorrhage patients? J Neurosci Methods 2019; 325:108358. [PMID: 31306719 DOI: 10.1016/j.jneumeth.2019.108358] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 12/22/2018] [Revised: 06/12/2019] [Accepted: 07/11/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Asymmetry of cerebral autoregulation (CA) was demonstrated in patients after aneurysmal subarachnoid haemorrhage (aSAH). A classical method for CA assessment requires simultaneous measurement of both arterial blood pressure (ABP) and cerebral blood flow velocity (CBFV). In this study, we have proposed a cerebral blood flow asymmetry index based only on CBFV and analysed its association with the occurrence of vasospasm after aSAH. NEW METHOD The phase shifts (PS) between slow oscillations in left and right CBFV (side-to-side PS) and between ABP and CBFV (CBFV-ABP PS) were estimated using multichannel matching pursuit (MMP) and cross-spectral analysis. RESULTS We retrospectively analysed data collected from 45 aSAH patients (26 with vasospasm). Data were analysed up to 7th day after aSAH unless the vasospasm was detected earlier. A progressive asymmetry, manifested by a gradual increase in side-to-side PS on consecutive days after aSAH, was observed in patients who developed vasospasm (Radj2 = 0.14, p = 0.009). In these patients, early side-to-side PS was more positive than in patients without vasospasm (2.8° ± 5.6° vs -1.7° ± 5.7°, p = 0.011). No such a difference was found in CBFV-ABP PS. Patients with positive side-to-side PS were more likely to develop vasospasm than patients with negative side-to-side PS (21/7 vs 5/12, p = 0.0047). COMPARISON WITH EXISTING METHOD MMP, in contrast to the spectral approach, accounts for non-stationarity of analysed signals. MMP applied to the PS estimation reflects the cerebral blood flow asymmetry in aSAH better than the spectral analysis. CONCLUSIONS Changes in side-to-side PS might be helpful to identify patients who are at risk of vasospasm.
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Affiliation(s)
- Michał M Placek
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, Wybrzeże S. Wyspiańskiego 27, 50-370 Wrocław, Poland; Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hills Road, Cambridge CB2 0QQ, United Kingdom.
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - Paweł Wachel
- Department of Control Systems and Mechatronics, Faculty of Electronics, Wrocław University of Science and Technology, Wybrzeże S. Wyspiańskiego 27, 50-370 Wrocław, Poland
| | - Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Hills Road, Cambridge CB2 0QQ, United Kingdom
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, Wybrzeże S. Wyspiańskiego 27, 50-370 Wrocław, Poland
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Sorteberg A, Bredmose PP, Hansen AE, Sorteberg W. The path from ictus to Neurosurgery: chronology and transport logistics of patients with aneurysmal subarachnoid haemorrhage in the South-Eastern Norway Health Region. Acta Neurochir (Wien) 2019; 161:1497-506. [PMID: 31197472 DOI: 10.1007/s00701-019-03971-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Revised: 05/04/2019] [Accepted: 05/29/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Guidelines state that patients with aneurysmal subarachnoid haemorrhage (aSAH) require neurosurgical treatment as early as possible. Little is known about the time frame of transport from the ictus scene to Neurosurgery in large, partially remote catchment areas. We therefore analysed the chronology and transport logistics of aSAH patients in the South-Eastern Norway Health Region and related them to the frequency of aneurysm rebleed and 1-year mortality. METHODS Retrospective analysis of aSAH patients bleeding within our region admitted to Neurosurgery during a 5-year period. Date, time and site of ictus and arrival at Neurosurgery, distance and mode of transport and admission were obtained from our institutional quality register and the emergency medical communication centre log. We scored the patients' clinical condition, rebleeds and 1-year mortality. RESULTS Five hundred forty-four patients were included. Median time from ictus to arrival Neurosurgery was 4.5 h. Transport by road ambulance was most common at distances between the ictus scene and Neurosurgery below 50 km, whereas airborne transport became increasingly more common at larger distances. Direct admissions, frequency of intubation and airborne transport to Neurosurgery increased with the severity of haemorrhage, leading to shorter transport times. The risk of rebleed was 0.8%/hour of transport. The rebleed rate was independent of distances travelled, but increased with the severity of aSAH, reaching up to 6.54%/hour in poor-grade patients. Distance and time of transport had no impact on 1-year mortality, whereas poor-grade aSAH and rebleed were strong predictors of mortality. CONCLUSIONS Poor-grade aSAH patients have a high risk of rebleed independent of the distance between the ictus scene and Neurosurgery. As rebleeding triples 1-year mortality, patients with Glasgow Coma Score < 9 with suspected aSAH should be admitted directly to Neurosurgery without delay after best possible cardiovascular and airway optimisation on site by competent personnel.
