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Oliveira Souza NVD, Rouanet C, Solla DJF, de Lima CVB, de Souza CA, Rezende F, Alves MM, de Oliveira Manuel AL, Chaddad Neto F, Frudit M, Silva GS. The Role of VASOGRADE as a Simple Grading Scale to Predict Delayed Cerebral Ischemia and Functional Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 38:96-104. [PMID: 36002635 DOI: 10.1007/s12028-022-01577-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 07/26/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The VASOGRADE is a simple aneurysmal subarachnoid hemorrhage (aSAH) grading scale that combines the modified Fisher scale (mFisher) and the World Federation of Neurological Societies (WFNS) grading system, allowing the stratification of delayed cerebral ischemia (DCI) risk. However, the VASOGRADE accuracy in predicting functional outcomes is still to be determined. METHODS We retrospectively evaluated a multiethnic cohort of consecutive patients with aSAH admitted to a high-volume center in Brazil from January 2016 to January 2019. Patients were classified according to the severity of the clinical presentation (WFNS), the amount of blood in the initial head computerized tomography (mFisher) scan, and the VASOGRADE (green, yellow, red). The primary outcome was to detect DCI-related cerebral infarction, and the secondary outcome was the functional outcome at hospital discharge according to the modified Rankin scale (mRs). Univariate and multivariate logistic regression models were employed. RESULTS A total of 212 patients (71.7% female, mean age 52.7 ± 12.8) were included. Sixty-nine patients were classified as VASOGRADE-Green (32.5%), 98 patients as VASOGRADE-Yellow (46.9%), and 45 patients as VASOGRADE-Red (20.6%). DCI-related infarction was present in 39 patients (18.9%). The proportions of patients in the VASOGRADE-Green, VASOGRADE-Yellow, and VASOGRADE-Red categories with DCI-related infarction were 7.7, 61.5, and 30.8%, respectively. After a multivariable analysis including age, sex, aneurysm location, and the VASOGRADE classification as variables, both VASOGRADE-Yellow and VASOGRADE-Red were independently associated with DCI-related infarction (odds ratio [OR] 7.69, 95% confidence interval [CI] 2.13-27.8, and OR 8.07, 95% CI 2.03-32.11, respectively) and unfavorable outcome (OR 4.16, 95% CI 1.33-13.03, and OR 25.57, 95% CI 4.45-147.1, respectively). The VASOGRADE discrimination performance for DCI-related infarction (area under the receiver operating characteristic curve) was 0.67 ± 0.04 (95% CI 0.58-0.75; p = 0.001). VASOGRADE-Red had 97.5% specificity for predicting an unfavorable mRs score at discharge (95% CI 92.8-99.5%). Conversely, VASOGRADE-Green had an excellent specificity for predicting favorable outcome at discharge (mRs score 0-2, 95% CI 82.6-95.5%). CONCLUSIONS In conclusion, in a multiethnic cohort of patients with aSAH, VASOGRADE-Green predicted the absence of DCI and good clinical outcome at discharge with very high specificity, and patients in this category might be selected for early intensive care unit (ICU) discharge, minimizing costs and medical complications associated with prolonged hospital stay. On the other hand, patients categorized as VASOGRADE-Yellow and VASOGRADE-Red were at the highest risk for DCI. They should, therefore, be selected as a priority for care in high-volume aSAH centers, being aggressively monitored for DCI at the ICU. Such stratification methods are crucial, especially in countries with low financial resources and high health care services demand.
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Affiliation(s)
- Natália Vasconcellos de Oliveira Souza
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil.
- Department of Neurology and Neurosurgery, Universidade de São Paulo, Sao Paulo, Brazil.
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Carolina Rouanet
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Department of Neurology and Neurosurgery, Federal Univesity of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | - Caio Augusto de Souza
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Flavio Rezende
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
| | - Maramelia Miranda Alves
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | - Feres Chaddad Neto
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Michel Frudit
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Universidade Federal de São Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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Alsbrook DL, Di Napoli M, Bhatia K, Desai M, Hinduja A, Rubinos CA, Mansueto G, Singh P, Domeniconi GG, Ikram A, Sabbagh SY, Divani AA. Pathophysiology of Early Brain Injury and Its Association with Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Review of Current Literature. J Clin Med 2023; 12:jcm12031015. [PMID: 36769660 PMCID: PMC9918117 DOI: 10.3390/jcm12031015] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 01/25/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
Background: Delayed cerebral ischemia (DCI) is a common and serious complication of aneurysmal subarachnoid hemorrhage (aSAH). Though many clinical trials have looked at therapies for DCI and vasospasm in aSAH, along with reducing rebleeding risks, none have led to improving outcomes in this patient population. We present an up-to-date review of the pathophysiology of DCI and its association with early brain injury (EBI). Recent Findings: Recent studies have demonstrated that EBI, as opposed to delayed brain injury, is the main contributor to downstream pathophysiological mechanisms that play a role in the development of DCI. New predictive models, including advanced monitoring and neuroimaging techniques, can help detect EBI and improve the clinical management of aSAH patients. Summary: EBI, the severity of subarachnoid hemorrhage, and physiological/imaging markers can serve as indicators for potential early therapeutics in aSAH. The microcellular milieu and hemodynamic pathomechanisms should remain a focus of researchers and clinicians. With the advancement in understanding the pathophysiology of DCI, we are hopeful that we will make strides toward better outcomes for this unique patient population.
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Affiliation(s)
- Diana L Alsbrook
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN 38163, USA
| | - Mario Di Napoli
- Neurological Service, SS Annunziata Hospital, Sulmona, 67039 L'Aquila, Italy
| | - Kunal Bhatia
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS 39216, USA
| | - Masoom Desai
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Archana Hinduja
- Department of Neurology, The Ohio State University Wexner Medical Center, Columbus, OH 43210, USA
| | - Clio A Rubinos
- Department of Neurology, University of North Carolina, Chapel Hill, NC 27599, USA
| | - Gelsomina Mansueto
- Department of Advanced Medical and Surgical Sciences, University of Campania, 80138 Naples, Italy
| | - Puneetpal Singh
- Department of Human Genetics, Punjabi University, Patiala 147002, India
| | - Gustavo G Domeniconi
- Unidad de Cuidados Intensivos, Sanatorio de la Trinidad San Isidro, Buenos Aires 1640, Argentina
| | - Asad Ikram
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02115, USA
| | - Sara Y Sabbagh
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico, Albuquerque, NM 87131, USA
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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] [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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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Zhou Z, Liu Z, Yang H, Zhang C, Zhang C, Chen J, Wang Y. A nomogram for predicting the risk of poor prognosis in patients with poor-grade aneurysmal subarachnoid hemorrhage following microsurgical clipping. Front Neurol 2023; 14:1146106. [PMID: 37034089 PMCID: PMC10073426 DOI: 10.3389/fneur.2023.1146106] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 03/06/2023] [Indexed: 04/11/2023] Open
Abstract
Objective Aneurysmal subarachnoid hemorrhage (aSAH) is a common and potentially fatal cerebrovascular disease. Poor-grade aSAH (Hunt-Hess grades IV and V) accounts for 20-30% of patients with aSAH, with most patients having a poor prognosis. This study aimed to develop a stable nomogram model for predicting adverse outcomes at 6 months in patients with aSAH, and thus, aid in improving the prognosis. Method The clinical data and imaging findings of 150 patients with poor-grade aSAH treated with microsurgical clipping of intracranial aneurysms on admission from December 2015 to October 2021 were retrospectively analyzed. Least absolute shrinkage and selection operator (LASSO), logistic regression analyses, and a nomogram were used to develop the prognostic models. Receiver operating characteristic (ROC) curves and Hosmer-Lemeshow tests were used to assess discrimination and calibration. The bootstrap method (1,000 repetitions) was used for internal validation. Decision curve analysis (DCA) was performed to evaluate the clinical validity of the nomogram model. Result LASSO regression analysis showed that age, Hunt-Hess grade, Glasgow Coma Scale (GCS), aneurysm size, and refractory hyperpyrexia were potential predictors for poor-grade aSAH. Logistic regression analyses revealed that age (OR: 1.107, 95% CI: 1.056-1.116, P < 0.001), Hunt-Hess grade (OR: 8.832, 95% CI: 2.312-33.736, P = 0.001), aneurysm size (OR: 6.871, 95% CI: 1.907-24.754, P = 0.003) and refractory fever (OR: 3.610, 95% CI: 1.301-10.018, P < 0.001) were independent predictors of poor outcome. The area under the ROC curve (AUC) was 0.909. The calibration curve and Hosmer-Lemeshow tests showed that the nomogram had good calibration ability. Furthermore, the DCA curve showed better clinical utilization of the nomogram. Conclusion This study provides a reliable and valuable nomogram that can accurately predict the risk of poor prognosis in patients with poor-grade aSAH after microsurgical clipping. This tool is easy to use and can help physicians make appropriate clinical decisions to significantly improve patient prognosis.
