Subarachnoid haemorrhage

The Effects of Glibenclamide on Cognitive Performance, Quality of Life, and Emotional Aspects Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Controlled Trial

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with a high incidence of long-term cognitive impairment, decreased quality of life (QoL), and psychiatric disorders. The effects of glibenclamide on such outcomes in the setting of aSAH are unknown.

OBJECTIVE

To assess the impact of glibenclamide in patients with aSAH on cognitive performance, QoL, and emotional aspects.

METHODS

Patients identified with aSAH were randomly allocated to receive 5 mg of glibenclamide for 21 days or placebo, starting within 96 hours of the ictus. After 6 months, patients were evaluated with Montreal Cognitive Assessment test (cognitive performance), Medical Outcomes Short-form Health Survey (QoL), and Hospital Anxiety and Depression Scale and Screen for Post-traumatic Stress Symptoms (emotional aspects).

RESULTS

The mean Montreal Cognitive Assessment score was 22.5 ± 6.2. No statistically significant difference was found between groups, with a mean score of 21.7 ± 6.4 in the Glibenclamide group and 23.4 ± 6.2 in the placebo group (P = 0.392). A score <23 was observed in 16 patients (35.6%) and its frequency was similar between groups (P = 0.900). The most frequently impaired domains were Attention (N = 21/45; 46.7%) and Visuospatial (18/45; 40.0%). Impairment of each domain was similar between groups (P > 0.05). In each domain, the mean score was similar between groups (P > 0.05). The Hospital Anxiety and Depression Scale scores did not differ between groups (P > 0.05). The mean Screen for Post-traumatic Stress Symptoms score as well as the mean scores of its domains were similar between groups (P > 0.05).

CONCLUSIONS

Glibenclamide did not improve cognitive performance, QoL, and emotional aspects after 6 months of follow-up of aSAH survivors.

Artificial intelligence can help detecting incidental intracranial aneurysm on routine brain MRI using TOF MRA data sets and improve the time required for analysis of these images

PURPOSE

The aim of our study was to assess the diagnostic performance of commercially available AI software for intracranial aneurysm detection and to determine if the AI system enhances the radiologist's accuracy in identifying aneurysms and reduces image analysis time.

METHODS

TOF-MRA clinical brain examinations were analyzed using commercially available software and by an consultant neuroradiologist for the presence of intracranial aneurysms. The results were compared with the reference standard, to measure the sensitivity and specificity of the software and the consultant neuroradiologist. Furthermore, we examined the time required for the neuroradiologist to analyze the TOF-MRA image set, both with and without use of the AI software.

RESULTS

In 500 TOF-MRI brain studies, 106 aneurysms were detected in 85 examinations by combining AI software with neuroradiologist readings. The neuroradiologist identified 98 aneurysms (92.5% sensitivity), while AI detected 77 aneurysms (72.6% sensitivity). Specificity and sensitivity were calculated from the combined effort as reference. Combining AI and neuroradiologist readings significantly improves detection reliability. Additionally, AI integration reduced TOF-MRA analysis time by 19 s (23% reduction).

CONCLUSIONS

Our findings indicate that the AI-based software can support neuroradiologists in interpreting brain TOF-MRA. A combined reading of the AI-based software and the neuroradiologist demonstrated higher reliability in identifying intracranial aneurysms as compared to reading by either neuroradiologist or software, thus improving diagnostic accuracy of the neuroradiologist. Simultaneously, reading time for the neuroradiologist was reduced by approximately one quarter.

Plasma Neurofilament Light Chain as a Biomarker for Poor Outcome After Aneurysmal Subarachnoid Hemorrhage

BACKGROUND

Neurofilament light chain (NfL), a biomarker reflecting neuro-axonal damage, may be useful in improving clinical outcome prediction after aneurysmal subarachnoid hemorrhage (aSAH). We explore the robust and additional value of NfL to neurologic and radiologic grading scales in predicting poor outcome after aSAH.

METHODS

In this prospective cohort study conducted in a single tertiary center, blood samples were collected of aSAH patients within 24 hours after ictus and before endovascular/surgical intervention. The primary endpoint was poor outcome at 6 months' follow-up. Receiver operating curves (ROC), area under the curve (AUC, 95% CI) and model-fit (Nagelkerke R2) were calculated for NfL, neurologic grading scale (WFNS), modified Fisher, age ,and sex. A combined ROC and AUC were calculated for variables with an AUC ≥ 0.70.

RESULTS

A total of 66 (42%) had poor outcome. The AUC of NfL for poor outcome was 0.70 (0.62-0.78). Combining NfL and WFNS resulted in a slightly higher model fit and not-significantly higher AUC for predicting poor outcome (R2 0.51; AUC 0.86, 0.80-0.92) compared with WFNS alone. When patients were stratified according to hemorrhage severity, median NfL [IQR] levels were significantly higher in poor grade (14 [7-32] pg/mL) than good grade patients (7 [5-14] pg/mL). Within poor grade patients, median NfL [IQR] levels were significantly higher in non-survivors (19 [11-36] pg/mL) than survivors (7 [6-13] pg/mL).

CONCLUSION

In the entire aSAH cohort, plasma NfL has an acceptable predictive performance but does not improve clinical outcome prediction. However, NfL may have potential value in subgroups based on hemorrhage severity.

Protective effects of flavonoids against intracerebral and subarachnoid hemorrhage (Review)

Intracerebral hemorrhage (ICH), known as non-traumatic cerebrovascular rupture and hemorrhage, often occurs in the deep basal brain segment. It is known for its high morbidity and mortality rates. Subarachnoid hemorrhage (SAH) is a clinical syndrome caused by the rupture of blood vessels at the base or surface of the brain that allows blood to flow directly into the subarachnoid space. It progresses quickly and typically manifests at younger ages compared with ICH. ICH and SAH are both devastating events in the category of hemorrhagic strokes and are attracting increasing attention from researchers. Flavonoids, being important natural molecules, have remarkable anti-inflammatory and antioxidant effects. Flavonoids have extensive biological activities in inflammation and oxidative stress (OS), and have protective effects in vascular function associated with cerebrovascular diseases. They have an impact on the onset of ICH and SAH by targeting various pathways, including the suppression of inflammation and OS. Recently, the role of flavonoid compounds in ICH and SAH has also received increasing interest. Thus, to serve as a resource for the prevention and treatment of ICH and SAH, the present review provided an overview of the research on flavonoid compounds in the prevention of brain damage after these two conditions have occurred.

Spontaneous subarachnoid hemorrhage in a referral health Centre in Central Africa

Background

Spontaneous subarachnoid hemorrhage (sSAH) is a medicosurgical emergency with high morbidity and mortality. The aimed of this study was to describe the clinical features and outcome of sSAH in Cameroon.

Methods

We reviewed medical records of patients aged ≥15 years old, admitted for sSAH from Januray 2011 to December 2020 in the Douala General Hospital. The diagnosis of sSAH was confirmed by neuroimaging (CT scan or MRI). Clinical and radiological severities were assessed by the WFNS score and the modified Fisher score respectively. Factors associated to in-hospital mortality was identified using cross-table (RR and 95%CI).

Results

Among the 111 cases of sSAH reviewed in emergencies records, we included 70 patients. The mean age was of 55.6 ± 13.6 years. Female were predominant (57.1%). Altered consciousness was the main clinical feature (55.7%). The WFNS score was grade 4-5 in 54.3% of patients. And 75.7% of cases presented a modified Fisher score of 3-4. Ruptured of intracranial aneurysm was the most common etiology (46.2%). Endovascular treatment and/or surgical treatment were not avaible. Hospital-based mortality was 40% and factor associated with death were Altered consciousness (RR: 4.3, 95%CI:1.52-12.33, p = 0.004), coma (RR: 23.9, 95%CI:2.85-200.62, p = 0.004), WFNS grade 5 (RR: 18.2, 95%CI:3.7-92.3, p < 0.001), and hospital length ≤ 7 days (RR: 13.5, 95%CI:4.28-42.56, p < 0.001).

Conclusion

Mortality and disability of sSAH are still high in our setting. Further studies with prospective follow up of patients are needed to determine the long-term outcome of these patients.

The Relationship Between Ionized Calcium Levels and Prognosis in Patients with Spontaneous Subarachnoid Hemorrhage

BACKGROUND

The serum calcium plays a role as a cofactor in critical steps such as cardiac contractility, vascular tone, and the coagulation cascade. This study aimed to determine if the level of ionized calcium can predict outcomes in patients with spontaneous subarachnoid hemorrhage (SAH) in the emergency department.

METHODS

The study was a retrospective cross-sectional case series. Patients aged 18 and over diagnosed with spontaneous SAH in the emergency department were included in the study. Patients' demographic characteristics, comorbidities, vital signs, laboratory parameters, World Federation of Neurosurgical Societies score, SAH grading according to the Fisher scale, needs of mechanical ventilation and inotropic treatment, administered treatments, complications, Rankin scores at discharge, and outcome were recorded in a standard data form.

RESULTS

A total of 267 patients were studied, with a mean age of 55.5 ± 13.4 years, and 53.9% (n = 144) were female. Hydrocephalus was present in 16.5% of patients. The average hospital stay was 20.4 ± 19.8 days. Mortality rate was 34.8% (n = 93). Mortality was significantly higher in patients with low calcium levels upon admission (P = 0.024). Ionized calcium levels during complication development independently predicted mortality (OR: 0.945, 95% CI: 0.898-0.996, P = 0.034). Patients with poor neurologic outcomes (Rankin: 3-6) had significantly lower initial ionized calcium levels (P = 0.002).

CONCLUSIONS

The ionized calcium level is a readily accessible blood gas parameter that assists clinicians in predicting functional independence and mortality at discharge in patients presenting to the emergency department with spontaneous SAH.