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Arati S, Chetan GK, Sibin MK, Bhat DI, Vazhayil V, Narasingarao KVL. Prognostic significance of factor XIIIA promoter methylation status in aneurysmal subarachnoid haemorrhage (aSAH). BMC Cardiovasc Disord 2019; 19:170. [PMID: 31315570 PMCID: PMC6637610 DOI: 10.1186/s12872-019-1146-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 06/06/2019] [Accepted: 07/01/2019] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Aneurysmal subarachnoid hemorrhage is a life- threatening condition with high rate of disability and mortality. Apolipoprotein E (APOE) and Factor XIIIA (F13A) genes are involved in the pathogenetic mechanism of aneurysmal subarachnoid haemorrhage (aSAH). We evaluated the association of promoter methylation status of APOE and F13A gene and risk of aSAH. METHODS For evaluating the effect of hypermethylation in the promoter region of these genes with risk of aSAH, we conducted a case -control study with 50 aSAH patients and 50 healthy control. The methylation pattern was analysed using methylation specific PCR. The risk factors associated with poor outcome after aSAH was also analysed in this study. The outcome was assessed using Glasgow outcome score (GOS) after 3 months from the initial bleed. RESULTS The frequency of APOE and F13A methylation pattern showed insignificant association with risk of aSAH in this study. Gender stratification analysis suggests that F13A promoter methylation status was significantly associated with the risk of aSAH in male gender. Age, aneurysm located at the anterior communicating artery and diabetes mellitus showed significant association with poor outcome after aSAH. CONCLUSION There was no significant association with APOE promoter methylation with the risk as well as outcome of patients after aSAH. F13A promoter methylation status was significantly associated with risk of aSAH in male gender, with no significant association with outcome after aSAH.
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Affiliation(s)
- S Arati
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore/Karnataka, Karnataka, 560029, India
| | - G K Chetan
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore/Karnataka, Karnataka, 560029, India
| | - M K Sibin
- Department of Biochemistry, Armed Forces Medical College, Pune, 411040, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India
| | - Vikas Vazhayil
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India
| | - K V L Narasingarao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India.
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Abstract
INTRODUCTION The prevalence of pituitary dysfunction is high following aneurysmal subarachnoid hemorrhage (aSAH) and when occurs it may contribute to residual symptoms of aSAH such as decreased cognition and quality of life. Hypopituitarism following aSAH may have non-specific, subtle symptoms and potentially serious consequences if remained undiagnosed. METHODS We reviewed the literature on epidemiology, pathophysiology, diagnostic methods and management of neuroendocrine changes after aSAH as well as on the impact of pituitary dysfunction on outcome of the patient. RESULTS The prevalence rates of pituitary dysfunction after aSAH varies greatly across studies due to different diagnostic methods, though growth hormone deficiency is generally the most frequently reported followed by adrenocorticotropic hormone, gonadotropin and thyroid stimulating hormone deficiencies. Pituitary deficiency tends to improve over time after aSAH but new onset deficiencies in chronic phase may also occur. There are no clinical parameters to predict the presence of hypopituitarism after aSAH. Age of the patient and surgical procedures are risk factors associated with development of hypopituitarism but the effect of pituitary dysfunction on outcome of the patient is not clear. Replacement of hypocortisolemia and hypothyroidism is essential but treatment of other hormonal insufficiencies should be individualized. CONCLUSIONS Hypopituitarism following aSAH necessitates screening despite lack of gold standard evaluation tests and cut-off values in the follow up, because missed diagnosis may lead to untoward consequences.