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Wang J, Li R, Li S, Ma T, Zhang X, Ren Y, Chen X, Peng Y. Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study. Front Neurosci 2023; 17:1064987. [PMID: 36875639 PMCID: PMC9982002 DOI: 10.3389/fnins.2023.1064987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Background Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive. Methods All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups. Results Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI. Conclusions The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.
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Affiliation(s)
- Jie Wang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Shu Li
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Tingting Ma
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingyue Zhang
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yue Ren
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuming Peng
- Department of Anesthesiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Khawaja AM, McNulty J, Thakur UV, Chawla S, Devi S, Liew A, Mirshahi S, Du R, Mekary RA, Gormley W. Transcranial Doppler and computed tomography angiography for detecting cerebral vasospasm post-aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2022; 46:3. [PMID: 36471088 DOI: 10.1007/s10143-022-01913-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
Cerebral vasospasm is a life-threatening complication following aneurysmal subarachnoid hemorrhage (aSAH). While digital subtraction angiography (DSA) is the current gold standard for detection, the diagnostic performance of computed tomography angiography (CTA) and transcranial Doppler (TCD) remains controversial. We aimed to summarize the available evidence and provide recommendations for their use based on GRADE criteria. A literature search was conducted for studies comparing CTA or TCD to DSA for adults ≥ 18 years with aSAH for radiographic vasospasm detection. The DerSimonian-Laird random-effects model was used to pool sensitivity and specificity and their 95% confidence intervals (CI) and derive positive and negative pooled likelihood ratios (LR + /LR -). Out of 2070 studies, seven studies (1646 arterial segments) met inclusion criteria and were meta-analyzed. Compared to the gold standard (DSA), CTA had a pooled sensitivity of 82% (95%CI, 68-91%) and a specificity of 97% (95%CI, 93-98%), while TCD had lower sensitivity 38% (95%CI, 19-62%) and specificity of 91% (95%CI, 87-94%). Only the LR + for CTA (27.3) reached clinical significance to rule in diagnosis. LR - for CTA (0.19) and TCD (0.68) approached clinical significance (< 0.1) to rule out diagnosis. CTA showed higher LR + and lower LR - than TCD for diagnosing radiographic vasospasm, thereby achieving a strong recommendation for its use in ruling in or out vasospasm, based on the high quality of evidence. TCDs had very low LR + and a reasonably low LR - , thereby achieving a weak recommendation against its use in ruling in vasospasm and weak recommendation for its use in ruling out vasospasm.
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Affiliation(s)
- Ayaz M Khawaja
- Department of Neurology, Wayne State University, Detroit, MI, 48201, USA
| | - Jack McNulty
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, 10032, USA
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
| | | | - Shreya Chawla
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Sharmila Devi
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Faculty of Life Science and Medicine, King's College London, London, UK
| | - Aaron Liew
- Portiuncula University Hospital and National University of Ireland Galway (NUIG), Galway, Ireland
| | - Shervin Mirshahi
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
| | - Rania A Mekary
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA.
- School of Pharmacy, MCPHS University, Boston, MA, USA.
| | - William Gormley
- Computational Neuroscience Outcomes Center, Department of Neurosurgery, Harvard Medical School, Brigham and Women's Hospital, 179 Longwood Avenue, MA, 02115, Boston, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, 02115, USA
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Medina-Suárez J, Rodríguez-Esparragón F, Sosa-Pérez C, Cazorla-Rivero S, Torres-Mata LB, Jiménez-O’Shanahan A, Clavo B, Morera-Molina J. A Review of Genetic Polymorphisms and Susceptibilities to Complications after Aneurysmal Subarachnoid Hemorrhage. Int J Mol Sci 2022; 23:ijms232315427. [PMID: 36499752 PMCID: PMC9739720 DOI: 10.3390/ijms232315427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 11/28/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022] Open
Abstract
Delayed cerebral ischemia (DCI) and vasospasm are two complications of subarachnoid hemorrhages (SAHs) which entail high risks of morbidity and mortality. However, it is unknown why only some patients who suffer SAHs will experience DCI and vasospasm. The purpose of this review is to describe the main genetic single nucleotide polymorphisms (SNPs) that have demonstrated a relationship with these complications. The SNP of the nitric oxide endothelial synthase (eNOS) has been related to the size and rupture of an aneurysm, as well as to DCI, vasospasm, and poor neurological outcome. The SNPs responsible for the asymmetric dimetilarginine and the high-mobility group box 1 have also been associated with DCI. An association between vasospasm and the SNPs of the eNOS, the haptoglobin, and the endothelin-1 receptor has been found. The SNPs of the angiotensin-converting enzyme have been related to DCI and poor neurological outcome. Studies on the SNPs of the Ryanodine Receptor yielded varying results regarding their association with vasospasm.
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Affiliation(s)
- Jose Medina-Suárez
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Specific Teaching Methodologies, University of Las Palmas de Gran Canaria, 35004 Gran Canaria, Spain
- Correspondence: (J.M.-S.); (F.R.-E.)
| | - Francisco Rodríguez-Esparragón
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna, 38296 Tenerife, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: (J.M.-S.); (F.R.-E.)
| | - Coralia Sosa-Pérez
- Neurosurgery Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Medical and Surgery Sciences, University of Las Palmas de Gran Canaria, 35016 Gran Canaria, Spain
| | - Sara Cazorla-Rivero
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- University of La Laguna, 38200 Tenerife, Spain
| | - Laura B. Torres-Mata
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
| | | | - Bernardino Clavo
- Research Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Instituto Universitario de Enfermedades Tropicales y Salud Pública de Canarias, Universidad de La Laguna, 38296 Tenerife, Spain
- CIBER de Enfermedades Infecciosas, Instituto de Salud Carlos III, 28029 Madrid, Spain
- RETIC de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), 28029 Madrid, Spain
- Instituto de Salud Carlos III, 28029 Madrid, Spain
- Chronic Pain Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Radiation Oncology Department, University Hospital of Gran Canaria Dr. Negrín, 35010 Las Palmas de Gran Canaria, Spain
| | - Jesús Morera-Molina
- Neurosurgery Unit, University Hospital of Gran Canaria Dr. Negrín, 35010 Gran Canaria, Spain
- Department of Medical and Surgery Sciences, University of Las Palmas de Gran Canaria, 35016 Gran Canaria, Spain
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Yi HJ, Shin DS, Kim BT. Elevated blood viscosity is associated with delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106732. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/28/2022] [Accepted: 08/14/2022] [Indexed: 11/21/2022] Open
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Lin H, Shen J, Zhu Y, Zhou L, Wu F, Liu Z, Zhang S, Zhan R. Elevated Serum CCL23 Levels at Admission Predict Delayed Cerebral Ischemia and Functional Outcome after Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2022; 11:jcm11236879. [PMID: 36498453 PMCID: PMC9737062 DOI: 10.3390/jcm11236879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 11/08/2022] [Accepted: 11/20/2022] [Indexed: 11/24/2022] Open
Abstract
(1) Background: CC chemokine ligand 23 (CCL23) is a chemokine implicated in the inflammatory response following brain damage. The aim of this study is to identify the change in serum CCL23 levels within 24 h after aSAH and whether serum CCL23 levels are associated with initial clinical severity, delayed cerebral ischemia (DCI), and functional outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). (2) Methods: 102 patients with aSAH and 61 controls were included in this prospective observational study. All clinical data were collected prospectively, and their serum CCL23 levels were measured. Initial clinical severity was reflected by the Hunt-Hess score and mFisher score. Functional outcome was evaluated in terms of the Glasgow Outcome Scale (GOS) score at 6-month follow-up. (3) Results: Patients with aSAH had higher serum CCL23 levels than controls. The temporal profile of serum CCL23 levels and neutrophils count exhibited a sustained increase within 24 h after aSAH. Serum CCL23 levels were related to blood neutrophils count, blood CRP levels, and initial clinical severity. Serum CCL23 level was an independent predictor of DCI and 6-month poor outcome in aSAH patients. (4) Conclusions: Serum CCL23 levels emerged as an independent predictor for DCI and poor outcome in patients with aSAH.