Development of a mechanical characterisation device for intracranial aneurysms: Calibration on polymeric phantom arteries

Intracranial aneurysm is a major health issue related to biomechanical arterial wall degradation. Currently, no method allows predicting rupture risk based on in vivo quantitative mechanical data. This work is part of a large-scale project aimed at providing clinicians with a non-invasive patient-specific decision support tool, based on the in vivo mechanical characterisation of the aneurysm wall. Thus, the primary objective of the project was to develop a deformation device prototype (DDP) of the artery wall and to calibrate it on polymeric phantom arteries. The deformations induced on the phantom arteries were quantified experimentally using a Digital Image Correlation (DIC) system. The results indicated that the DIC system was able to measure the small displacements generated by the DDP. We also observed that the flow mimicking the blood flow did not significantly disturb the measurements of the artery wall displacement caused by the DDP. Finally, a limit displacement value generated by the DDP was evaluated. This value corresponds to the lowest displacement value detectable by the clinical imaging system that will be tested on animals in the future (Spectral Photon Counting CT).

Pipeline Embolization Device and Flow Re-Direction Endoluminal Device for Intracranial Aneurysms: A Comparative Systematic Review and Meta-Analysis Study

BACKGROUND

When it comes to intracranial aneurysms, the quest for more effective treatments is ongoing. Flow diversion represents a growing advancement in this field. This review seeks to compare 2 variants of the endovascular flow diversion method: the Flow Re-Direction Endoluminal Device (FRED) and the Pipeline Embolization Device (PED).

METHODS

A systematic review was conducted according to the PRISMA guideline using PubMed, Scopus, Web of Science, and Embase, using appropriate terms to compare PED and FRED in double-arm studies from conception until October 8th, 2023.

RESULTS

The meta-analysis encompassed 1769 patients, with a predominance of females (75.5%), among whom 973 patients underwent FRED procedures, while 651 received PED interventions. At 6 months, complete occlusion rates were 0.62 for FRED and 0.68 for PED (P = 0.68). At 1 year and the last follow-up, no significant differences were observed between FRED and PED, respectively. Adequate occlusion rates were similar between FRED and PED (0.82 vs. 0.79, P = 0.68). FRED showed a statistically significant higher rate of good mRS scores at follow-up (1.00 vs. 0.97, P = 0.03). Hemorrhage and re-treatment rates were higher in PED (P < 0.01) without considering the rupture status of the aneurysms due to the lack of data.

CONCLUSIONS

This meta-analysis suggests comparable efficacy but different safety profiles between FRED and PED in treating intracranial aneurysms. FRED demonstrated a higher rate of good modified Rankin scores, while PED showed increased hemorrhage and re-treatment rates. Understanding these differences is crucial for informed decision-making in clinical practice.

Nanoarchitectonic Engineering of Thermal-Responsive Magnetic Nanorobot Collectives for Intracranial Aneurysm Therapy

Stent-assisted coiling is a main treatment modality for intracranial aneurysms (IAs) in clinics, but critical challenges remain to be overcome, such as exogenous implant-induced stenosis and reliance on antiplatelet agents. Herein, an endovascular approach is reported for IA therapy without stent grafting or microcatheter shaping, enabled by active delivery of thrombin (Th) to target aneurysms using innovative phase-change material (PCM)-coated magnetite-thrombin (Fe3O4-Th@PCM) FTP nanorobots. The nanorobots are controlled by an integrated actuation system of dynamic torque-force hybrid magnetic fields. With robust intravascular navigation guided by real-time ultrasound imaging, nanorobotic collectives can effectively accumulate and retain in model aneurysms constructed in vivo, followed by controlled release of the encapsulated Th for rapid occlusion of the aneurysm upon melting the protective PCM (thermally responsive in a tunable manner) through focused magnetic hyperthermia. Complete and stable aneurysm embolization is confirmed by postoperative examination and 2-week postembolization follow-up using digital subtraction angiography (DSA), contrast-enhanced ultrasound (CEUS), and histological analysis. The safety of the embolization therapy is assessed through biocompatibility evaluation and histopathology assays. This strategy, seamlessly integrating secure drug packaging, agile magnetic actuation, and clinical interventional imaging, avoids possible exogenous implant rejection, circumvents cumbersome microcatheter shaping, and offers a promising option for IA therapy.

Role and mechanisms of mast cells in brain disorders

Mast cells serve as crucial effector cells within the innate immune system and are predominantly localized in the skin, airways, gastrointestinal tract, urinary and reproductive tracts, as well as in the brain. Under physiological conditions, brain-resident mast cells secrete a diverse array of neuro-regulatory mediators to actively participate in neuroprotection. Meanwhile, as the primary source of molecules causing brain inflammation, mast cells also function as the "first responders" in brain injury. They interact with neuroglial cells and neurons to facilitate the release of numerous inflammatory mediators, proteases, and reactive oxygen species. This process initiates and amplifies immune-inflammatory responses in the brain, thereby contributing to the regulation of neuroinflammation and blood-brain barrier permeability. This article provides a comprehensive overview of the potential mechanisms through which mast cells in the brain may modulate neuroprotection and their pathological implications in various neurological disorders. It is our contention that the inhibition of mast cell activation in brain disorders could represent a novel avenue for therapeutic breakthroughs.

Volatile Sedation in Neurointensive Care Patients After Aneurysmal Subarachnoid Hemorrhage: Effects on Delayed Cerebral Ischemia, Cerebral Vasospasm, and Functional Outcome

BACKGROUND

Volatile anesthetics have shown neuroprotective effects in preclinical studies, but clinical data on their use after aneurysmal subarachnoid hemorrhage (aSAH) are limited. This study aimed to analyze whether the use of volatile anesthetics for neurocritical care sedation affects the incidence of delayed cerebral ischemia (DCI), cerebral vasospasm (CVS), DCI-related infarction, or functional outcome.

METHODS

Data were retrospectively collected for ventilated aSAH patients (2016-2022), who received sedation for at least 180 hours. For comparative analysis, patients were assigned to a control and a study group according to the sedation used (intravenous vs. volatile sedation). Logistic regression analysis was performed to identify independent predictors of DCI, CVS, DCI-related infarction, and functional outcome.

RESULTS

Ninety-nine patients with a median age of 58 years (interquartile range: 52-65 years) were included. Forty-seven patients (47%) received intravenous sedation, while 52 patients (53%) received (additional) volatile sedation with isoflurane (n = 30, 58%) or sevoflurane (n = 22, 42%) for a median duration of 169 hours (range: 5-298 hours). There were no significant differences between the 2 groups regarding the occurrence of DCI, angiographic CVS, DCI-related infarction, or functional outcome. In a multivariable logistic regression analysis, the use of volatile anesthetics had no impact on the incidence of DCI-related infarction or the patients' functional outcome.

CONCLUSIONS

Volatile sedation in aSAH patients is not associated with the incidence of DCI, CVS, DCI-related infarction, or functional outcome. Although we could not demonstrate neuroprotective effects of volatile anesthetics, our results suggest that volatile sedation after aSAH has no negative effect on the patient's outcome.

Knowledge domain and emerging trends in the rupture risk of intracranial aneurysms research from 2004 to 2023

BACKGROUND

Intracranial aneurysms (IAs) pose significant health risks, attributable to their potential for sudden rupture, which can result in severe outcomes such as stroke and death. Despite extensive research, the variability of aneurysm behavior, with some remaining stable for years while others rupture unexpectedly, remains poorly understood.

AIM

To employ bibliometric analysis to map the research landscape concerning risk factors associated with IAs rupture.

METHODS

A systematic literature review of publications from 2004 to 2023 was conducted, analyzing 3804 documents from the Web of Science Core Collection database, with a focus on full-text articles and reviews in English. The analysis encompassed citation and co-citation networks, keyword bursts, and temporal trends to delineate the evolution of research themes and collaboration patterns. Advanced software tools, CiteSpace and VOSviewer, were utilized for comprehensive data visualization and trend analysis.

RESULTS

Analysis uncovered a total of 3804 publications on IA rupture risk factors between 2006 and 2023. Research interest surged after 2013, peaking in 2023. The United States led with 28.97% of publications, garnering 37706 citations. Notable United States-China collaborations were observed. Capital Medical University produced 184 publications, while Utrecht University boasted a citation average of 69.62 per publication. "World Neurosurgery" published the most papers, contrasting with "Stroke", the most cited journal. The PHASES score from "Lancet Neurology" emerged as a vital rupture risk prediction tool. Early research favored endovascular therapy, transitioning to magnetic resonance imaging and flow diverters. "Subarachnoid hemorrhage" stood out as a recurrent keyword.

CONCLUSION

This study assesses global IA research trends and highlights crucial gaps, guiding future investigations to improve preventive and therapeutic approaches.

Stable and Thin-Polymer-Based Modification of Neurovascular Stents with 2-Methacryloyloxyethyl Phosphorylcholine Polymer for Antithrombogenicity

The advent of intracranial stents has revolutionized the endovascular treatment of cerebral aneurysms. The utilization of stents has rendered numerous cerebral aneurysm amenable to endovascular treatment, thereby obviating the need for otherwise invasive open surgical options. Stent placement has become a mainstream approach because of its safety and efficacy. However, further improvements are required for clinically approved devices to avoid the frequent occurrence of thrombotic complications. Therefore, controlling the thrombotic complications associated with the use of devices is of significant importance. Our group has developed a unique stent coated with a 2-methacryloyloxyethyl phosphorylcholine (MPC)-based polymer. In this study, the surface characteristics of the polymer coating were verified using X-ray photoelectron spectroscopy and atomic force microscopy. Subsequently, the antithrombotic properties of the coating were evaluated by measuring platelet count and thrombin-antithrombin complex levels of whole human blood after 3 h of incubation in a Chandler loop model. Scanning electron microscopy was utilized to examine thrombus formation on the stent surface. We observed that MPC polymer-coated stents significantly reduced thrombus formation as compared to bare stents and several clinically approved devices. Finally, the coated stents were further analyzed by implanting them in the internal thoracic arteries of pigs. Angiographic imaging and histopathological examinations that were performed one week after implantation revealed that the vascular lumen was well maintained and coated stents were integrated within the vascular endothelium without inducing adverse effects. Thus, we demonstrated the efficacy of MPC polymer coating as a viable strategy for avoiding the thrombotic risks associated with neurovascular stents.