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Affiliation(s)
- Zuleyha Karaca
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey.
| | - Aysa Hacioglu
- Department of Endocrinology and Metabolism, Erciyes University Medical School, Kayseri, Turkey
| | - Fahrettin Kelestimur
- Department of Endocrinology and Metabolism, Yeditepe University Medical School, Istanbul, Turkey
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Wiśniewski K, Jóźwik-Pruska J, Bieńkowski M, Bobeff EJ, Bryl M, Kałużna-Czaplińska J, Jaskólski DJ. Isoprostanes as potential cerebral vasospasm biomarkers. Neurol Neurochir Pol 2018; 52:643-651. [PMID: 30314904 DOI: 10.1016/j.pjnns.2018.09.009] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Revised: 09/01/2018] [Accepted: 09/25/2018] [Indexed: 11/29/2022]
Abstract
Despite enormous progress in medicine, symptomatic cerebral vasospasm (CVS), remains an unexplained clinical problem, which leaves both physicians and patients helpless and relying on chance, due to the lack of specific marker indicative of imminent danger as well as the lack of specific treatment. In our opinion CVS occurrence depends on dynamic disbalance between free radicals' formation (oxidative stress) and antioxidant activity. Isoprostanes are products of free-radical peroxidation of polyunsaturated fatty acids, and seem to mark a promising path for the research aiming to unravel its possible mechanism. Not only are they the biomarkers of oxidative stress in vivo and in vitro, but also have manifold biological effects (including vasoactive, inflammatory and mitogenic) via activation of the thromboxane A2 receptor (TBXA2R), both in physiological and pathophysiological processes. This review addresses the importance of isoprostanes in CVS in quest of appropriate biomarkers.
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Affiliation(s)
- Karol Wiśniewski
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland.
| | - Jagoda Jóźwik-Pruska
- Institute of General and Ecological Chemistry, Department of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Michał Bieńkowski
- Department of Molecular Pathology and Neuropathology, Chair of Oncology, Medical University of Lodz, Pomorska 251, 92-213 Lodz, Poland
| | - Ernest J Bobeff
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
| | - Maciej Bryl
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
| | - Joanna Kałużna-Czaplińska
- Institute of General and Ecological Chemistry, Department of Chemistry, Lodz University of Technology, Żeromskiego 116, 90-924 Lodz, Poland
| | - Dariusz J Jaskólski
- Department of Neurosurgery and Neurooncology, Medical University of Lodz, Barlicki University Hospital, Kopcińskiego 22, 90-153 Lodz, Poland
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Suvatha A, Sibin MK, Bhat DI, Narasingarao KVL, Vazhayil V, Chetan GK. Factor XIII polymorphism and risk of aneurysmal subarachnoid haemorrhage in a south Indian population. BMC Med Genet 2018; 19:159. [PMID: 30185149 PMCID: PMC6126001 DOI: 10.1186/s12881-018-0674-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Accepted: 08/29/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND The rupture of a brain aneurysm causes bleeding in the subarachnoid space and is known as aneurysmal subarachnoid haemorrhage (aSAH). In our study, we evaluated the association of factor XIII polymorphism and the risk of Aneurysmal subarachnoid haemorrhage (aSAH) in South Indian population. METHODS The study was performed in 200 subjects with aSAH and 205 healthy control subjects. Genotyping of rs5985(c.103G > T (p.Val35Leu)) and rs5982(c.1694C > T (p.Pro564Leu)) polymorphism was performed by Taqman® allelic discrimination assay. RESULTS In our study, Val/Leu genotype frequency was higher in control subjects (18%) compared to aSAH patients (9%).The Val/Leu genotype was associated with lower risk of aSAH (OR = 0.48, 95%CI = 0.26-0.88, p = 0.02). When compared with Val allele, Leu allele was significantly associated with lower risk of aSAH (OR = 0.55, 95%CI = 0.32-0.95, p = 0.03). In subtyping, we found a significant association of Leu/Leu genotype with the Basilar top aneurysm (OR = 3.59, 95%CI = 1.11-11.64, p = 0.03). In c.1694C > T (p.Pro565Leu) variant, Pro/Pro Vs Pro/Leu genotype (OR = 2.06, 95%CI = 1.10-3.85, p = 0.02) was significantly associated with higher risk of aSAH. The 564Leu allelic frequency in aSAH patients (36%) was higher when compared with that in healthy controls (30%) in our study. When allele frequency (Pro Vs Leu) was compared, 564Leu allele was found to be significantly associated with higher aSAH risk (OR = 1.36, 95%CI = 1.01-1.83, p = 0.04). (OR = 1.36, 95%CI = 1.01-1.83, p = 0.04). Regarding rs5985 and rs5982, significant association was found in the log-additive model (OR = 0.57, 95%CI = 0.33-0.97, p = 0.034; OR = 1.32, 95%CI = 1.00-1.72, p = 0.043). CONCLUSION These results suggest that 34Leu allele was a protective factor for lower risk of aSAH whereas 564Leu allele was associated with higher risk of aSAH in South Indian population.