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Tsolaki V, Aravantinou-fatorou A, Georgakopoulou VE, Spandidos DA, Papalexis P, Mathioudakis N, Tarantinos K, Trakas N, Sklapani P, Fotakopoulos G. Early diagnosis of cerebral vasospasm associated with cerebral ischemia following subarachnoid hemorrhage: Evaluation of computed tomography perfusion and transcranial doppler as accurate methods. MEDICINE INTERNATIONAL 2022; 2:34. [PMID: 36699155 PMCID: PMC9829237 DOI: 10.3892/mi.2022.59] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 11/01/2022] [Indexed: 01/27/2023]
Abstract
Cerebral vasospasm (CV) constitutes a major post-operative complication and source of morbidity in cases of subarachnoid hemorrhage (SAH). The early detection of CV in SAH may be difficult both clinically and radiographically. The present pilot study thus aimed to evaluate the practicability of the technique in a tertiary healthcare setting and to assess the diagnostic effectiveness of various diagnostic computed tomography (CT) perfusion (CTP) aspects in predicting the clinical outcome of patients with SAH (traumatic and aneurysmal). A retrospective study including 34 patients in a tertiary care hospital was thus conducted. The results revealed that of the 34 patients, 18 (52.9%) were males, and the mean age was 54.4±18.5 years (16-85 years old; range, 69 years). In total, 15 (44.1%) patients had traumatic SAH following traumatic brain injury (TBI), 11 (33.3%) had aneurysmal SAH, and 8 patients (23.6%) presented with TBI without SAH as controls. CTP was performed on the third to the sixth day, and 15-20 min prior to CPT, a transcranial Doppler ultrasound was performed. Clinical outcomes were documented at 30 days using a CT scan and a complete neurological evaluation, including Glasgow Coma Scale assessment. The results of a multivariate analysis revealed that cerebral blood flow (CBF) was an independent factor for detecting an ischemic event in 1 month (P=0.003). On the whole, the present study demonstrates that CTP, and consequently CBF, is a considerable index that may identify the onset of cerebral ischemia in patients with SAH.
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Affiliation(s)
- Vasiliki Tsolaki
- Department of Pulmonary and Critical Care Medicine, General University Hospital of Larisa, 41221 Larisa, Greece
| | - Aikaterini Aravantinou-fatorou
- First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Correspondence to: Dr Vasiliki Epameinondas Georgakopoulou, Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 17 Agiou Thoma Street, 11527 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, Medical School, University of Crete, 71003 Heraklion, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece,Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | | | - Kyriakos Tarantinos
- First Department of Pulmonology, Sismanogleio Hospital, 15126 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Cytology, Mitera Hospital, 15123 Athens, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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Koester SW, Catapano JS, Rumalla K, Dabrowski SJ, Benner D, Winkler EA, Cole TS, Baranoski JF, Srinivasan VM, Graffeo CS, Jha RM, Jadhav AP, Ducruet AF, Albuquerque FC, Lawton MT. Health Care Expenditures Associated with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis. World Neurosurg 2022; 167:e600-e606. [PMID: 35995358 DOI: 10.1016/j.wneu.2022.08.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 08/10/2022] [Accepted: 08/11/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE The additional hospital costs associated with delayed cerebral ischemia (DCI) have not been well investigated in prior literature. In this study, the total hospital cost of DCI in aneurysmal subarachnoid hemmorhage (aSAH) patients treated at a single quaternary center was analyzed. METHODS All patients in the Post-Barrow Ruptured Aneurysm Trial treated for an aSAH between January 1, 2014, and July 31, 2019, were retrospectively analyzed. DCI was defined as cerebral infarction identified on computed tomography, magnetic resonance imaging, or autopsy after exclusion of procedure-related infarctions. The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Propensity score covariate-adjusted linear regression analysis included age, sex, open versus endovascular treatment, Hunt and Hess score, and Charlson Comorbidity Index score. RESULTS Of the 391 patients included, 144 (37%) had DCI. Patients with DCI had a significantly greater cost compared to patients without DCI (mean standard deviation $112,081 [$54,022] vs. $86,159 [$38,817]; P < 0.001) and a significantly greater length of stay (21 days [11] vs. 18 days [8], P = 0.003, respectively). In propensity-adjusted linear regression analysis, both DCI (odds ratio, $13,871; 95% confidence interval, $7558-$20,185; P < 0.001) and length of stay (odds ratio, $3815 per day; 95% confidence interval, $3480-$4149 per day; P < 0.001) were found to significantly increase the cost. CONCLUSIONS The significantly higher costs associated with DCI further support the evidence that adverse effects associated with DCI in aSAH pose a significant burden to the health care system.
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Affiliation(s)
- Stefan W Koester
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Joshua S Catapano
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Stephen J Dabrowski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Dimitri Benner
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ethan A Winkler
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Tyler S Cole
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Jacob F Baranoski
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Christopher S Graffeo
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ruchira M Jha
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA
| | - Michael T Lawton
- Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Gao Y, Li K, Li X, Li Q, Wang J, Zhang S, Zhang J. Exploration of cerebral vasospasm from the perspective of microparticles. Front Neurosci 2022; 16:1013437. [PMID: 36389239 PMCID: PMC9650082 DOI: 10.3389/fnins.2022.1013437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 10/14/2022] [Indexed: 02/28/2024] Open
Abstract
Cerebral vasospasm is a frequently encountered clinical problem, especially in patients with traumatic brain injury and subarachnoid hemorrhage. Continued cerebral vasospasm can cause cerebral ischemia, even infarction and delayed ischemic neurologic deficits. It significantly affects the course of the disease and the outcome of the patient. However, the underlying mechanism of cerebral vasospasm is still unclear. Recently, increasing studies focus on the pathogenic mechanism of microparticles. It has been found that microparticles have a non-negligible role in promoting vasospasm. This research aims to summarize the dynamics of microparticles in vivo and identify a causal role of microparticles in the occurrence and development of cerebral vasospasm. We found that these various microparticles showed dynamic characteristics in body fluids and directly or indirectly affect the cerebral vasospasm or prompt it. Due to the different materials carried by microparticles from different cells, there are also differences in the mechanisms that lead to abnormal vasomotor. We suggest that microparticle scavengers might be a promising therapeutic target against microparticles associated complications.
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Affiliation(s)
- Yalong Gao
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Kai Li
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Xiaotian Li
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Qifeng Li
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Jiwei Wang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Shu Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
| | - Jianning Zhang
- Key Laboratory of Post-Neurotrauma Neurorepair and Regeneration in Central Nervous System, Ministry of Education and Tianjin Neurological Institute, Tianjin Medical University General Hospital, Tianjin, China
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Barbosa S, Jorge N, Silva ML, Maia I, Dias C, Pereira E, Paiva JA. Treatment of Cerebral Vasospasm With Continuous Intra-Arterial Nimodipine: A Case Report. Cureus 2022; 14:e30507. [DOI: 10.7759/cureus.30507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/19/2022] [Indexed: 11/06/2022] Open
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Döring K, Sperling S, Ninkovic M, Schroeder H, Fischer A, Stadelmann C, Streit F, Binder L, Mielke D, Rohde V, Malinova V. Ultrasound-Induced Release of Nimodipine from Drug-Loaded Block Copolymer Micelles: In Vivo Analysis. Transl Stroke Res 2022; 13:792-800. [PMID: 34988870 PMCID: PMC9391244 DOI: 10.1007/s12975-021-00979-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 12/01/2021] [Accepted: 12/14/2021] [Indexed: 12/03/2022]
Abstract
Nimodipine prevents cerebral vasospasm and improves functional outcome after aneurysmal subarachnoid hemorrhage (aSAH). The beneficial effect is limited by low oral bioavailability of nimodipine, which resulted in an increasing use of nanocarriers with sustained intrathecal drug release in order to overcome this limitation. However, this approach facilitates only a continuous and not an on-demand nimodipine release during the peak time of vasospasm development. In this study, we aimed to assess the concept of controlled drug release from nimodipine-loaded copolymers by ultrasound application in the chicken chorioallantoic membrane (CAM) model. Nimodipine-loaded copolymers were produced with the direct dissolution method. Vasospasm of the CAM vessels was induced by means of ultrasound (Physiomed, continuous wave, 3 MHz, 1.0 W/cm2). The ultrasound-mediated nimodipine release (Physiomed, continuous wave, 1 MHz, 1.7 W/cm2) and its effect on the CAM vessels were evaluated. Measurements of vessel diameter before and after ultrasound-induced nimodipine release were performed using ImageJ. The CAM model could be successfully carried out in all 25 eggs. After vasospasm induction and before drug release, the mean vessel diameter was at 57% (range 44-61%) compared to the baseline diameter (set at 100%). After ultrasound-induced drug release, the mean vessel diameter of spastic vessels increased again to 89% (range 83-91%) of their baseline diameter, which was significant (p = 0.0002). We were able to provide a proof of concept for in vivo vasospasm induction by ultrasound application in the CAM model and subsequent resolution by ultrasound-mediated nimodipine release from nanocarriers. This concept merits further evaluation in a rat SAH model.
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Affiliation(s)
- Katja Döring
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Swetlana Sperling
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Milena Ninkovic
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Henning Schroeder
- Department for Epigenetics and System Medicine in Neurodegenerative Diseases, German Center for Neurodegenerative Diseases, Göttingen, Germany
| | - André Fischer
- Department for Epigenetics and System Medicine in Neurodegenerative Diseases, German Center for Neurodegenerative Diseases, Göttingen, Germany
| | - Christine Stadelmann
- Department of Neuropathology, University Medical Center Göttingen, Göttingen, Germany
| | - Frank Streit
- Institute for Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - Lutz Binder
- Institute for Clinical Chemistry, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany.