Ligation of cervical lymphatic vessels decelerates blood clearance and worsens outcomes after experimental subarachnoid hemorrhage

Subarachnoid hemorrhage (SAH) is characterized by the extravasation of blood into the subarachnoid space, in which erythrocyte lysis is the primary contributor to cell death and brain injuries. New evidence has indicated that meningeal lymphatic vessels (mLVs) are essential in guiding fluid and macromolecular waste from cerebrospinal fluid (CSF) into deep cervical lymph nodes (dCLNs). However, the role of mLVs in clearing erythrocytes after SAH has not been completely elucidated. Hence, we conducted a cross-species study. Autologous blood was injected into the subarachnoid space of rabbits and rats to induce SAH. Erythrocytes in the CSF were measured with/without deep cervical lymph vessels (dCLVs) ligation. Additionally, prior to inducing SAH, we administered rats with vascular endothelial growth factor C (VEGF-C), which is essential for meningeal lymphangiogenesis and maintaining integrity and survival of lymphatic vessels. The results showed that the blood clearance rate was significantly lower after dCLVs ligation in both the rat and rabbit models. DCLVs ligation aggravated neuroinflammation, neuronal damage, brain edema, and behavioral impairment after SAH. Conversely, the treatment of VEGF-C enhanced meningeal lymphatic drainage of erythrocytes and improved outcomes in SAH. In summary, our research highlights the indispensable role of the meningeal lymphatic pathway in the clearance of blood and mediating consequences after SAH.

MFGE8 promotes adult hippocampal neurogenesis in rats following experimental subarachnoid hemorrhage via modifying the integrin β3/Akt signaling pathway

Subarachnoid hemorrhage (SAH) is one of the most severe type of cerebral strokes, which can cause multiple cellular changes in the brain leading to neuronal injury and neurological deficits. Specifically, SAH can impair adult neurogenesis in the hippocampal dentate gyrus, thus may affecting poststroke neurological and cognitive recovery. Here, we identified a non-canonical role of milk fat globule epidermal growth factor 8 (MFGE8) in rat brain after experimental SAH, involving a stimulation on adult hippocampal neurogenesis(AHN). Experimental SAH was induced in Sprague-Dawley rats via endovascular perforation, with the in vivo effect of MFGE8 evaluated via the application of recombinant human MFGE8 (rhMFGE8) along with pharmacological interventions, as determined by hemorrhagic grading, neurobehavioral test, and histological and biochemical analyses of neurogenesis related markers. Results: Levels of the endogenous hippocampal MFGE8 protein, integrin-β3 and protein kinase B (p-Akt) were elevated in the SAH relative to control groups, while that of hippocalcin (HPCA) and cyclin D1 showed the opposite change. Intraventricular rhMGFE8 infusion reversed the decrease in doublecortin (DCX) immature neurons in the DG after SAH, along with improved the short/long term neurobehavioral scores. rhMGFE8 treatment elevated the levels of phosphatidylinositol 3-kinase (PI3K), p-Akt, mammalian target of rapamycin (mTOR), CyclinD1, HPCA and DCX in hippocampal lysates, but not that of integrin β3 and Akt, at 24 hr after SAH. Treatment of integrin β3 siRNA, the PI3K selective inhibitor ly294002 or Akt selective inhibitor MK2206 abolished the effects of rhMGFE8 after SAH. In conclusion, MFGE8 is upregulated in the hippocampus in adult rats with reduced granule cell genesis. rhMFGE8 administration can rescue this impaired adult neurogenesis and improve neurobehavioral recovery. Mechanistically, the effect of MFGE8 on hippocampal adult neurogenesis is mediated by the activation of integrin β3/Akt pathway. These findings suggest that exogenous MFGE8 may be of potential therapeutic value in SAH management. Graphical abstract and proposed pathway of rhMFGE8 administration attenuate hippocampal injury by improving neurogenesis in SAH models. SAH caused hippocampal injury and neurogenesis interruption. Administered exogenous MFGE8, recombinant human MFGE8(rhMFGE8), could ameliorate hippocampal injury and improve neurological functions after SAH. Mechanistically, MFGE8 bind to the receptor integrin β3, which activated the PI3K/Akt pathway to increase the mTOR expression, and further promote the expression of cyclin D1, HPCA and DCX. rhMFGE8 could attenuated hippocampal injury by improving neurogenesis after SAH, however, know down integrin β3 or pharmacological inhibited PI3K/Akt by ly294002 or MK2206 reversed the neuro-protective effect of rhMFGE8.

Aneurysmal Subarachnoid Hemorrhage and Sex Differences: Analysis of Epidemiology, Outcomes, and Risk Factors

BACKGROUND

The differences in outcomes after aneurysmal subarachnoid hemorrhage (aSAH) between the sexes have not been concretely determined. This study aimed to evaluate the differences in epidemiology, outcomes, and risk factors between male and female patients with aSAH.

METHODS

We performed a multicenter, retrospective study of patients with aSAH from 2017 to 2020. We investigated the epidemiological differences between the two sexes. Propensity score matching (PSM) was used to compare short-term outcomes between the sexes. Binary logarithmic regression was performed to investigate the odds ratio (OR) for dependent survival in patients of different sexes.

RESULTS

A total of 5,407 consecutive patients with aSAH were included in this study, and the female-to-male ratio was 1.8:1. The peak incidence of aSAH occurred in the 6th and 7th decades in males and females, respectively. There were more female patients with internal carotid artery or posterior communicating artery aneurysms (53.2%), and there were more male patients with anterior cerebral artery or anterior communicating artery aneurysms (43.2%). The incidence of multiple aneurysms was greater in female patients (21.5% vs. 14.2%, P < 0.001). There was no significant difference in outcomes before and after PSM at discharge. The dependent survival risk was related only to the clinical condition on admission in women. In addition, age > 50 years (OR 1.88, 95% confidence interval 1.17-3.02; P = 0.01) and hypertension (OR 1.81, 95% confidence interval 1.25-2.61; P = 0.002) were also risk factors for male patients.

CONCLUSIONS

There were more female patients with aneurysms than male patients in this study. Most aneurysm locations were different between the two groups. There was no significant difference in discharge outcomes before and after PSM. The risk factors for dependent survival were different between female and male patients.

Knowledge-Augmented Deep Learning for Segmenting and Detecting Cerebral Aneurysms With CT Angiography: A Multicenter Study

Background Deep learning (DL) could improve the labor-intensive, challenging processes of diagnosing cerebral aneurysms but requires large multicenter data sets. Purpose To construct a DL model using a multicenter data set for accurate cerebral aneurysm segmentation and detection on CT angiography (CTA) images and to compare its performance with radiology reports. Materials and Methods Consecutive head or head and neck CTA images of suspected unruptured cerebral aneurysms were gathered retrospectively from eight hospitals between February 2018 and October 2021 for model development. An external test set with reference standard digital subtraction angiography (DSA) scans was obtained retrospectively from one of the eight hospitals between February 2022 and February 2023. Radiologists (reference standard) assessed aneurysm segmentation, while model performance was evaluated using the Dice similarity coefficient (DSC). The model's aneurysm detection performance was assessed by sensitivity and comparing areas under the receiver operating characteristic curves (AUCs) between the model and radiology reports in the DSA data set with use of the DeLong test. Results Images from 6060 patients (mean age, 56 years ± 12 [SD]; 3375 [55.7%] female) were included for model development (training: 4342; validation: 1086; and internal test set: 632). Another 118 patients (mean age, 59 years ± 14; 79 [66.9%] female) were included in an external test set to evaluate performance based on DSA. The model achieved a DSC of 0.87 for aneurysm segmentation performance in the internal test set. Using DSA, the model achieved 85.7% (108 of 126 aneurysms [95% CI: 78.1, 90.1]) sensitivity in detecting aneurysms on per-vessel analysis, with no evidence of a difference versus radiology reports (AUC, 0.93 [95% CI: 0.90, 0.95] vs 0.91 [95% CI: 0.87, 0.94]; P = .67). Model processing time from reconstruction to detection was 1.76 minutes ± 0.32 per scan. Conclusion The proposed DL model could accurately segment and detect cerebral aneurysms at CTA with no evidence of a significant difference in diagnostic performance compared with radiology reports. © RSNA, 2024 Supplemental material is available for this article. See also the editorial by Payabvash in this issue.

Improving intracranial aneurysms image quality and diagnostic confidence with deep learning reconstruction in craniocervical CT angiography

BACKGROUND

The diagnostic impact of deep learning computed tomography (CT) reconstruction on intracranial aneurysm (IA) remains unclear.

PURPOSE

To quantify the image quality and diagnostic confidence on IA in craniocervical CT angiography (CTA) reconstructed with DEep Learning Trained Algorithm (DELTA) compared to the routine hybrid iterative reconstruction (HIR).

MATERIAL AND METHODS

A total of 60 patients who underwent craniocervical CTA and were diagnosed with IA were retrospectively enrolled. Images were reconstructed with DELTA and HIR, where the image quality was first compared in noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR). Next, two radiologists independently graded the noise appearance, arterial sharpness, small vessel visibility, conspicuity of calcifications that may present in arteries, and overall image quality, each with a 5-point Likert scale. The diagnostic confidence on IAs of various sizes was also graded.