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Affiliation(s)
- Arati Suvatha
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, 560029, India
| | - M K Sibin
- Department of Biochemistry, Armed Forces Medical College, Pune, 411040, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India
| | - K V L Narasingarao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India
| | - Vikas Vazhayil
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore, 560029, India
| | - G K Chetan
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore, Karnataka, 560029, India.
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Wanderer S, Mrosek J, Gessler F, Seifert V, Konczalla J. Vasomodulatory effects of the angiotensin II type 1 receptor antagonist losartan on experimentally induced cerebral vasospasm after subarachnoid haemorrhage. Acta Neurochir (Wien) 2018; 160:277-84. [PMID: 29214400 DOI: 10.1007/s00701-017-3419-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 11/28/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Cerebral vasospasm following subarachnoid haemorrhage (SAH) remains one of the major factors contributing to poor overall patient outcome. Prostaglandin F2-alpha (PGF2a) induces vasoconstriction. After SAH, PGF2a leads to cerebral inflammation and enhanced vasoconstriction, resulting in cerebral vasospasm. Losartan is already known to have beneficial effects in stroke models and also on several cerebral inflammatory processes. Therefore, the aim of the study was to analyse the effect of losartan on PGF2a-enhanced vasoconstriction after SAH. METHODS To investigate the effect of losartan on PGF2a-enhanced vasoconstriction after SAH, cerebral vasospasm was induced by a double-haemorrhage model. Rats were killed on day 3 and 5 after SAH followed by measurement of the isometric force of basilar artery ring segments in an organ bath. RESULTS PGF2a induced a dose-dependent contraction. After pre-incubation with losartan, the maximum contraction (Emax) for sham-operated animals was significantly lowered [Emax 6% in losartan 3 × 10-4 molar (M) vs. 56% without losartan]. Also, after induced SAH, PGF2a induced no vasoconstriction in pre-incubated vessels with losartan 3 × 10-4 M on day 3 (d3) as well as on day 5 (d5). For the vasorelaxative investigations, vessel segments were pre-incubated with PFG2a. Cumulative application of losartan completely resolved the pre-contraction in sham-operated animals (non SAH: 95% relaxation). After SAH, losartan not only resolved the pre-contraction (d5: 103%), but also exceeded the pre-contraction (d3: 119%). Therefore, a statistically significantly increased and earlier relaxation was calculated for all losartan concentrations [Emax (d3/d5) and pD2 (d3/d5)] compared with the solvent control group. CONCLUSION In a physiological and pathophysiological setup, losartan reduces a PGF2-induced vasoconstriction and reverses a PGF2a-precontraction completely. This fact can be integrated in pushing forward further concepts trying to antagonise/prevent cerebral vasospasm after SAH.
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Falk Delgado A, Andersson T, Falk Delgado A. Ruptured carotid-ophthalmic aneurysm treatment: a non-inferiority meta-analysis comparing endovascular coiling and surgical clipping. Br J Neurosurg 2017. [PMID: 28637115 DOI: 10.1080/02688697.2017.1297371] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [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: 10/19/2022]
Abstract
INTRODUCTION Aneurysms of the carotid-ophthalmic segment are relatively rare, comprising only five percent of all intracranial aneurysms. There is no consensus regarding the optimal management for ruptured carotid-ophthalmic aneurysms, whether endovascular coiling or surgical clipping provide the most favourable patient outcome. The aim of this meta-analysis is to analyse these two treatment modalities for ruptured carotid-ophthalmic aneurysms with respect to independent clinical outcome. METHODS We performed a systematic literature search in PubMed, Cochrane Central Registry of Controlled Trials and Clinicaltrials.gov for treatment of ruptured carotid-ophthalmic aneurysms, comparing endovascular coiling and surgical clipping. Primary outcome in the study was independent clinical patient outcome at follow up (defined as Glasgow Outcome Scale four-five). Secondary outcomes were poor clinical patient outcome, mortality and total angiographic occlusion. The meta-analysis was performed using the Mantel-Haenszel method for dichotomous outcome. RESULTS Four studies met the inclusion criteria and were included in the meta-analysis. In total, 152 patients were included. Sixty-seven of these patients were treated with endovascular coiling and 85 patients were treated with microsurgical clipping. The proportion of patients with an independent clinical outcome after coiling and clipping was comparable, OR 1.04 (95% CI: 0.40, 2.71). The proportion of patients with an independent outcome in the endovascular group was 76% and in the surgical group 71%. Mortality between the two treatment arms was equal. CONCLUSION Clinical outcome after endovascular coiling and surgical clipping for ruptured carotid-ophthalmic aneurysms was comparable between surgical clipping and endovascular coiling. There was no proven difference in clinical outcome after endovascular coiling and surgical clipping for ruptured carotid-ophthalmic aneurysms but the evidence was based on few studies of moderate to low quality and we cannot rule out the possibility of a difference in clinical outcome between the two treatment modalities.