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Solhpour A, Kumar S, Koch MJ, Doré S. Impact of blood component transfusions, tranexamic acid and fluids on subarachnoid hemorrhage outcomes. BRAIN HEMORRHAGES 2022. [DOI: 10.1016/j.hest.2022.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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67
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Gathier CS, van der Jagt M, van den Bergh WM, Dankbaar JW, Rinkel GJE, Slooter AJC. Slow recruitment in the HIMALAIA study: lessons for future clinical trials in patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage based on feasibility data. Pilot Feasibility Stud 2022; 8:193. [PMID: 36042527 PMCID: PMC9426269 DOI: 10.1186/s40814-022-01155-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 08/15/2022] [Indexed: 11/21/2022] Open
Abstract
Background Our randomized clinical trial on induced hypertension in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) was halted prematurely due to unexpected slow recruitment rates. This raised new questions regarding recruitment feasibility. As our trial can therefore be seen as a feasibility trial, we assessed the reasons for the slow recruitment, aiming to facilitate the design of future randomized trials in aSAH patients with DCI or other critically ill patient categories. Methods Efficiency of recruitment and factors influencing recruitment were evaluated, based on the patient flow in the two centers that admitted most patients during the study period. We collected numbers of patients who were screened for eligibility, provided informed consent, and developed DCI and who eventually were randomized. Results Of the 862 aSAH patients admitted in the two centers during the course of the trial, 479 (56%) were eligible for trial participation of whom 404 (84%) were asked for informed consent. Of these, 188 (47%) provided informed consent, of whom 50 (27%) developed DCI. Of these 50 patients, 12 (24%) could not be randomized due to a logistic problem or a contraindication for induced hypertension emerging at the time of randomization, and four (8%) were missed for randomization. Eventually, 34 patients were randomized and received intervention or control treatment. Conclusions Enrolling patients in a randomized trial on a treatment strategy for DCI proved unfeasible: only 1 out of 25 admitted and 1 out of 14 eligible patients could eventually be randomized. These rates, caused by a large proportion of ineligible patients, a small proportion of patients providing informed consent, and a large proportion of patients with contraindications for treatment, can be used to make sample size calculations for future randomized trials in DCI or otherwise critically ill patients. Facilitating informed consent through improved provision of information on risks, possible benefits, and study procedures may result in improved enrolment. Trial registration The original trial was prospectively registered with ClinicalTrials.gov (NCT01613235), date of registration 07-06-2012.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands. .,Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508, Utrecht, The Netherlands.
| | - Mathieu van der Jagt
- Department of Intensive Care Adults and Erasmus MC Stroke Center, Erasmus MC - University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508, Utrecht, The Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Flat Detector CT with Cerebral Pooled Blood Volume Perfusion in the Angiography Suite: From Diagnostics to Treatment Monitoring. Diagnostics (Basel) 2022; 12:diagnostics12081962. [PMID: 36010312 PMCID: PMC9406673 DOI: 10.3390/diagnostics12081962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Revised: 08/09/2022] [Accepted: 08/12/2022] [Indexed: 11/17/2022] Open
Abstract
C-arm flat-panel detector computed tomographic (CT) imaging in the angiography suite increasingly plays an important part during interventional neuroradiological procedures. In addition to conventional angiographic imaging of blood vessels, flat detector CT (FD CT) imaging allows simultaneous 3D visualization of parenchymal and vascular structures of the brain. Next to imaging of anatomical structures, it is also possible to perform FD CT perfusion imaging of the brain by means of cerebral blood volume (CBV) or pooled blood volume (PBV) mapping during steady state contrast administration. This enables more adequate decision making during interventional neuroradiological procedures, based on real-time insights into brain perfusion on the spot, obviating time consuming and often difficult transportation of the (anesthetized) patient to conventional cross-sectional imaging modalities. In this paper we review the literature about the nature of FD CT PBV mapping in patients and demonstrate its current use for diagnosis and treatment monitoring in interventional neuroradiology.
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Association of pre-admission antihypertensive agents and outcomes in aneurysmal subarachnoid hemorrhage. J Clin Neurosci 2022; 103:119-123. [PMID: 35868228 DOI: 10.1016/j.jocn.2022.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2022] [Revised: 06/18/2022] [Accepted: 07/13/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) and poor functional outcome are common complications in patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). It has been proposed that pre-admission beta-blocker therapy may lower cerebral vasospasm (cVSP) risk after aSAH; however, this association with other antihypertensives is unknown. We sought to determine the association between antihypertensives and clinical outcomes in aSAH patients. METHODS We performed a retrospective study on a prospectively collected cohort of consecutive patients with aSAH who were admitted to an academic center from 2016 to 2021. Association between pre-admission use of antihypertensives and patient outcomes was determined. Primary outcomes included DCI and poor functional outcome at 3 months after discharge defined as modified Rankin scale [mRS] 4-6. The secondary outcome was cVSP identified using transcranial Doppler (TCD). RESULTS The cohort consisted of 306 aSAH patients with mean age 57.1 (SD 13.6) years with 187 females (61 %). Although pre-admission use of beta-blockers (OR 0.40, 95 % CI 0.21-80, p = 0.02), calcium channel blockers (OR 0.43, 95 % CI 0.19-0.93, p = 0.035), and thiazide (OR 0.31, 95 % CI 0.11-0.86, p = 0.025) were associated with lower risk of cVSP in univariate analysis, we did not find any association in a multivariate model after adjusting for age. There was no association between any class of antihypertensives and DCI or functional outcome. CONCLUSION Pre-admission use of antihypertensive agents may affect TCD findings, however, none of them appear to be independently associated with DCI or functional outcome. Larger prospective studies are needed to establish any potential association.
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Coppalini G, Duvigneaud E, Diosdado A, Migliorino E, Schuind S, Creteur J, Taccone FS, Gouvêa Bogossian E. Effect of inotropic agents on oxygenation and cerebral perfusion in acute brain injury. Front Neurol 2022; 13:963562. [PMID: 35928138 PMCID: PMC9343780 DOI: 10.3389/fneur.2022.963562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 06/28/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionTissue hypoxia and insufficient energy delivery is one of the mechanisms behind the occurrence of several complications in acute brain injured patients. Several interventions can improve cerebral oxygenation; however, the effects of inotropic agents remain poorly characterized.MethodsRetrospective analysis including patients suffering from acute brain injury and monitored with brain oxygen pressure (PbtO2) catheter, in whom inotropic agents were administered according to the decision of the treating physician's decision; PbtO2 values were collected before, 1 and 2 h after the initiation of therapy from the patient data monitoring system. PbtO2 “responders” were patients with a relative increase in PbtO2 from baseline values of at least 20%.ResultsA total of 35 patients were included in this study. Most of them (31/35, 89%) suffered from non-traumatic subarachnoid hemorrhage (SAH). Compared with baseline values [20 (14–24) mmHg], PbtO2 did not significantly increase over time [19 (15–25) mmHg at 1 h and 19 (17–25) mmHg at 2 h, respectively; p = 0.052]. A total of 12/35 (34%) patients were PbtO2 “responders,” in particular if low PbtO2 was observed at baseline. A PbtO2 of 17 mmHg at baseline had a sensibility of 84% and a specificity of 91% to predict a PbtO2 responder. A significant direct correlation between changes in PbtO2 and cardiac output [r = 0.496 (95% CI 0.122 to 0.746), p = 0.01; n = 25] and a significant negative correlation between changes in PbtO2 and cerebral perfusion pressure [r = −0.389 (95% CI −0.681 to −0.010), p = 0.05] were observed.ConclusionsIn this study, inotropic administration significantly increased brain oxygenation in one third of brain injured patients, especially when tissue hypoxia was present at baseline. Future studies should highlight the role of inotropic agents in the management of tissue hypoxia in this setting.
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Affiliation(s)
- Giacomo Coppalini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Elie Duvigneaud
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Alberto Diosdado
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Ernesto Migliorino
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, Brussels, Belgium
- *Correspondence: Elisa Gouvêa Bogossian
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Snyder MH, Ironside N, Kumar JS, Doan KT, Kellogg RT, Provencio JJ, Starke RM, Park MS, Ding D, Chen CJ. Antiplatelet therapy and delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. J Neurosurg 2022; 137:95-107. [PMID: 34740185 DOI: 10.3171/2021.7.jns211239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/20/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) is a potentially preventable cause of morbidity and mortality after aneurysmal subarachnoid hemorrhage (aSAH). The authors performed a meta-analysis to assess the effect of antiplatelet therapy (APT) on DCI in patients with aSAH. METHODS A systematic review of the PubMed and MEDLINE databases was performed. Study inclusion criteria were 1) ≥ 5 aSAH patients; 2) direct comparison between aSAH management with APT and without APT; and 3) reporting of DCI, angiographic, or symptomatic vasospasm rates for patients treated with versus without APT. The primary efficacy outcome was DCI. The outcomes of the APT versus no-APT cohorts were compared. Bias was assessed using the Downs and Black checklist. RESULTS The overall cohort comprised 2039 patients from 15 studies. DCI occurred less commonly in the APT compared with the no-APT cohort (pooled = 15.9% vs 28.6%; OR 0.47, p < 0.01). Angiographic (pooled = 51.6% vs 68.7%; OR 0.46, p < 0.01) and symptomatic (pooled = 23.6% vs 37.7%; OR 0.51, p = 0.01) vasospasm rates were lower in the APT cohort. In-hospital mortality (pooled = 1.7% vs 4.1%; OR 0.53, p = 0.01) and functional dependence (pooled = 21.0% vs 35.7%; OR 0.53, p < 0.01) rates were also lower in the APT cohort. Bleeding event rates were comparable between the two cohorts. Subgroup analysis of cilostazol monotherapy compared with no APT demonstrated a lower DCI rate in the cilostazol cohort (pooled = 10.6% vs 28.1%; OR 0.31, p < 0.01). Subgroup analysis of surgically treated aneurysms demonstrated a lower DCI rate for the APT cohort (pooled = 18.4% vs 33.9%; OR 0.43, p = 0.02). CONCLUSIONS APT is associated with improved outcomes in aSAH without an increased risk of bleeding events, particularly in patients who underwent surgical aneurysm repair and those treated with cilostazol. Although study heterogeneity is the most significant limitation of the analysis, the findings suggest that APT is worth exploring in patients with aSAH, particularly in a randomized controlled trial setting.