RESULTS

Significantly lower noise and higher SNR and CNR were found on DELTA than on HIR images (all P < 0.05). All five subjective metrics were scored higher by both readers on the DELTA images (all P < 0.05), with good to excellent inter-observer agreement (κ = 0.77-0.93). DELTA images were rated with higher diagnostic confidence on IAs compared to HIR (P < 0.001), particularly for those with size ≤3 mm, which were scored 4.5 ± 0.6 versus 3.4 ± 0.8 and 4.4 ± 0.7 versus 3.5 ± 0.8 by two readers, respectively.

CONCLUSION

The DELTA shows potential for improving the image quality and the associated confidence in diagnosing IA that may be worth consideration for routine craniocervical CTA applications.

Deep learning for intracranial aneurysm segmentation using CT angiography

Objective.This study aimed to employ a two-stage deep learning method to accurately detect small aneurysms (4-10 mm in size) in computed tomography angiography images.Approach.This study included 956 patients from 6 hospitals and a public dataset obtained with 6 CT scanners from different manufacturers. The proposed method consists of two components: a lightweight and fast head region selection (HRS) algorithm and an adaptive 3D nnU-Net network, which is used as the main architecture for segmenting aneurysms. Segments generated by the deep neural network were compared with expert-generated manual segmentation results and assessed using Dice scores.MainResults.The area under the curve (AUC) exceeded 79% across all datasets. In particular, the precision and AUC reached 85.2% and 87.6%, respectively, on certain datasets. The experimental results demonstrated the promising performance of this approach, which reduced the inference time by more than 50% compared to direct inference without HRS.Significance.Compared with a model without HRS, the deep learning approach we developed can accurately segment aneurysms by automatically localizing brain regions and can accelerate aneurysm inference by more than 50%.

Protective Effects of Adropin in Experimental Subarachnoid Hemorrhage

PURPOSE

We aimed to investigate early effects of exogenously administered adropin (AD) on neurological function, endothelial nitric oxide synthase (eNOS) expression, nitrite/nitrate levels, oxidative stress, and apoptosis in subarachnoid hemorrhage (SAH).

METHODS

Following intracerebroventricular AD administration (10 µg/5 µl at a rate of 1 µl/min) SAH model was carried out in Sprague-Dawley rats by injection of autologous blood into the prechiasmatic cistern. The effects of AD were assessed 24 h following SAH. The modified Garcia score was employed to evaluate functional insufficiencies. Adropin and caspase-3 proteins were measured by ELISA, while nitrite/nitrate levels, total antioxidant capacity (TAC) and reactive oxygen/nitrogen species (ROS/RNS) were assayed by standard kits. eNOS expression and apoptotic neurons were detected by immunohistochemical analysis.

RESULTS

The SAH group performed notably lower on the modified Garcia score compared to sham and SAH + AD groups. Adropin administration increased brain eNOS expression, nitrite/nitrate and AD levels compared to SHAM and SAH groups. SAH produced enhanced ROS/RNS generation and reduced antioxidant capacity in the brain. Adropin boosted brain TAC and diminished ROS/RNS production in SAH rats and no considerable change amongst SHAM and SAH + AD groups were detected. Apoptotic cells were notably increased in intensity and number after SAH and were reduced by AD administration.

CONCLUSIONS

Adropin increases eNOS expression and reduces neurobehavioral deficits, oxidative stress, and apoptotic cell death in SAH model. Presented results indicate that AD provides protection in early brain injury associated with SAH.

'We are still here, we are survivors': patients' experiences of attending a multidisciplinary group-based support programme following subarachnoid haemorrhage

PURPOSE

People who survive a subarachnoid haemorrhage (SAH) often face enduring health challenges including physical disability, fatigue, cognitive impairments, psychological difficulties, and reduced quality of life. While group interventions have shown positive results in addressing similar issues in chronic conditions, the evidence involving SAH specifically is still sparse. This service evaluation aimed to explore SAH survivors' experiences of attending a multidisciplinary group-based support programme tailored to address unmet needs identified in previous literature, with the ultimate aim to refine future iterations of the programme and improve quality of care post-SAH.

MATERIALS AND METHODS

Semi-structured interviews were carried out with 12 individuals who attended the programme. The resulting data were analysed thematically.

RESULTS

Four overarching themes emerged from the analysis: (1) Barriers to accessing support after a SAH, (2) Factors acting as enablers of recovery, (3) Sharing lived experience to support one another, (4) Feeling connected while navigating a group format.

CONCLUSIONS

Lack of communication, fear, loneliness, and cognitive impairments can act as barriers to engagement with support, while acceptance and adjustment, holistic multidisciplinary input, and psychological support may represent successful enablers of recovery. Implications for future iterations of the programme as well as clinical rehabilitation and service development are discussed.

HSV-1 and Cellular miRNAs in CSF-Derived Exosomes as Diagnostically Relevant Biomarkers for Neuroinflammation

Virus-associated chronic inflammation may contribute to autoimmunity in a number of diseases. In the brain, autoimmune encephalitis appears related to fluctuating reactivation states of neurotropic viruses. In addition, viral miRNAs and proteins can be transmitted via exosomes, which constitute novel but highly relevant mediators of cellular communication. The current study questioned the role of HSV-1-encoded and host-derived miRNAs in cerebrospinal fluid (CSF)-derived exosomes, enriched from stress-induced neuroinflammatory diseases, mainly subarachnoid hemorrhage (SAH), psychiatric disorders (AF and SZ), and various other neuroinflammatory diseases. The results were compared with CSF exosomes from control donors devoid of any neuroinflammatory pathology. Serology proved positive, but variable immunity against herpesviruses in the majority of patients, except controls. Selective ultrastructural examinations identified distinct, herpesvirus-like particles in CSF-derived lymphocytes and monocytes. The likely release of extracellular vesicles and exosomes was most frequently observed from CSF monocytes. The exosomes released were structurally similar to highly purified stem-cell-derived exosomes. Exosomal RNA was quantified for HSV-1-derived miR-H2-3p, miR-H3-3p, miR-H4-3p, miR-H4-5p, miR-H6-3p, miR-H27 and host-derived miR-21-5p, miR-146a-5p, miR-155-5p, and miR-138-5p and correlated with the oxidative stress chemokine IL-8 and the axonal damage marker neurofilament light chain (NfL). Replication-associated miR-H27 correlated with neuronal damage marker NfL, and cell-derived miR-155-5p correlated with oxidative stress marker IL-8. Elevated miR-138-5p targeting HSV-1 latency-associated ICP0 inversely correlated with lower HSV-1 antibodies in CSF. In summary, miR-H27 and miR-155-5p may constitute neuroinflammatory markers for delineating frequent and fluctuating HSV-1 replication and NfL-related axonal damage in addition to the oxidative stress cytokine IL-8 in the brain. Tentatively, HSV-1 remains a relevant pathogen conditioning autoimmune processes and a psychiatric clinical phenotype.

The relationship between autoimmune disorders and intracranial aneurysms in East Asian and European populations: a bidirectional and multivariable two-sample Mendelian randomization study

Background

It remains unclear about the pathogenesis of intracranial aneurysms (IAs) in the setting of autoimmune disorders (ADs). However, the underlying systemic inflammatory characteristics of ADs may affect IAs through shared inflammatory pathways. Therefore, this study was conducted to explore the relationship between ADs and IAs and assess causal effects.

Methods

In this study, 6 common ADs were included to explore their causal relationship with IAs. Besides, a bidirectional two-sample univariable Mendelian randomization (UVMR) analysis was performed. In addition, the primary analysis was performed by the inverse variance weighted (IVW) and Bayesian weighted Mendelian randomization (BWMR) method, and a series of sensitivity analyses were performed to assess the robustness of the results. Further, the data related to ADs and IAs were collected from open genome-wide association study studies (GWASs) and the Cerebrovascular Disease Knowledge Portal (CDKP) (including 11,084 cases and 311,458 controls), respectively. These analyses were conducted based on both the East Asian and European populations. Moreover, 6 ADs were subject to grouping according to connective tissue disease, inflammatory bowel disease, and thyroid disease. On that basis, a multivariate MR (MVMR1) analysis was further performed to explore the independent causal relationship between each AD and IAs, and an MVMR 2 analysis was conducted to investigate such potential confounders as smoking, alcohol consumption, and systolic blood pressure. Finally, these results were verified based on the data from another GWAS of IAs.

Results

The UVMR analysis results demonstrated that systemic lupus erythematosus (SLE) was associated with a high risk of IAs in the East Asian population (IVW OR, 1.06; 95%CI, 1.02-1.11; p = 0.0065, UVMR), which was supported by the results of BWMR (OR, 1.06; 95%CI, 1.02-1.11; p = 0.0067, BWMR), MVMR1 (OR, 1.06; 95%CI, 1.01-1.10; p = 0.015, MVMR1), MVMR2 (OR, 1.05; 95%CI, 1.00-1.11; p = 0.049, MVMR2), and sensitivity analyses. The results in the validation group also suggested a causal relationship between SLE and IAs (IVW OR, 1.04; 95% CI, 1.00-1.09; p = 0.046). The reverse MR analysis results did not reveal a causal relationship between IAs and ADs.

Conclusion

In this MR study, SLE was validated to be a risk factor for IAs in the East Asian population. Therefore, the management of IAs in patients with SLE should be highlighted to avoid stroke events.