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Affiliation(s)
| | - Tommy Andersson
- b Department of Clinical Neuroscience , Karolinska Institute , Stockholm , Sweden.,c Department of Neuroradiology , Karolinska University Hospital , Stockholm , Sweden.,d Department of Medical Imaging , AZ Groeninge , Kortrijk , Belgium
| | - Anna Falk Delgado
- b Department of Clinical Neuroscience , Karolinska Institute , Stockholm , Sweden.,c Department of Neuroradiology , Karolinska University Hospital , Stockholm , Sweden
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Gathier CS, Oostdijk EA, Rinkel GJ, Dorhout Mees SM, Vergouwen MD, de Smet AM, van de Beek D, Vandertop WP, Verbaan D, Algra A, Bonten MJ, van den Bergh WM. Preventive Antibiotics and Delayed Cerebral Ischaemia in Patients with Aneurysmal Subarachnoid Haemorrhage Admitted to the Intensive Care Unit. Neurocrit Care 2016; 24:122-7. [PMID: 26450848 DOI: 10.1007/s12028-015-0202-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is an important contributor to poor outcome after aneurysmal subarachnoid haemorrhage (aSAH). Development of DCI is multifactorial, and inflammation, with or without infection, is one of the factors independently associated with development of DCI and poor outcome. We thus postulated that preventive antibiotics might be associated with a reduced risk of DCI and subsequent poor outcome in aSAH patients. METHODS We performed a retrospective cohort-study in intensive care units (ICU) of three university hospitals in The Netherlands. We included consecutive aSAH patients with minimal ICU stay of 72 h who received either preventive antibiotics (SDD: selective digestive tract decontamination including systemic cefotaxime or SOD: selective oropharyngeal decontamination) or no preventive antibiotics. DCI was defined as a new hypodensity on CT with no other explanation than DCI. Hazard ratio's (HR) for DCI and risk ratio's (RR) for 28-day case-fatality and poor outcome at 3 months were calculated, with adjustment (aHR/aRR) for clinical condition on admission, recurrent bleeding, aneurysm treatment modality and treatment site. RESULTS Of 459 included patients, 274 received preventive antibiotics (SOD or SDD) and 185 did not. With preventive antibiotics, the aHR for DCI was 1.0 (95% CI 0.6-1.8), the aRR for 28-day case-fatality was 1.1 (95% CI 0.7-1.9) and the aRR for poor functional outcome 1.2 (95% CI 1.0-1.4). CONCLUSIONS Preventive antibiotics were not associated with reduced risk of DCI or poor outcome in aSAH patients in the ICU.