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Affiliation(s)
- M Harrison Snyder
- 1Department of Neurosurgery, Tufts Medical Center, Boston, Massachusetts
| | - Natasha Ironside
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Jeyan S Kumar
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Kevin T Doan
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Ryan T Kellogg
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - J Javier Provencio
- 3Department of Neurology, University of Virginia Health System, Charlottesville, Virginia
| | - Robert M Starke
- 4Department of Neurosurgery, University of Miami, Miami, Florida
| | - Min S Park
- 2Department of Neurosurgery, University of Virginia Health System, Charlottesville, Virginia
| | - Dale Ding
- 5Department of Neurosurgery, University of Louisville School of Medicine, Louisville, Kentucky; and
| | - Ching-Jen Chen
- 6Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Yan J, Li W, Zhou C, Wu N, Yang X, Pan Q, He T, Wu Y, Guo Z, Xia Y, Sun X, Cheng C. Dynamic Measurements of Cerebral Blood Flow Responses to Cortical Spreading Depolarization in the Murine Endovascular Perforation Subarachnoid Hemorrhage Model. Transl Stroke Res 2022:10.1007/s12975-022-01052-1. [PMID: 35749033 DOI: 10.1007/s12975-022-01052-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/30/2022] [Accepted: 06/10/2022] [Indexed: 12/13/2022]
Abstract
Delayed cerebral ischemia (DCI) is the most severe complication after subarachnoid hemorrhage (SAH), and cortical spreading depolarization (CSD) is believed to play a vital role in it. However, the dynamic changes in cerebral blood flow (CBF) in response to CSD in typical SAH models have not been well investigated. Here, SAH was established in mice with endovascular perforation. Subsequently, the spontaneous CBF dropped instantly and then returned to baseline rapidly. After KCl application to the cortex, subsequent hypoperfusion waves occurred across the groups, while a lower average perfusion level was found in the SAH groups (days 1-7). Moreover, in the SAH groups, the number of CSD decreased within day 7, and the duration and spreading velocity of the CSD increased within day 3 and day 14, respectively. Next, we continuously monitored the local field potential (LFP) in the prefrontal cortex. The results showed that the decrease in the percentage of gamma oscillations lasted throughout the whole process in the SAH group. In the chronic phase after SAH, we found that the mice still had cognitive deficits but experienced no obvious tissue damage. In summary, SAH negatively affects the CBF responses to CSD and the spontaneous LFP activity and causes long-term cognitive deficits in mice. Based on these findings, in the specific phase after SAH, DCI is induced or exacerbated more easily by potential causers of CSD in clinical practice (edema, erythrocytolysis, inflammation), which may lead to neurological deterioration.
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Affiliation(s)
- Jin Yan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Wenlang Li
- Department of Anesthesiology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chao Zhou
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Na Wu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Xiaomin Yang
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Qiuling Pan
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Tao He
- Department of Orthopaedics, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wu
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Zongduo Guo
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Yongzhi Xia
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China
| | - Xiaochuan Sun
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China.
| | - Chongjie Cheng
- Department of Neurosurgery, the First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing, 400016, People's Republic of China.
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Hu P, Li Y, Liu Y, Guo G, Gao X, Su Z, Wang L, Deng G, Yang S, Qi Y, Xu Y, Ye L, Sun Q, Nie X, Sun Y, Li M, Zhang H, Chen Q. Comparison of Conventional Logistic Regression and Machine Learning Methods for Predicting Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Multicentric Observational Cohort Study. Front Aging Neurosci 2022; 14:857521. [PMID: 35783143 PMCID: PMC9247265 DOI: 10.3389/fnagi.2022.857521] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 05/09/2022] [Indexed: 11/16/2022] Open
Abstract
Background Timely and accurate prediction of delayed cerebral ischemia is critical for improving the prognosis of patients with aneurysmal subarachnoid hemorrhage. Machine learning (ML) algorithms are increasingly regarded as having a higher prediction power than conventional logistic regression (LR). This study aims to construct LR and ML models and compare their prediction power on delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Methods This was a multicenter, retrospective, observational cohort study that enrolled patients with aneurysmal subarachnoid hemorrhage from five hospitals in China. A total of 404 aSAH patients were prospectively enrolled. We randomly divided the patients into training (N = 303) and validation cohorts (N = 101) according to a ratio of 75–25%. One LR and six popular ML algorithms were used to construct models. The area under the receiver operating characteristic curve (AUC), accuracy, balanced accuracy, confusion matrix, sensitivity, specificity, calibration curve, and Hosmer–Lemeshow test were used to assess and compare the model performance. Finally, we calculated each feature of importance. Results A total of 112 (27.7%) patients developed DCI. Our results showed that conventional LR with an AUC value of 0.824 (95%CI: 0.73–0.91) in the validation cohort outperformed k-nearest neighbor, decision tree, support vector machine, and extreme gradient boosting model with the AUCs of 0.792 (95%CI: 0.68–0.9, P = 0.46), 0.675 (95%CI: 0.56–0.79, P < 0.01), 0.677 (95%CI: 0.57–0.77, P < 0.01), and 0.78 (95%CI: 0.68–0.87, P = 0.50). However, random forest (RF) and artificial neural network model with the same AUC (0.858, 95%CI: 0.78–0.93, P = 0.26) were better than the LR. The accuracy and the balanced accuracy of the RF were 20.8% and 11% higher than the latter, and the RF also showed good calibration in the validation cohort (Hosmer-Lemeshow: P = 0.203). We found that the CT value of subarachnoid hemorrhage, WBC count, neutrophil count, CT value of cerebral edema, and monocyte count were the five most important features for DCI prediction in the RF model. We then developed an online prediction tool (https://dynamic-nomogram.shinyapps.io/DynNomapp-DCI/) based on important features to calculate DCI risk precisely. Conclusions In this multicenter study, we found that several ML methods, particularly RF, outperformed conventional LR. Furthermore, an online prediction tool based on the RF model was developed to identify patients at high risk for DCI after SAH and facilitate timely interventions. Clinical Trial Registration http://www.chictr.org.cn, Unique identifier: ChiCTR2100044448.
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Affiliation(s)
- Ping Hu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, Affiliated Hospital of Panzhihua University, Panzhihua, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangfan Liu
- Department of Neurosurgery, Affiliated Hospital of Panzhihua University, Panzhihua, China
| | - Geng Guo
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Xu Gao
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Long Wang
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Shuang Yang
- School of Physics and Technology, Wuhan University, Wuhan, China
- School of Electronic Information and Automation, Guilin University of Aerospace Technology, Guilin, China
| | - Yangzhi Qi
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Xu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liguo Ye
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Sun
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Xiaohu Nie
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Yanqi Sun
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Mingchang Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongbo Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Hongbo Zhang
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Qianxue Chen
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Shaban S, Huasen B, Haridas A, Killingsworth M, Worthington J, Jabbour P, Bhaskar SMM. Digital subtraction angiography in cerebrovascular disease: current practice and perspectives on diagnosis, acute treatment and prognosis. Acta Neurol Belg 2022; 122:763-780. [PMID: 34553337 DOI: 10.1007/s13760-021-01805-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/15/2021] [Indexed: 12/12/2022]
Abstract
Digital Subtraction Angiography (DSA) is the gold-standard imaging modality in acute cerebrovascular diagnosis. The role of DSA has become increasingly prominent since the incorporation of endovascular therapy in standards of care for acute ischemic stroke. It is used in the assessment of cerebral vessel patency; however, the therapeutic role of DSA from a prognostic standpoint merits further investigation. The current paper provides an update on current practice on diagnostic, therapeutic and prognostic use of DSA in acute cerebrovascular diseases and various indications and perspectives that may apply, or limit its use, in ongoing surveillance or prognosis. Pre-clinical and clinical studies on the aspects, including but not limited to the morphology of cerebrovasculature in acute ischaemic stroke, are required to delineate and inform its prognostic role.