Rupture risk of intracranial aneurysms: Comparison between small ruptured intracranial aneurysms and large unruptured intracranial aneurysms

To compare the differences in clinical and morphological features between small ruptured intracranial aneurysms and large unruptured intracranial aneurysms to evaluate the risk factors for the rupture of IAs. The clinical data of 189 consecutive patients with 193 IAs were reviewed. The patients and IAs were divided into ruptured (<5 mm) and unruptured groups (>10 mm). The characteristics of the patients and the intracranial aneurysms (IAs) were compared between the 2 groups, and the risk factors for rupture of IAs were assessed using multiple logistic regression. Patient age (odds ratio [OR], 0.955), IA located at the internal carotid artery (ICA, OR, 0.202), irregular shape (OR, 0.083) and parent vessel diameter (OR, 0.426) were negatively correlated with the risk of IA rupture. IAs located at bifurcations (OR, 6.766) were positively correlated with the risk of IA rupture. In addition to the size of the IAs, regardless of IAs shape, other factors, such as younger age (<63.5 years), location at a bifurcation, IAs located at the ICA and a small parent vessel diameter (<3.25 mm), can influence the risk of IA rupture.

Identifying hemodynamic factors associated with the rupture of anterior communicating artery aneurysms based on global modeling of blood flow in the cerebral artery network

Anterior communicating artery (ACoA) aneurysms are more prone to rupture compared to aneurysms present in other cerebral arteries. We hypothesize that systemic blood flow in the cerebral artery network plays an important role in shaping intra-aneurysmal hemodynamic environment thereby affecting the rupture risk of ACoA aneurysms. The majority of existing numerical studies in this field employed local modeling methods where the physical boundaries of a model are confined to the aneurysm region, which, though having the benefit of reducing computational cost, may compromise the physiological fidelity of numerical results due to insufficient account of systemic cerebral arterial hemodynamics. In the present study, we firstly carried out numerical experiments to address the difference between the outcomes of local and global modeling methods, demonstrating that local modeling confined to the aneurysm region results in inaccurate predictions of hemodynamic parameters compared with global modeling of the ACoA aneurysm as part of the cerebral artery network. Motivated by this finding, we built global hemodynamic models for 40 ACoA aneurysms (including 20 ruptured and 20 unruptured ones) based on medical image data. Statistical analysis of the computed hemodynamic data revealed that maximum wall shear stress (WSS), minimum WSS divergence, and maximum WSS gradient differed significantly between the ruptured and unruptured ACoA aneurysms. Optimal threshold values of high/low WSS metrics were determined through a series of statistical tests. In the meantime, some morphological parameters of aneurysms, such as large nonsphericity index, aspect ratio, and bottleneck factor, were found to be associated closely with aneurysm rupture. Furthermore, multivariate logistic regression analyses were performed to derive models combining hemodynamic and morphological parameters for discriminating the rupture status of aneurysms. The capability of the models in rupture status discrimination was high, with the area under the receiver operating characteristic curve reaching up to 0.9. The findings of the study suggest that global modeling of the cerebral artery network is essential for reliable quantification of hemodynamics in ACoA aneurysms, disturbed WSS and irregular aneurysm morphology are associated closely with aneurysm rupture, and multivariate models integrating hemodynamic and morphological parameters have high potential for assessing the rupture risk of ACoA aneurysms.

Delayed spinal arachnoiditis with syringomyelia following aneurysmal subarachnoid haemorrhage: a case report with patient experience

BACKGROUND AND IMPORTANCE

Syringomyelia, or the formation of fluid-filled cysts within the spinal cord, associated with delayed spinal arachnoiditis is an uncommon complication of aneurysmal subarachnoid haemorrhage. To date, about 18 cases have been reported in medical literature, with just two reported in patients under the age of 35 years.

CLINICAL PRESENTATION

A 27-year-old female patient complained of sudden, severe headaches in the occipital region, nuchal rigidity, and drowsiness when she presented at our institution. A head computed tomography scan revealed intraventricular bleeding in the lateral and fourth ventricles with more extensive haemorrhaging in the frontal horns. A left posterior inferior cerebellar artery (PICA) aneurysm was confirmed via digital subtraction angiogram, and endovascular embolization was done. Two years later, the patient reported intense pain in the lower back along with symptoms suggestive of spinal cord compression. Spinal magnetic resonance imaging (MRI) showed spinal adhesions from C1 to L4, syringomyelia with some vasogenic oedema extending from T3 to T9 level, and a cyst in the lumbar region. Consequently, a right hemilaminectomy was performed along with microsurgical release of arachnoid adhesions and placement of a subdural drain. Radiological and symptomatic improvements were observed. Since then, the patient's clinical condition has remained stable during the past three years of follow-up visits.

CONCLUSIONS

Literature on optimal treatment modalities and patient prognosis is scarce and debated. The time for symptom improvement depends on the level and extent of spinal cord involvement. Rehabilitation may be required for most patients, as complete symptomatic recovery may not be attainable.

Transcranial Doppler in the Detection of Cerebral Vasospasm After Subarachnoid Hemorrhage

Background Transcranial Doppler (TCD) is a simple, noninvasive, nonionizing, portable technique but not widely practiced to detect cerebral vasospasm after subarachnoid hemorrhage (SAH). Objective The aim of this study was to assess the performance of TCD in the detection of cerebral vasospasm in patients with SAH considering CT angiography (CTA) as a gold standard. Methods and material This cross-sectional study included 50 patients with acute SAH admitted to the National Institute of Neurosciences & Hospital (NINS & H), Dhaka, Bangladesh, from February to June 2021. The neurological status, severity of SAH, and initial CT findings were recorded. All patients were screened for cerebral vasospasm with TCD on the 4th, 7th, 10th, and 14th days after the event. Screening of cerebral vasospasm by CTA was done on the 14th day of the event or earlier if TCD suggested vasospasm. Results The mean age of the participants was 51.4 ±13.4 years (mean ± SD), and females were predominant (N=29, 58%). CTA detected cerebral vasospasm in 18 (36%) participants, but TCD could detect it in only 13 (26%) cases. Among the participants who had no vasospasm by CTA, all but one were also found to have no vasospasm by TCD. The agreement between TCD and CTA in detecting cerebral vasospasm was significant (p<0.001, κ=0.726). TCD shows good specificity (96.9%) and positive predictive value (92.8%), but sensitivity (72.2%) and negative predictive value (81.6%) were comparatively lower. Overall, the diagnostic accuracy of TCD in detecting cerebral vasospasm was 88%. Conclusions Although compared to CTA, TCD is a highly specific but less sensitive tool in detecting vasospasm, TCD remains a reliable screening tool for detecting vasospasm following SAH.

Intracranial aneurysms in patients with acute ischemic stroke prevalence and influence on mechanical thrombectomy over 14 years in a tertiary-care center

INTRODUCTION

The prevalence of intracranial aneurysms (IA) in patients with acute ischemic stroke (AIS) requiring mechanical thrombectomy (MT) is unclear.

OBJECTIVE

To describe the prevalence of IA in patients with AIS and their influence on MT.

MATERIALS & METHODS

This is a retrospective cohort study on all patients admitted with a diagnosis of AIS from January 2008 to March 2022 at a tertiary academic center. The records were reviewed for demographic, clinical, imaging, and outcomes data. Only patients who had CTA at admission were included in this analysis.

RESULTS

Among 2265 patients admitted with AIS, this diagnosis was confirmed in 2113 patients (93.3 %). We included 1111 patients (52.6 %) who had head CTA and 321 (28.9 %) who underwent MT. The observed prevalence of aneurysms on CTA was 4.5 % (50/1111 patients), and 8 (16 %) had multiple aneurysms. MT was performed in 7 patients harboring IAs: 6 ipsilateral (5 proximal and 1 distal to the occlusion)and 1 contralateral aneurysm.. The patient with a contralateral aneurysm had a TICI 2B score In patients with ipsilateral aneurysms, TICI 2B or 3 was achieved in 3 cases (50 %), which is significantly lower than historical control of MT (91.6 %) without IA (p = 0.01). No aneurysms ruptured during MT. The aneurysm noted distal to the occlusion was mycotic.

CONCLUSION

In this analysis, the observed prevalence of IA in patients with AIS was 4.5%. Ipsilateral aneurysms (proximal or distal to the occlusion site) deserve particular attention, given the potential risk of rupture during MT. Aneurysms located distal to the occlusion were mycotic and the rate of recanization in patients with ipsilateral aneurysms was low compared to historical controls. Further studies are needed to improve the outcomes in patients with IA requiring MT.

Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis

BACKGROUND

Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI.

METHODS

aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (<3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality.

RESULTS

Among 276 aSAH patients included in the analysis, 35.5% (N.=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI=1.17, 5.10; P=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI=1.08, 3.54; P=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI=1.18, 5.36; P=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity = 0.55, specificity = 0.75).

CONCLUSIONS

Serum albumin, a routine and inexpensive laboratory measurement, may potentially aid in the identification of patients with aSAH at risk for the development of DCI.

Efficacy of an intervention program to prevent patient safety indicators in aneurysmal subarachnoid haemorrhage

OBJECTIVE

Patient safety indicators (PSI) are a set of potentially preventable events related to patient safety and opportunities for improvement. Eight pertinent PSI have been identified in patients with aneurysmal subarachnoid haemorrhage (ASAH), such as decubitus ulcer, and central line-related bacteraemia. Our aim was to evaluate the efficacy of a health care quality protocol to prevent the appearance of PSI in ASAH patients.

METHODS

Adult patients treated for ASAH were included in a retrospective control group of 35 patients and a prospective experimental group of 35 patients when the prevention program was implemented. We evaluated the occurrence of PSI, and its relation to age, sex, Hunt and Hess scale grade, type of aneurysm treatment, length of hospital stay, and Glasgow Outcome Scale scores.

RESULTS

Both groups had similar characteristics except for a longer hospital stay in the control group. The overall PSI prevalence decreased significantly in the experimental group compared to the control group. The experimental group had a decreased risk for having at least one PSI: OR = 0.21 (0.08-0.57, CI 95%). The absolute risk reduction is 37.1% (58.9%-15.4%), the preventable fraction for the population is 28.3% (10.6%-40.0%), and the number needed to treat is 2.69.