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Arati S, Sibin MK, Bhat DI, Narasingarao KVL, Chetan GK. Polymorphisms of apolipoprotein E and aneurysmal subarachnoid haemorrhage: A meta-analysis. Meta Gene 2016; 9:151-8. [PMID: 27408823 PMCID: PMC4925774 DOI: 10.1016/j.mgene.2016.06.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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: 03/22/2016] [Revised: 05/25/2016] [Accepted: 06/13/2016] [Indexed: 12/21/2022] Open
Abstract
Subarachnoid haemorrhage (SAH) is characterised by bleeding in the subarachnoid space in the brain. There are various polymorphisms in genes which are associated with this disease. We performed a systematic meta- analysis to investigate the relationship of APOE polymorphism on aSAH. A comprehensive literature search was done in the Pubmed database, Science Direct, Cochrane library and Google Scholar. The OR and 95% CI were evaluated for the gene and aSAH association using fixed and random effect models. Publication bias was assessed using Begg's funnel plot and Egger's regression test. All statistical evaluations were done using the software Review Manager 5.0 and Comprehensive Meta Analysis v2.2.023. A total of 9 studies were assessed on APOE polymorphism (1100 Cases, 2732 Control). Meta analysis results showed significant association in ε2/ ε2 versus ε3/ε3, ε2 versus ε3 genetic models and ε2 allele frequency. In subgroup analysis statistically significant association was observed in Asians in the genetic models ε2/ ε2 versus ε3/ε3, ε2/ε3 versus ε3/ε3, ε2 versus ε3 and also in ε2 allele frequency. However, in Caucasian population only ε2/ε2 versus ε3/ε3 genetic model showed significant association between APOE and risk of aSAH. In this meta-analysis study, the ε2/ε2 genotype is associated with increased risk of aSAH.
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Affiliation(s)
- S Arati
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India
| | - M K Sibin
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India
| | - Dhananjaya I Bhat
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India
| | - K V L Narasingarao
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India
| | - G K Chetan
- Department of Human Genetics, National Institute of Mental Health and Neuro Sciences, Bangalore 560029, India
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Goel R, Aggarwal A, Salunke P, Kumar A, Chhabra R. Is intra arterial nimodipine really beneficial in vasospasm following aneurysmal subarachnoid haemorrhage? Br J Neurosurg 2016; 30:407-10. [PMID: 26999260 DOI: 10.3109/02688697.2016.1161172] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [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: 11/13/2022]
Abstract
UNLABELLED Object/Background: Vasospasm is a common cause of mortality and morbidity following rupture of intracranial aneurysm. Hemodynamic therapy instituted in these patients in the past has been replaced by direct manipulation of the spastic vessels by angioplasty and intra-arterial infusion of vasodilators. However, no case control studies exist proving its superiority. The purpose of our study was to compare the efficacy of intra-arterial nimodipine (IAN) to that of hemodynamic therapy in patients with vasospasm following aSAH. MATERIAL AND METHODS Fifty-three patients who developed vasospasm following aSAH were included in the study. IAN was instilled in addition to hemodynamic therapy in 39 patients and 14 patients (who refused to give consent for IAN) were continued on hemodynamic therapy alone and served as controls. The response to IAN was studied on angiogram. The clinical response was assessed in both the groups at regular intervals. IAN was repeated if necessary. The outcome (GOS) at discharge and at 3 months after discharge was compared. RESULTS Thirty-six (92.3%) out of 39 patients showed immediate angiographic reversal of vasospasm.28 of them showed clinical response, of which only 11 had lasting response. 11(28.2%) of 39 patients who received IAN had a good outcome at discharge and 23(58.9%) had a favourable outcome at 3 months follow up. In those who received hemodynamic therapy alone, 4 out of 14(28.6%) patients had a good outcome at discharge and 8 (57.1%) a favourable outcome at 3 months. CONCLUSIONS Angiographic reversal of vasospasm is seen in majority of the patients following IAN. However, this does not necessarily translate into a long lasting clinical response. The final outcome in patients who received hemodynamic therapy is comparable to those who received additional IAN. IAN does not appear to provide a major added advantage over the conventional hemodynamic therapy.