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Affiliation(s)
- Shirin Shaban
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, Australia
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, NSW, Australia
| | - Bella Huasen
- Department of Interventional Radiology, Lancashire University Teaching Hospitals, Lancashire Care NHS Foundation Trust, Preston, UK
| | - Abilash Haridas
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, Australia
- Baycare Medical Group, Pediatric Neurosurgery, Cerebrovascular and Skull Base Neurosurgery, St Joseph's Hospital, Tampa, FL, USA
| | - Murray Killingsworth
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, Australia
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, NSW, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, Australia
- Department of Anatomical Pathology, Correlative Microscopy Facility, NSW Health Pathology, Sydney, Australia
| | - John Worthington
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, Australia
- RPA Comprehensive Stroke Service and Department of Neurology, Royal Prince Alfred Hospital, Camperdown, Sydney, Australia
| | - Pascal Jabbour
- Division of Neurovascular Surgery and Endovascular Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, USA
| | - Sonu Menachem Maimonides Bhaskar
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, Australia.
- University of New South Wales (UNSW), South Western Sydney Clinical School, Liverpool, NSW, Australia.
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, Australia.
- Department of Neurology and Neurophysiology, Liverpool Hospital and South Western Sydney Local Health District, Sydney, Australia.
- Department of Neurology and Neurophysiology, Clinical Sciences Building, Liverpool Hospital, Elizabeth St, Liverpool, NSW, 2170, Australia.
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Picetti E, Barbanera A, Bernucci C, Bertuccio A, Bilotta F, Boccardi EP, Cafiero T, Caricato A, Castioni CA, Cenzato M, Chieregato A, Citerio G, Gritti P, Lanterna L, Menozzi R, Munari M, Panni P, Rossi S, Stocchetti N, Sturiale C, Zoerle T, Zona G, Rasulo F, Robba C. Early management of patients with aneurysmal subarachnoid hemorrhage in a hospital with neurosurgical/neuroendovascular facilities: a consensus and clinical recommendations of the Italian Society of Anesthesia and Intensive Care (SIAARTI)-part 2. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE (ONLINE) 2022; 2:21. [PMID: 37386571 DOI: 10.1186/s44158-022-00049-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 04/27/2022] [Indexed: 07/01/2023]
Abstract
BACKGROUND Questions remain on the optimal management of subarachnoid hemorrhage (SAH) patients once they are admitted to the referring center, before and after the aneurysm treatment. To address these issues, we created a consensus of experts endorsed by the Italian Society of Anesthesia and Intensive Care (SIAARTI) to provide clinical guidance regarding this topic. Specifically, in this manuscript (part 2), we aim to provide a list of experts' recommendations regarding the management of SAH patients in a center with neurosurgical/neuroendovascular facilities after aneurysm treatment. METHODS A multidisciplinary consensus panel composed by 24 physicians selected for their established clinical and scientific expertise in the acute management of SAH patients with different specializations (anesthesia/intensive care, neurosurgery, and interventional neuroradiology) was created. A modified Delphi approach was adopted. RESULTS A total of 33 statements were discussed, voted, and approved. Consensus was reached on 30 recommendations (28 strong and 2 weak). In 3 cases, where consensus could not be agreed upon, no recommendation was provided. CONCLUSIONS This consensus provides practical recommendations (and not mandatory standard of practice) to support clinician's decision-making in the management of SAH patients in centers with neurosurgical/neuroendovascular facilities after aneurysm securing.
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Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy.
| | - Andrea Barbanera
- Department of Neurosurgery, "SS Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Claudio Bernucci
- Department of Neuroscience and Surgery of the Nervous System, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessandro Bertuccio
- Department of Neurosurgery, "SS Antonio e Biagio e Cesare Arrigo" Hospital, Alessandria, Italy
| | - Federico Bilotta
- Department of Anesthesiology and Critical Care, Policlinico Umberto I Hospital, La Sapienza University of Rome, Rome, Italy
| | - Edoardo Pietro Boccardi
- Department of Interventional Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Tullio Cafiero
- Department of Anesthesia and Intensive Care Unit, AORN Cardarelli, Naples, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Carlo Alberto Castioni
- Department of Anesthesia and Intensive Care, IRCCS Institute of Neurological Sciences of Bologna, Bologna, Italy
| | - Marco Cenzato
- Department of Neurosurgery, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Arturo Chieregato
- Neurointensive Care Unit, Department of Neuroscience and Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano - Bicocca, Milan, Italy
| | - Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Lanterna
- Department of Neuroscience and Surgery of the Nervous System, ASST Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Roberto Menozzi
- Interventional Neuroradiology Unit, University Hospital of Parma, Parma, Italy
| | - Marina Munari
- Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Pietro Panni
- Department of Neuroradiology, San Raffaele Hospital, Milan, Italy
| | - Sandra Rossi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria di Parma, Parma, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Carmelo Sturiale
- Neurosurgery Unit, IRCCS Istituto delle Scienze Neurologiche Ospedale Bellaria di Bologna, Bologna, Italy
| | - Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, Policlinico San Martino Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Frank Rasulo
- Department of Anesthesia, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Subarachnoid Hemorrhage, Delayed Cerebral Ischemia and Milrinone Use in Canada. Can J Neurol Sci 2022; 50:380-388. [PMID: 35477442 DOI: 10.1017/cjn.2022.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. There is little high-quality evidence available to guide the management of DCI. The Canadian Neurosurgery Research Collaborative (CNRC) is comprised of resident physicians who are positioned to capture national, multi-site data. The objective of this study was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. METHODS We performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. A 19-question electronic survey (Survey Monkey) was developed and validated by the CNRC following a DCI-related literature review (PubMed, Embase). The survey was distributed to members of the Canadian Neurosurgical Society and to Canadian members of the Neurocritical Care Society. Responses were analyzed using quantitative and qualitative methods. RESULTS The response rate was 129/340 (38%). Agreement among respondents was limited to the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for the prevention of DCI. Several inconsistencies were identified. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients who felt to require IV milrinone, IA vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. CONCLUSION DCI is an important clinical entity for which no homogeneity and standardization exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the definition, identification, and treatment of DCI.
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Zheng Z, Luo J, Cao Z, Tan S, Lv J. Spatiotemporal Patterns of Spreading Depolarization and its Correlation with Brain Injury During the Acute Stage of Subarachnoid Hemorrhage in Mice. J Stroke Cerebrovasc Dis 2022; 31:106476. [PMID: 35413591 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Revised: 02/19/2022] [Accepted: 03/24/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Spreading depolarization (SD) has been regarded as one cause of neuronal injury in subarachnoid hemorrhage (SAH). However, SD in the hyperacute phase of SAH is still unclear. The objective of this study was to detect real-time spatial-temporal patterns of SD, assess the effect of SD on cerebral blood flow, and test the relationship between SD and brain injury in the acute phase of SAH. METHODS Twenty-eight mice were separated into two groups: 16 animals in the SAH group and 12 animals in the sham group. Experimental SAH was done with an endovascular filament perforation model. Changes in optical reflection were registered with intrinsic optical signal imaging (IOSI) after SAH. Spatial-temporal patterns of SDs were analyzed and brain injury including brain edema and infarction was tested. RESULTS Totally, 117 SDs occurred after SAH. According to the hemodynamic response and duration, SDs could be classified into Type I (short SD), Type II (intermediate SD), and Type III (persistent SD). Most of SDs originated from the somatosensory and visual cortex. SDs demonstrated distinct spreading patterns. Moreover, the number and duration of SDs associated with brain water content (p < 0.05, p < 0.01). SDs, especially, persistent SDs associated with infarct volume in the hyperacute phase of SAH (p < 0.001, p < 0.001). CONCLUSION Our results suggest that SD occurs with a high incidence during the acute stage of SAH in mice. And the lissencephalic mouse brain is capable of different SD propagation patterns. Additionally, SD may aggravate brain edema and induce brain infarction, contributing to early brain injury after SAH.
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Affiliation(s)
- Zelong Zheng
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Panfu Road No.1, Guangdong 510180, China
| | - Jinbiao Luo
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Panfu Road No.1, Guangdong 510180, China
| | - Zhikai Cao
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Panfu Road No.1, Guangdong 510180, China
| | - Shaojuan Tan
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Panfu Road No.1, Guangdong 510180, China
| | - Jianping Lv
- The Department of Neurosurgery, Guangzhou First People's Hospital, School of Medicine, South China University of Technology, Panfu Road No.1, Guangdong 510180, China.