CONCLUSIONS

The health care quality protocol is effective to prevent ISP in ASAH patients. Implementing this prevention program has no effect on the neurological state of the patient at the hospital discharge. Still, it is successful in decreasing the PSI prevalence and the days of hospital stay.

Prediction of aneurysmal subarachnoid hemorrhage in comparison with other stroke types using routine care data

Aneurysmal subarachnoid hemorrhage (aSAH) can be prevented by early detection and treatment of intracranial aneurysms in high-risk individuals. We investigated whether individuals at high risk of aSAH in the general population can be identified by developing an aSAH prediction model with electronic health records (EHR) data. To assess the aSAH model's relative performance, we additionally developed prediction models for acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) and compared the discriminative performance of the models. We included individuals aged ≥35 years without history of stroke from a Dutch routine care database (years 2007-2020) and defined outcomes aSAH, AIS and ICH using International Classification of Diseases (ICD) codes. Potential predictors included sociodemographic data, diagnoses, medications, and blood measurements. We cross-validated a Cox proportional hazards model with an elastic net penalty on derivation cohorts and reported the c-statistic and 10-year calibration on validation cohorts. We examined 1,040,855 individuals (mean age 54.6 years, 50.9% women) for a total of 10,173,170 person-years (median 11 years). 17,465 stroke events occurred during follow-up: 723 aSAH, 14,659 AIS, and 2,083 ICH. The aSAH model's c-statistic was 0.61 (95%CI 0.57-0.65), which was lower than the c-statistic of the AIS (0.77, 95%CI 0.77-0.78) and ICH models (0.77, 95%CI 0.75-0.78). All models were well-calibrated. The aSAH model identified 19 predictors, of which the 10 strongest included age, female sex, population density, socioeconomic status, oral contraceptive use, gastroenterological complaints, obstructive airway medication, epilepsy, childbirth complications, and smoking. Discriminative performance of the aSAH prediction model was moderate, while it was good for the AIS and ICH models. We conclude that it is currently not feasible to accurately identify individuals at increased risk for aSAH using EHR data.

Predicting who has delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage using machine learning approach: a multicenter, retrospective cohort study

BACKGROUND

Early prediction of delayed cerebral ischemia (DCI) is critical to improving the prognosis of aneurysmal subarachnoid hemorrhage (aSAH). Machine learning (ML) algorithms can learn from intricate information unbiasedly and facilitate the early identification of clinical outcomes. This study aimed to construct and compare the ability of different ML models to predict DCI after aSAH. Then, we identified and analyzed the essential risk of DCI occurrence by preoperative clinical scores and postoperative laboratory test results.

METHODS

This was a multicenter, retrospective cohort study. A total of 1039 post-operation patients with aSAH were finally included from three hospitals in China. The training group contained 919 patients, and the test group comprised 120 patients. We used five popular machine-learning algorithms to construct the models. The area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, precision, and f1 score were used to evaluate and compare the five models. Finally, we performed a Shapley Additive exPlanations analysis for the model with the best performance and significance analysis for each feature.

RESULTS

A total of 239 patients with aSAH (23.003%) developed DCI after the operation. Our results showed that in the test cohort, Random Forest (RF) had an AUC of 0.79, which was better than other models. The five most important features for predicting DCI in the RF model were the admitted modified Rankin Scale, D-Dimer, intracranial parenchymal hematoma, neutrophil/lymphocyte ratio, and Fisher score. Interestingly, clamping or embolization for the aneurysm treatment was the fourth button-down risk factor in the ML model.

CONCLUSIONS

In this multicenter study, we compared five ML methods, among which RF performed the best in DCI prediction. In addition, the essential risks were identified to help clinicians monitor the patients at high risk for DCI more precisely and facilitate timely intervention.

Endothelial EGLN3-PKM2 signaling induces the formation of acute astrocytic barrier to alleviate immune cell infiltration after subarachnoid hemorrhage

BACKGROUND

Most subarachnoid hemorrhage (SAH) patients have no obvious hematoma lesions but exhibit blood-brain barrier dysfunction and vasogenic brain edema. However, there is a few days between blood‒brain barrier dysfunction and vasogenic brain edema. The present study sought to investigate whether this phenomenon is caused by endothelial injury induced by the acute astrocytic barrier, also known as the glial limitans.

METHODS

Bioinformatics analyses of human endothelial cells and astrocytes under hypoxia were performed based on the GEO database. Wild-type, EGLN3 and PKM2 conditional knock-in mice were used to confirm glial limitan formation after SAH. Then, the effect of endothelial EGLN3-PKM2 signaling on temporal and spatial changes in glial limitans was evaluated in both in vivo and in vitro models of SAH.

RESULTS

The data indicate that in the acute phase after SAH, astrocytes can form a temporary protective barrier, the glia limitans, around blood vessels that helps maintain barrier function and improve neurological prognosis. Molecular docking studies have shown that endothelial cells and astrocytes can promote glial limitans-based protection against early brain injury through EGLN3/PKM2 signaling and further activation of the PKC/ERK/MAPK signaling pathway in astrocytes after SAH.

CONCLUSION

Improving the ability to maintain glial limitans may be a new therapeutic strategy for improving the prognosis of SAH patients.

Rutaecarpine Alleviates Early Brain Injury-Induced Inflammatory Response Following Subarachnoid Hemorrhage via SIRT6/NF-[Formula: see text]B Pathway

Subarachnoid hemorrhage (SAH), a specific subtype of cerebrovascular accident, is characterized by the extravasation of blood into the interstice between the brain and its enveloping delicate tissues. This pathophysiological phenomenon can precipitate an early brain injury (EBI), which is characterized by inflammation and neuronal death. Rutaecarpine (Rut), a flavonoid compound discovered in various plants, has been shown to have protective effects against SAH-induced cerebral insult in rodent models. In our study, we used a rodent SAH model to evaluate the effect of Rut on EBI and investigated the effect of Rut on the inflammatory response and its regulation of SIRT6 expression in vitro. We found that Rut exerts a protective effect on EBI in SAH rats, which is partly due to its ability to inhibit the inflammatory response. Notably, Rut up-regulated Sirtuin 6 (SIRT6) expression, leading to an increase in H3K9 deacetylation and inhibition of nuclear factor-kappa B (NF-[Formula: see text]B) transcriptional activation, thereby mediating the inflammatory response. In addition, further data showed that SIRT6 was proven to mediate the regulation of Rut on the microglial inflammatory response. These findings highlight the importance of SIRT6 in the regulation of inflammation and suggest a potential mechanism for the protective effect of Rut on EBI. In summary, Rut may have the potential to prevent and treat SAH-induced brain injury by interacting with SIRT6. Our findings may provide a new therapeutic strategy for the treatment of SAH-induced EBI.

Transition of intracranial aneurysmal wall enhancement from high to low wall shear stress mediation with size increase: A hemodynamic study based on 7T magnetic resonance imaging

Background

Wall shear stress (WSS) has been proved to be related to the formation, development and rupture of intracranial aneurysms. Aneurysm wall enhancement (AWE) on magnetic resonance imaging (MRI) can be caused by inflammation and have confirmed its relationship with low WSS. High WSS can also result in inflammation but the research of its correlation with AWE is lack because of the focus on large aneurysms limited by 3T MRI in most previous studies.This study aimed to assess the potential association between high or low WSS and AWE in different aneuryms. Especially the relationship between high WSS and AWE in small aneurysm.

Methods

Forty-three unruptured intracranial aneurysms in 42 patients were prospectively included for analysis. 7.0 T MRI was used for imaging. Aneurysm size was measured on three-dimensional time-of-flight (TOF) images. Aneurysm-to-pituitary stalk contrast ratio (CRstalk) was calculated on post-contrast black-blood T1-weighted fast spin echo sequence images. Hemodynamics were assessed by four-dimensional flow MRI.

Results

The small aneurysms group had more positive WSS-CRstalk correlation coefficient distribution (dome: 78.6 %, p = 0.009; body: 50.0 %, p = 0.025), and large group had more negative coefficient distribution (dome: 44.8 %, p = 0.001; body: 69.0 %, p = 0.002). Aneurysm size was positively correlated with the significant OSI-CRstalk correlation coefficient at the dome (p = 0.012) and body (p = 0.010) but negatively correlated with the significant WSS-CRstalk correlation coefficient at the dome (p < 0.001) and body (p = 0.017).

Conclusion

AWE can be mediated by both high and low WSS, and translate from high WSS- to low WSS-mediated pathways as size increase. Additionally, AWE may serve as an indicator of the stage of aneurysm development via different correlations with hemodynamic factors.

Sex-Related Differences in Mortality, Delayed Cerebral Ischemia, and Functional Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis

Background/Objective: Sex-related differences among patients with aneurysmal subarachnoid hemorrhage (aSAH) and their potential clinical implications have been insufficiently investigated. To address this knowledge gap, we conduct a comprehensive systematic review and meta-analysis. Methods: Sex-specific differences in patients with aSAH, including mortality, delayed cerebral ischemia (DCI), and functional outcomes were assessed. The functional outcome was dichotomized into favorable or unfavorable based on the modified Rankin Scale (mRS), Glasgow Outcome Scale (GOS), and Glasgow Outcome Scale Extended (GOSE). Results: Overall, 2823 studies were identified in EMBASE, MEDLINE, PubMed, and by manual search on 14 February 2024. After an initial assessment, 74 studies were included in the meta-analysis. In the analysis of mortality, including 18,534 aSAH patients, no statistically significant differences could be detected (risk ratio (RR) 0.99; 95% CI, 0.90-1.09; p = 0.91). In contrast, the risk analysis for DCI, including 23,864 aSAH patients, showed an 11% relative risk reduction in DCI in males versus females (RR, 0.89; 95% CI, 0.81-0.97; p = 0.01). The functional outcome analysis (favorable vs. unfavorable), including 7739 aSAH patients, showed a tendency towards better functional outcomes in men than women; however, this did not reach statistical significance (RR, 1.02; 95% CI, 0.98-1.07; p = 0.34). Conclusions: In conclusion, the available data suggest that sex/gender may play a significant role in the risk of DCI in patients with aSAH, emphasizing the need for sex-specific management strategies.