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Affiliation(s)
- Rajeev Goel
- a Department of Neurosurgery , PGIMER , Chandigarh , India
| | | | - Pravin Salunke
- a Department of Neurosurgery , PGIMER , Chandigarh , India
| | - Ajay Kumar
- b Department of Radiodiagnosis , PGIMER , Chandigarh , India
| | - Rajesh Chhabra
- a Department of Neurosurgery , PGIMER , Chandigarh , India
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Yu H, Yang M, Zhan X, Zhu Y, Shen J, Zhan R. Ventriculoperitoneal shunt placement in poor-grade patients with chronic normal pressure hydrocephalus after aneurysmal subarachnoid haemorrhage. Brain Inj 2015; 30:74-8. [PMID: 26713399 DOI: 10.3109/02699052.2015.1075153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [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: 11/13/2022]
Abstract
OBJECTIVE The aim of this study was to analyse the shunt placement in patients who had normal pressure hydrocephalus after poor-grade aneurysmal subarachnoid haemorrhage (aSAH). METHODS Patients diagnosed with NPH after poor-grade aSAH were divided into a treatment group and control group, based on whether they had received ventriculoperitoneal shunt placement. The treatment group was then divided into an improvement group and non-improvement group according to their recovery. The Glasgow Outcome Scale and Mini Mental Scale Examination were used for 3 month and 1 year follow-up rehabilitation measures. RESULTS Of the 46 total patients, significant improvement was observed at the 3 month and 1 year follow-ups (p < 0.01) after shunt implantation in the treatment group compared to the control group. Furthermore, patients who were younger (p = 0.022), had better neurological function (higher Glasgow Coma Score, p < 0.01) and less severe hydrocephalus (lower EI, p < 0.01) appears to be more likely to benefit from the shunt. CONCLUSIONS Patients who had NPH due to poor-grade aSAH would benefit from shunt placement when given the correct candidates and timely management of shunt malfunction. Additionally, the curative effect of the shunt should have been regarded as a long-term goal of rehabilitation in these patients.
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Affiliation(s)
- Hai Yu
- a Department of Neurosurgery
| | | | - Xiaobo Zhan
- c Department of Vascular Surgery , Tongde Hospital of Zhejiang Province , Hangzhou , P.R. China , and
| | - Yu Zhu
- d Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , P.R. China
| | - Jian Shen
- d Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , P.R. China
| | - Renya Zhan
- d Department of Neurosurgery , First Affiliated Hospital, College of Medicine, Zhejiang University , Hangzhou , P.R. China
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Abstract
Through evolving research, recent years have witnessed remarkable achievements in neuromonitoring and neuroanesthetic techniques, with a huge body of literature consisting of excellent studies in neuroanaesthesiology. However, little of this work appears to be directly important to clinical practice. Many controversies still exist in care of patients with neurologic injury. This review discusses studies of great clinical importance carried out in the last five years, which have the potential of influencing our current clinical practice and also attempts to define areas in need of further research. Relevant literature was obtained through multiple sources that included professional websites, medical journals and textbooks using key words “neuroanaesthesiology,” “traumatic brain injury,” “aneurysmal subarachnoid haemorrhage,” “carotid artery disease,” “brain protection,” “glycemic management” and “neurocritical care.” In head injured patients, administration of colloid and pre-hospital hypertonic saline resuscitation have not been found beneficial while use of multimodality monitoring, individualized optimal cerebral perfusion pressure therapy, tranexamic acid and decompressive craniectomy needs further evaluation. Studies are underway for establishing cerebroprotective potential of therapeutic hypothermia. Local anaesthesia provides better neurocognitive outcome in patients undergoing carotid endarterectomy compared with general anaesthesia. In patients with aneurysmal subarachnoid haemorrhage, induced hypertension alone is currently recommended for treating suspected cerebral vasospasm in place of triple H therapy. Till date, nimodipine is the only drug with proven efficacy in preventing cerebral vasospasm. In neurocritically ill patients, intensive insulin therapy results in substantial increase in hypoglycemic episodes and mortality rate, with current emphasis on minimizing glucose variability. Results of ongoing multicentric trials are likely to further improvise our practice.
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Affiliation(s)
- Nidhi Gupta
- Department of Neuroanaesthesiology, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) occurs in the extraparenchymal vessels in the subarachnoid space at the base of the brain. Ischemia/ Infarction affecting primarily the perforator vessels in isolation, following aneurysmal SAH is uncommon. A 28-year-old man with a ruptured middle cerebral artery aneurysm underwent clipping of the aneurysm. He developed delayed bilateral deep seated infarcts involving both internal capsular regions, the thalamus and basal ganglia without any major vessel infarct. The patient was managed with triple H (hypertensive hypervolemic hemodilutional) therapy and calcium channel antagonists but did not show any improvement and remained in poor neurological status. Perforator vasospasm occurring secondary to aneurysmal SAH, though documented in experimental animal studies, has rarely been reported in humans in a clinical setting. The present case provides evidence, albeit indirect, of isolated perforator vasospasm, which possibly should be the target of future therapeutic strategies.
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Affiliation(s)
- Pravin Salunke
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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