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Walter J, Grutza M, Möhlenbruch M, Vollherbst D, Vogt L, Unterberg A, Zweckberger K. The Local Intraarterial Administration of Nimodipine Might Positively Affect Clinical Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage and Delayed Cerebral Ischemia. J Clin Med 2022; 11:jcm11072036. [PMID: 35407643 PMCID: PMC8999377 DOI: 10.3390/jcm11072036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/26/2022] [Accepted: 04/01/2022] [Indexed: 12/10/2022] Open
Abstract
The effect of the intraarterial administration of nimodipine as a rescue measure to treat delayed vasospasm after aSAH remains understudied; therefore, we evaluated its effect on short- and long-term functional and neuropsychological outcomes after aSAH. In this prospective observational study, a total of 107 consecutive patients treated for aSAH of WFNS grades I−V were recruited. At follow-up visits 3-, 12- and 24-months after the hemorrhage, functional outcome was assessed using the Extended Glasgow Outcome (GOSE) and modified Rankin (mRS) scales, while neurocognitive function was evaluated using the screening module of the Neuropsychological Assessment Battery (NAB-S). The outcome of patients, who had received rescue therapy according to the local standard treatment protocol (interventional group, n = 37), and those, who had been treated conservatively (conservative group, n = 70), were compared. Even though significantly more patients in the interventional treatment group suffered from high-grade aSAH (WFNS Grades IV and V, 54.1% vs. 31.4%, p = 0.04) and required continuous drainage of cerebrospinal fluid at discharge (67.7% vs. 37.7%, p = 0.02) compared to the control group, significant differences in functional outcome were present only at discharge and three months after the bleeding (GOSE > 4 in 8.1% vs. 41.4% and 28.6% vs. 72.7%, p < 0.001 and p = 0.01 for the interventional and control group, respectively). Thereafter, group differences were no longer significant. While significantly more patients in the intervention group had severe neuropsychological deficits (76.3% vs. 36.0% and 66.7% vs. 29.2%, p = 0.04 and 0.05, respectively) and were unable to work (5.9% vs. 38.1%, p = 0.03 at twelve months) at three and twelve months after the hemorrhage, no significant differences between the two groups could be detected at long-term follow-up. The presence of moderate neuropsychological impairments did not significantly differ between the groups at any timepoint. In conclusion, despite initially being significantly more impaired, patients treated with intraarterial administration of nimodipine reached the same functional and neuropsychological outcomes at medium- and long-term follow-up as conservatively treated patients suggesting a potential beneficial effect of intraarterial nimodipine treatment for delayed vasospasm after aSAH.
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Affiliation(s)
- Johannes Walter
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
- Correspondence: ; Tel.: +49-62-213-4356
| | - Martin Grutza
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.M.); (D.V.)
| | - Dominik Vollherbst
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.M.); (D.V.)
| | - Lidia Vogt
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Andreas Unterberg
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
| | - Klaus Zweckberger
- Department of Neurosurgery, University of Heidelberg, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany; (M.G.); (L.V.); (A.U.); (K.Z.)
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Merkel H, Lindner D, Gaber K, Ziganshyna S, Jentzsch J, Mucha S, Gerhards T, Sari S, Stock A, Vothel F, Falter L, Quäschling U, Hoffmann KT, Meixensberger J, Halama D, Richter C. Standardized Classification of Cerebral Vasospasm after Subarachnoid Hemorrhage by Digital Subtraction Angiography. J Clin Med 2022; 11:jcm11072011. [PMID: 35407619 PMCID: PMC9000178 DOI: 10.3390/jcm11072011] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/31/2022] [Accepted: 04/01/2022] [Indexed: 02/05/2023] Open
Abstract
Background: During the last decade, cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH) was a current research focus without a standardized classification in digital subtraction angiography (DSA). This study was performed to investigate a device-independent visual cerebral vasospasm classification for endovascular treatment. Methods: The analyses are DSA based rather than multimodal. Ten defined points of intracranial arteries were measured in 45 patients suffering from cerebral vasospasm after SAH at three time points (hospitalization, before spasmolysis, control after six months). Mathematical clustering of vessel diameters was performed to generate four objective grades for comparison. Six interventional neuroradiologists in two groups scored 237 DSAs after a new visual classification (grade 0–3) developed on a segmental pattern of vessel contraction. For the second group, a threshold-based criterion was amended. Results: The raters had a reproducibility of 68.4% in the first group and 75.2% in the second group. The complementary threshold-based criterion increased the reproducibility by about 6.8%, while the rating deviated more from the mathematical clustering in all grades. Conclusions: The proposed visual classification scheme of cerebral vasospasm is suitable as a standard grading procedure for endovascular treatment. There is no advantage of a threshold-based criterion that compensates for the effort involved. Automated vessel analysis is superior to compare inter-group results in research settings.
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Affiliation(s)
- Helena Merkel
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Dirk Lindner
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Khaled Gaber
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Svitlana Ziganshyna
- Department of Anaesthesiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany;
| | - Jennifer Jentzsch
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Simone Mucha
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Thilo Gerhards
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Sabine Sari
- Department of Neuroradiology, Giessen University Hospital, Klinikstraße 33, 35392 Giessen, Germany;
| | - Annika Stock
- Department of Neuroradiology, Würzburg University Hospital, Josef-Schneider-Straße 2, 97080 Würzburg, Germany;
| | - Felicitas Vothel
- Department of Radiology and Neuroradiology, Sana Hospital Borna, Rudolf-Virchow-Straße 2, 04552 Borna, Germany;
| | - Lea Falter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Ulf Quäschling
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
| | - Jürgen Meixensberger
- Department of Neurosurgery, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (D.L.); (K.G.); (J.M.)
| | - Dirk Halama
- Department of Oral and Maxillofacial Surgery, Leipzig University Hospital, Liebigstraße 12, 04103 Leipzig, Germany;
| | - Cindy Richter
- Department of Neuroradiology, Leipzig University Hospital, Liebigstraße 20, 04103 Leipzig, Germany; (H.M.); (J.J.); (S.M.); (T.G.); (L.F.); (U.Q.); (K.-T.H.)
- Correspondence: ; Tel.: +49-341-97-20196
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Shah KA, White TG, Woo HH, Narayan RK, Li C. Delayed Cerebral Ischemia following Subarachnoid Hemorrhage: Hope For a New Therapy? World Neurosurg 2022; 164:148-149. [DOI: 10.1016/j.wneu.2022.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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81
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Schlaeppi JA, Affentranger L, Bervini D, Z’Graggen WJ, Raabe A, Pollo C. Electrical Stimulation for Cerebral Vasospasm After Subarachnoid Hemorrhage: A Systematic Review. Neuromodulation 2022; 25:1227-1239. [DOI: 10.1016/j.neurom.2022.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 10/18/2022]
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82
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Megjhani M, Weiss M, Kwon SB, Ford J, Nametz D, Kastenholz N, Fogel H, Velazquez A, Roh D, Agarwal S, Connolly ES, Claassen J, Schubert GA, Park S. Vector Angle Analysis of Multimodal Neuromonitoring Data for Continuous Prediction of Delayed Cerebral Ischemia. Neurocrit Care 2022; 37:230-236. [DOI: 10.1007/s12028-022-01481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 02/28/2022] [Indexed: 10/18/2022]
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83
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Hu P, Liu Y, Li Y, Guo G, Su Z, Gao X, Chen J, Qi Y, Xu Y, Yan T, Ye L, Sun Q, Deng G, Zhang H, Chen Q. A Comparison of LASSO Regression and Tree-Based Models for Delayed Cerebral Ischemia in Elderly Patients With Subarachnoid Hemorrhage. Front Neurol 2022; 13:791547. [PMID: 35359648 PMCID: PMC8960268 DOI: 10.3389/fneur.2022.791547] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 01/31/2022] [Indexed: 11/23/2022] Open
Abstract
Backgrounds As a most widely used machine learning method, tree-based algorithms have not been applied to predict delayed cerebral ischemia (DCI) in elderly patients with aneurysmal subarachnoid hemorrhage (aSAH). Hence, this study aims to develop the conventional regression and tree-based models and determine which model has better prediction performance for DCI development in hospitalized elderly patients after aSAH. Methods This was a multicenter, retrospective, observational cohort study analyzing elderly patients with aSAH aged 60 years and older. We randomly divided the multicentral data into model training and validation cohort in a ratio of 70–30%. One conventional regression and tree-based model, such as least absolute shrinkage and selection operator (LASSO), decision tree (DT), random forest (RF), and eXtreme Gradient Boosting (XGBoost), was developed. Accuracy, sensitivity, specificity, area under the precision-recall curve (AUC-PR), and area under the receiver operating characteristic curve (AUC-ROC) with 95% CI were employed to evaluate the model prediction performance. A DeLong test was conducted to calculate the statistical differences among models. Finally, we figured the importance weight of each feature to visualize the contribution on DCI. Results There were 111 and 42 patients in the model training and validation cohorts, and 53 cases developed DCI. According to AUC-ROC value in the model internal validation, DT of 0.836 (95% CI: 0.747–0.926, p = 0.15), RF of 1 (95% CI: 1–1, p < 0.05), and XGBoost of 0.931 (95% CI: 0.885–0.978, p = 0.01) outperformed LASSO of 0.793 (95% CI: 0.692–0.893). However, the LASSO scored a highest AUC-ROC value of 0.894 (95% CI: 0.8–0.989) than DT of 0.764 (95% CI: 0.6–0.928, p = 0.05), RF of 0.821 (95% CI: 0.683–0.959, p = 0.27), and XGBoost of 0.865 (95% CI: 0.751–0.979, p = 0.69) in independent external validation. Moreover, the LASSO had a highest AUC-PR value of 0.681 than DT of 0.615, RF of 0.667, and XGBoost of 0.622 in external validation. In addition, we found that CT values of subarachnoid clots, aneurysm therapy, and white blood cell counts were the most important features for DCI in elderly patients with aSAH. Conclusions The LASSO had a superior prediction power than tree-based models in external validation. As a result, we recommend the conventional LASSO regression model to predict DCI in elderly patients with aSAH.