Longitudinal change of serum AIM2 levels after aneurysmal subarachnoid hemorrhage and its prognostic significance: a two-center prospective cohort study

Absent in melanoma 2 (AIM2) is implicated in neuroinflammation. Here, we explored the prognostic significance of serum AIM2 in human aneurysmal subarachnoid hemorrhage (aSAH). We conducted a consecutive enrollment of 127 patients, 56 of whom agreed with blood-drawings not only at admission but also at days 1, 2, 3, 5, 7 and 10 days after aSAH. Serum AIM2 levels of patients and 56 healthy controls were measured. Disease severity was assessed using the modified Fisher scale (mFisher) and World Federation of Neurological Surgeons Scale (WFNS). Neurological outcome at poststroke 90 days was evaluated via the modified Rankin Scale (mRS). Univariate analysis and multivariate analysis were sequentially done to ascertain relationship between serum AIM2 levels, severity, delayed cerebral ischemia (DCI) and 90-day poor prognosis (mRS scores of 3-6). Patients, in comparison to controls, had a significant elevation of serum AIM2 levels at admission and at days 1, 2, 3, 5, 7 and 10 days after aSAH, with the highest levels at days 1, 2, 3 and 5. AIM2 levels were independently correlated with WFNS scores and mFisher scores. Significantly higher serum AIM2 levels were detected in patients with a poor prognosis than in those with a good prognosis, as well as in patients with DCI than in those without DCI. Moreover, serum AIM2 levels independently predicted a poor prognosis and DCI, and were linearly correlated with their risks. Using subgroup analysis, there were no significant interactions between serum AIM2 levels and age, gender, hypertension and so on. There were substantially high predictive abilities of serum AIM2 for poor prognosis and DCI under the receiver operating characteristic curve. The combination models of DCI and poor prognosis, in which serum AIM2, WFNS scores and mFisher scores were incorporated, showed higher discriminatory efficiencies than anyone of the preceding three variables. Moreover, the models are delineated using the nomogram, and performed well under the calibration curve and decision curve. Serum AIM2 levels, with a substantial enhancement during early phase after aSAH, are closely related to bleeding severity, poor 90-day prognosis and DCI of patients, substantializing serum AIM2 as a potential prognostic biomarker of aSAH.

Sodium and Its Impact on Outcome After Aneurysmal Subarachnoid Hemorrhage in Patients With and Without Delayed Cerebral Ischemia

OBJECTIVES

To perform a detailed examination of sodium levels, hyponatremia and sodium fluctuations, and their association with delayed cerebral ischemia (DCI) and poor outcome after aneurysmal subarachnoid hemorrhage (aSAH).

DESIGN

An observational cohort study from a prospective SAH Registry.

SETTING

Tertiary referral center focused on SAH treatment in the Amsterdam metropolitan area.

PATIENTS

A total of 964 adult patients with confirmed aSAH were included between 2011 and 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 277 (29%) developed DCI. Hyponatremia occurred significantly more often in DCI patients compared with no-DCI patients (77% vs. 48%). Sodium levels, hyponatremia, hypernatremia, and sodium fluctuations did not predict DCI. However, higher sodium levels were significantly associated with poor outcome in DCI patients (DCI onset -7, DCI +0, +1, +2, +4, +5, +8, +9 d), and in no-DCI patients (postbleed day 6-10 and 12-14). Also, hypernatremia and greater sodium fluctuations were significantly associated with poor outcome in both DCI and no-DCI patients.

CONCLUSIONS

Sodium levels, hyponatremia, and sodium fluctuations were not associated with the occurrence of DCI. However, higher sodium levels, hypernatremia, and greater sodium fluctuations were associated with poor outcome after aSAH irrespective of the presence of DCI. Therefore, sodium levels, even with mild changes in levels, warrant close attention.

Towards the mechanical characterisation of unruptured intracranial aneurysms: Numerical modelling of interactions between a deformation device and the aneurysm wall

Intracranial aneurysm is a critical pathology related to the arterial wall deterioration. This work is an essential aspect of a large scale project aimed at providing clinicians with a non-invasive patient-specific decision support tool regarding the rupture risk assessment. A machine learning algorithm links the aneurysm shape observed and a database of UIA clinical images associated with in vivo wall mechanical properties and rupture characterisation. The database constitution is derived from a device prototype coupled with medical imaging. It provides the mechanical characterisation of the aneurysm from the wall deformation obtained by inverse analysis based on the variation of luminal volume. Before performing in vivo tests of the device on small animals, a numerical model was built to quantify the device's impact on the aneurysm wall under natural blood flow conditions. As the clinician will never be able to precisely situate the device, several locations were considered. In preparation for the inverse analysis procedure, artery material laws of increasing complexity were studied (linear elastic, hyper elastic Fung-like). Considering all the device locations and material laws, the device induced relative displacements to the Systole peak (worst case scenario with the highest mechanical stimulus linked to the blood flow) ranging from 375 μm to 1.28 mm. The variation of luminal volume associated with the displacements was between 0.95 % and 4.3 % compared to the initial Systole volume of the aneurysm. Significant increase of the relative displacements and volume variations were found with the study of different cardiac cycle moments between the blood flow alone and the device application. For forthcoming animal model studies, Spectral Photon CT Counting, with a minimum spatial resolution of 250 μm, was selected as the clinical imaging technique. Based on this preliminary study, the displacements and associated volume variations (baseline for inverse analyse), should be observable and exploitable.

Development of a predictive nomogram for 28-day mortality risk in non-traumatic or post-traumatic subarachnoid hemorrhage patients

OBJECTIVE

Subarachnoid hemorrhage (SAH) is associated with high rates of mortality and permanent disability. At present, there are few definite clinical tools to predict prognosis in SAH patients. The current study aims to develop and assess a predictive nomogram model for estimating the 28-day mortality risk in both non-traumatic or post-traumatic SAH patients.

METHODS

The MIMIC-III database was searched to select patients with SAH based on ICD-9 codes. Patients were separated into non-traumatic and post-traumatic SAH groups. Using LASSO regression analysis, we identified independent risk factors associated with 28-day mortality and incorporated them into nomogram models. The performance of each nomogram was assessed by calculating various metrics, including the area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA).

RESULTS

The study included 999 patients with SAH, with 631 in the non-traumatic group and 368 in the post-traumatic group. Logistic regression analysis revealed critical independent risk factors for 28-day mortality in non-traumatic SAH patients, including gender, age, glucose, platelet, sodium, BUN, WBC, PTT, urine output, SpO2, and heart rate and age, glucose, PTT, urine output, and body temperature for post-traumatic SAH patients. The prognostic nomograms outperformed the commonly used SAPSII and APSIII systems, as evidenced by superior AUC, NRI, IDI, and DCA results.

CONCLUSION

The study identified independent risk factors associated with the 28-day mortality risk and developed predictive nomogram models for both non-traumatic and post-traumatic SAH patients. The nomogram holds promise in guiding prognosis improvement strategies for patients with SAH.

Intraoperative neuromonitoring as real-time diagnostic for cerebral ischemia in endovascular treatment of ruptured brain aneurysms

OBJECTIVE

To evaluate the diagnostic accuracy of intraoperative neurophysiological monitoring (IONM) during endovascular treatment (EVT) of ruptured intracranial aneurysms (rIA).

METHODS

IONM and clinical data from 323 patients who underwent EVT for rIA from 2014-2019 were retrospectively reviewed. Significant IONM changes and outcomes were evaluated based on visual review of data and clinical documentation.

RESULTS

Of the 323 patients undergoing EVT, significant IONM changes were noted in 30 patients (9.29%) and 46 (14.24%) experienced postprocedural neurological deficits (PPND). 22 out of 30 (73.33%) patients who had significant IONM changes experienced PPND. Univariable analysis showed changes in somatosensory evoked potential (SSEP) and electroencephalogram (EEG) were associated with PPND (p-values: <0.001 and <0.001, retrospectively). Multivariable analysis showed that IONM changes were significantly associated with PPND (Odd ratio (OR) 20.18 (95%CI:7.40-55.03, p-value: <0.001)). Simultaneous changes in both IONM modalities had specificity of 98.9% (95% CI: 97.1%-99.7%). While sensitivity when either modality had a change was 47.8% (95% CI: 33.9%-62.0%) to predict PPND.

CONCLUSIONS

Significant IONM changes during EVT for rIA are associated with an increased risk of PPND.

SIGNIFICANCE

IONM can be used confidently as a real time neurophysiological diagnostic guide for impending neurological deficits during EVT treatment of rIA.

Aneurysmal subarachnoid haemorrhage: Volumetric quantification of the blood distribution pattern to accurately predict the ruptured aneurysm location

BACKGROUND

In spontaneous subarachnoid haemorrhage (SAH) accurate determination of the bleeding source is paramount to guide treatment. Traditionally, the bleeding pattern has been used to predict the aneurysm location. Here, we have tested a software-based tool, which quantifies the volume of intracranial blood and stratifies it according to the regional distribution, to predict the location of the ruptured aneurysm.

METHODS

A consecutive series of SAH patients admitted to a single tertiary centre between 2012-2018, within 72 h of onset, harbouring a single intracranial aneurysm. A semi-automatized method of blood quantification, based on the relative density increase, was applied to initial non-contrast CTs. Five regions were used to define the bleeding patterns and to correlate them with aneurysm location: perimesencephalic, interhemispheric, right/left hemisphere and intraventricular.

RESULTS

68 patients were included for analysis. There was a strong association between the distribution of blood and the aneurysm location (p < 0.001). In particular: ACom and interhemispheric fissure (p < 0.001), MCA and ipsilateral hemisphere (p < 0.001), ICA and ipsilateral hemisphere and perimesencephalic cisterns (p < 0.001), PCom and hemispheric, perimesencephalic and intraventricular (p = 0.019), and PICA and perimesencephalic and intraventricular (p < 0.001). The internal diagnostic value was high (AUROC ≥ 0.900) for these locations.

CONCLUSION

Regional automatised volumetry seems a reliable and objective tool to quantify and describe the distribution of blood within the subarachnoid spaces. This tool accurately predicts the location of the ruptured aneurysm; its use may be prospectively considered in the emergency setting when speed and simplicity are attained.

Bioinformatics analysis revealed the potential crosstalk genes and molecular mechanisms between intracranial aneurysms and periodontitis

OBJECTIVES

The risk of intracranial aneurysms (IAs) development and rupture is significantly higher in patients with periodontitis (PD), suggesting an association between the two. However, the specific mechanisms of association between these two diseases have not been fully investigated.

MATERIALS AND METHODS

In this study, we downloaded IAs and PD data from the Gene Expression Omnibus. Differentially expressed genes (DEGs) were identified, and functional enrichment analysis was performed. The protein-protein interaction (PPI) network and weighted gene co-expression network analysis (WGCNA) was performed to identified key modules and key crosstalk genes. In addition, the immune cell landscape was assessed and the correlation of key crosstalk genes with each immune cell was calculated. Finally, transcription factors (TFs) regulating key crosstalk genes were explored.

RESULTS

127 overlapping DEGs were identified and functional enrichment analysis highlighted the important role of immune reflection in the pathogenesis of IAs and PD. We identified ITGAX and COL4A2 as key crosstalk genes. In addition, the expression of multiple immune cells was significantly elevated in PDs and IAs compared to controls, and both key crosstalk genes were significantly negatively associated with Macrophages M2. Finally, GATA2 was identified as a potential key transcription factor (TF), which regulates two key crosstalk gene.

CONCLUSIONS

The present study identifies key crosstalk genes and TF in PD and IAs, providing new insights for further study of the co-pathogenesis of PD and IAs from an immune and inflammatory perspective. Also, this is the first study to report the above findings.

Olfactory three needle regulates the proliferation of olfactory bulb neural stem cells and ameliorates brain injury after subarachnoid hemorrhage by regulating Wnt/β-catenin signaling

Background

Subarachnoid hemorrhage (SAH) is a serious cerebrovascular emergency. The incidence of SAH and hazard ratio of death increase with age.

Objective

In this study, we aimed to observe the effects and potential mechanisms of olfactory three needle (OTN) on cognitive impairment, neuronal activity, and neural stem cell differentiation in SAH rats.

Methods

Sprague-Dawley (SD) rats were randomly divided into five groups: Sham, SAH group, SAH + Nimodipine (NMP) group, and SAH + OTN group. The rats in the SAH + OTN group received the OTN electroacupuncture treatment. For treatment with recombinant DKK1 (a Wnt/β-catenin inhibitor), mice were injected with DKK1.

Results

Our results found that OTN improved cognitive impairment and hippocampal neuron damage in SAH rats. Furthermore, OTN promoted the proliferation of neural stem cells in SAH rats. Mechanistically, OTN activated Wnt/β-catenin signaling in SAH rats, as indicated by the increased expression levels of Wnt1, β-Catenin, LMNB1, and p-GSK-3β. DKK1 reversed the improvement effect of OTN on cognitive impairment and neuronal damage in SAH rats. Meanwhile, DKK1 blocked the promoting effect of OTN on the proliferation of NSCs in SAH rats.

Conclusions

OTN electroacupuncture may be an effective therapeutic strategy for SAH.

One-year survival of aneurysmal subarachnoid hemorrhage after airplane transatlantic transfer - a monocenter retrospective study

BACKGROUND

Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients.

METHODS

Retrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010-2019).

RESULTS

The median [interquartile range] age was 53 [45-64] years and 61% were female. On admission, Glasgow coma scale was 15 [13-15], World Federation of Neurological Surgeons (WFNS) grading scale was 1 [1-3] and Fisher scale was 4 [2-4]. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio [HR] 2.34, 95% confidence interval [CI] 0.98-5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16-2.02) and age (OR 1.03, 95% 1.00-1.07) were associated with one-year mortality.

CONCLUSION

When necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.

Comparison of Ultra-High-Resolution and Normal-Resolution CT-Angiography for Intracranial Aneurysm Detection in Patients with Subarachnoid Hemorrhage

RATIONALE AND OBJECTIVES

Ruptured intracranial aneurysms (IAs) are the leading cause for atraumatic subarachnoid hemorrhage. In case of aneurysm rupture, patients may face life-threatening complications and require aneurysm occlusion. Detection of the aneurysm in computed tomography (CT) imaging is therefore essential for patient outcome. This study provides an evaluation of the diagnostic accuracy of Ultra-High-Resolution Computed Tomography Angiography (UHR-CTA) and Normal-Resolution Computed Tomography Angiography (NR-CTA) concerning IA detection and characterization.

MATERIALS AND METHODS

Consecutive patients with atraumatic subarachnoid hemorrhage who received Digital Subtraction Angiography (DSA) and either UHR-CTA or NR-CTA were retrospectively included. Three readers evaluated CT-Angiography regarding image quality, diagnostic confidence and presence of IAs. Sensitivity and specificity were calculated on patient-level and segment-level with reference standard DSA-imaging. CTA patient radiation exposure (effective dose) was compared.

RESULTS

One hundred and eight patients were identified (mean age = 57.8 ± 14.1 years, 65 women). UHR-CTA revealed significantly higher image quality and diagnostic confidence (P < 0.001) for all readers and significantly lower effective dose (P < 0.001). Readers correctly classified ≥55/56 patients on UHR-CTA and ≥44/52 patients on NR-CTA. We noted significantly higher patient-level sensitivity for UHR-CTA compared to NR-CTA for all three readers (reader 1: 41/41 [100%] vs. 28/34 [82%], reader 2: 41/41 [100%] vs. 30/34 [88%], reader 3: 41/41 [100%] vs. 30/34 [88%], P ≤ 0.04). Segment-level analysis also revealed significantly higher sensitivity for UHR-CTA compared to NR-CTA for all three readers (reader 1: 47/49 [96%] vs. 34/45 [76%], reader 2: 47/49 [96%] vs. 37/45 [82%], reader 3: 48/49 [98%] vs. 37/45 [82%], P ≤ 0.04). Specificity was comparable for both techniques.

CONCLUSION

We found Ultra-High-Resolution CT-Angiography to provide higher sensitivity than Normal-Resolution CT-Angiography for the detection of intracranial aneurysms in patients with aneurysmal subarachnoid hemorrhage while improving image quality and reducing patient radiation exposure.

Predictors of hospital length of stay and long-term care facility placement in aneurysmal subarachnoid hemorrhage

Background

Aneurysmal subarachnoid hemorrhage (aSAH) is frequently associated with complications, extended hospital length of stay (LOS) and high health care related costs. We sought to determine predictors for hospital LOS and discharge disposition to a long-term care facility (LTCF) in aSAH patients.

Methods

We performed a retrospective study of a prospectively collected cohort of consecutive patients with aSAH admitted to an academic referral center from 2016 to 2021. Multiple linear regression was performed to identify predictors for hospital LOS. We then created a 10-point scoring system to predict discharge disposition to a LTCF.

Results

In a cohort of 318 patients with confirmed aSAH, mean age was 57 years (SD 13.7), 61% were female and 70% were white. Hospital LOS was longer for survivors (median 19 days, IQR 14-25) than for non-survivors (median 5 days, IQR 2-8; p < 0.001). Main predictors for longer LOS for this cohort were ventriculoperitoneal shunt (VPS) requirement (p < 0.001), delayed cerebral ischemia (p = 0.026), and pneumonia (p = 0.014). The strongest predictor for LTCF disposition was age older than 60 years (OR 1.14, 95% CI 1.07-1.21; p < 0.001). LTCF score had high accuracy in predicting discharge disposition to a LTCF (area under the curve [AUC] 0.83; 95% CI 0.75-0.91). Forty-one percent of patients who were discharged to a LTCF had significant functional recovery at 3 months post-discharge.

Conclusions

VPS requirement and aSAH related complications were associated with longer hospital LOS compared to other factors. LTCF score has high accuracy in predicting discharge disposition to a LTCF.

In vivo mechanical characterization of arterial wall using an inverse analysis procedure: application on an animal model of intracranial aneurysm

Intracranial aneurysm is a pathology related to the deterioration of the arterial wall. This work is an essential part of a large-scale project aimed at providing clinicians with a non-invasive patient-specific decision support tool to facilitate the rupture risk assessment. It will lean on the link between the aneurysm shape clinically observed and a database derived from the in vivo mechanical characterization of aneurysms. To supply this database, a deformation device prototype of the arterial wall was developed. Its use coupled with medical imaging (spectral photon-counting computed tomography providing a spatial resolution down to 250 μm) is used to determine the in vivo mechanical properties of the wall based on the inverse analysis of the quantification of the wall deformation observed experimentally. This study presents the in vivo application of this original procedure to an animal model of aneurysm. The mechanical properties of the aneurysm wall identified were consistent with the literature, and the errors between the numerical and experimental results were less than 10%. Based on these parameters, this study allows the assessment of the aneurysm stress state for a known solicitation and points towards the definition of a rupture criterion.