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Affiliation(s)
- Ping Hu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangfan Liu
- Department of Neurosurgery, Affiliated Hospital of Panzhihua University, Panzhihua, China
| | - Yuntao Li
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Geng Guo
- Department of Neurosurgery, First Hospital of Shanxi Medical University, Taiyuan, China
| | - Zhongzhou Su
- Department of Neurosurgery, Huzhou Central Hospital, Huzhou, China
| | - Xu Gao
- Department of Neurosurgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Junhui Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yangzhi Qi
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Yang Xu
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Tengfeng Yan
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Liguo Ye
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Qian Sun
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Gang Deng
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
| | - Hongbo Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Nanchang University, Nanchang, China
- *Correspondence: Hongbo Zhang
| | - Qianxue Chen
- Department of Neurosurgery, Renmin Hospital of Wuhan University, Wuhan, China
- Qianxue Chen
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Csók I, Grauvogel J, Scheiwe C, Bardutzky J, Wehrum T, Beck J, Reinacher PC, Roelz R. Basic Surveillance Parameters Improve the Prediction of Delayed Cerebral Infarction After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 13:774720. [PMID: 35309593 PMCID: PMC8926032 DOI: 10.3389/fneur.2022.774720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 01/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background To establish a practical risk chart for prediction of delayed cerebral infarction (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) by using information that is available until day 5 after ictus. Methods We assessed all consecutive patients with aSAH admitted to our service between September 2008 and September 2015 (n = 417). The data set was randomly split into thirds. Two-thirds were used for model development and one-third was used for validation. Characteristics that were present between the bleeding event and day 5 (i.e., prior to >95% of DCI diagnoses) were assessed to predict DCI by using logistic regression models. A simple risk chart was established and validated. Results The amount of cisternal and ventricular blood on admission CT (Hijdra sum score), early sonographic vasospasm (i.e., mean flow velocity of either intracranial artery >160 cm/s until day 5), and a simplified binary level of consciousness score until day 5 were the strongest predictors of DCI. A model combining these predictors delivered a high predictive accuracy [the area under the receiver operating characteristic (AUC) curve of 0.82, Nagelkerke's R2 0.34 in the development cohort]. Validation of the model demonstrated a high discriminative capacity with the AUC of 0.82, Nagelkerke's R2 0.30 in the validation cohort. Conclusion Adding level of consciousness and sonographic vasospasm between admission and postbleed day 5 to the initial blood amount allows for simple and precise prediction of DCI. The suggested risk chart may prove useful for selection of appropriate candidates for interventions to prevent DCI.
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Affiliation(s)
- István Csók
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Grauvogel
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Scheiwe
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Thomas Wehrum
- Department of Neurology, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Peter C. Reinacher
- Department of Stereotactic and Functional Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Fraunhofer Institute for Laser Technology, Aachen, Germany
| | - Roland Roelz
- Department of Neurosurgery, Medical Center – University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- *Correspondence: Roland Roelz
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Schacht H, Küchler J, Neumann A, Schramm P, Tronnier VM, Ditz C. Analysis of angiographic treatment response to intra-arterial nimodipine bolus injection in patients with medically refractory cerebral vasospasm after spontaneous subarachnoid hemorrhage. World Neurosurg 2022; 162:e457-e467. [DOI: 10.1016/j.wneu.2022.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/08/2022] [Indexed: 10/18/2022]
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Dunn K, Rumbach A, Finch E. Language function in the acute phase following non-traumatic subarachnoid haemorrhage: A prospective cohort study. JOURNAL OF COMMUNICATION DISORDERS 2022; 96:106192. [PMID: 35149316 DOI: 10.1016/j.jcomdis.2022.106192] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 01/19/2022] [Accepted: 01/31/2022] [Indexed: 06/14/2023]
Abstract
BACKGROUND Aphasia is common following stroke, with associated negative impacts on quality of life and psychosocial functioning. However, the language function of individuals who develop non-traumatic subarachnoid haemorrhage (SAH) has been minimally investigated from a speech-language pathology (SLP) perspective. AIMS To examine and characterise the language function of individuals following non-traumatic SAH in the acute phase and describe the clinical profile and outcomes of individuals in this cohort with language impairment. METHODS & PROCEDURES Prospective cohort study of adults admitted to a tertiary hospital with primary non-traumatic SAH over a 12-month period (June 2018 to June 2019). Language assessment using the Brisbane Evidence-Based Language Test (EBLT) was performed within 72 h of medical stability. Assessment scores were analysed for 43 participants. OUTCOMES & RESULTS Language impairment was present in 18.6% (n = 8/43) of the cohort, and was associated with increased intensive care unit (ICU) length of stay (LOS) (p < 0.01) and increased hospital length of stay (p = 0.01). The profile of participants with impaired language was highly variable with difficulties across auditory comprehension, verbal expression, reading comprehension, and written expression. Associated cognitive and attention difficulties also impacted test performance in this cohort. Six of the eight participants with impaired language required ongoing SLP support beyond hospital discharge. CONCLUSIONS & IMPLICATIONS Early, routine assessment of language function of individuals following non-traumatic SAH is essential and should be incorporated into clinical care pathways.
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Affiliation(s)
- Katrina Dunn
- Speech Pathology Department, West Moreton Health, Queensland Health, Ipswich, Queensland, Australia; School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia.
| | - Anna Rumbach
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia
| | - Emma Finch
- School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia; Centre for Functioning and Health Research (CFAHR), Metro South Hospital and Health Service, Brisbane, Australia; Speech Pathology Department, Princess Alexandra Hospital, Metro South Hospital and Health Service, Queensland Health, Queensland, Australia
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Leukocytosis and C-Reactive Protein May Predict Development of Secondary Cerebral Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. Medicina (B Aires) 2022; 58:medicina58020323. [PMID: 35208646 PMCID: PMC8880412 DOI: 10.3390/medicina58020323] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Revised: 02/12/2022] [Accepted: 02/17/2022] [Indexed: 11/16/2022] Open
Abstract
Background and Objectives: Secondary cerebral vasospasm (CV) with subsequent delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains an unpredictable pathology. The aim of this retrospective study was to investigate the association between inflammatory parameters, white blood cell (WBC) count, and C-reactive protein plasma levels (CRP) and the occurrence of secondary CV in patients with aSAH. Materials and Methods: The medical records of 201 Intensive Care Unit patients in Riga East University Hospital with aSAH were retrospectively reviewed in a 24-month period. WBC count and CRP values were observed at admission to the hospital and on the third day. According to the inclusion criteria, 117 (48 males) participants were enrolled for further analysis, with average age of 56 ± 15 years (mean ± SD). In total, secondary CV was diagnosed in 21.4% of cases, and DCI in 22.4% of cases. The patients were classified into three groups: SAH-CV group (n = 25), SAH-DCI group (n = 12), and SAH or control group (n = 80), for comparative analysis. Results: We found that SAH-CV patients demonstrated notably higher inflammatory parameters compared to controls: WBC 13.2 ± 3.3 × 109/L vs. 11.2 ± 3.7 × 109/L; p = 0.01 and CRP median 9.3 mg/L vs. 1.9 mg/L; p < 0.001, respectively. We found that the odds of developing CV increased by 5% for each CRP increase of 1 mg/L at admission (OR, 1.05; CI, 1.014–1.087; p = 0.006). Concomitantly, the odds increased by 16% for every rise in WBC count of 1 × 109/L (OR, 1.16; CI, 1.02–1.32; p = 0.02). WBC count was associated with the occurrence of CV with 96% sensitivity and 40% specificity, with a cut off level of 10.015 × 109/L and AUC 0.683; p = 0.006. CRP displayed 54% sensitivity and 90% specificity with a cut off value of 8.9 mg/L and AUC 0.751; p < 0.001. Moreover, higher values of inflammatory parameters at admission correlated with a longer stay in ICU (r = 0.3, p = 0.002 for WBC count and r = 0.305, p = 0.002 for CRP values), and poor outcome (death) was significantly associated with higher CRP values at admission and on the third day (16.1. vs. 2.2. and 57.4. vs. 11.1, p < 0.001, respectively). Higher mortality was detected in SAH-CV patients (32%) compared to controls (6.3%; p < 0.001). Conclusions: Inflammatory parameters such as WBC count and CRP values at admission might be helpful to predict the development of secondary CV.
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Kapapa T, König R, Mayer B, Braun M, Schmitz B, Müller S, Schick J, Wirtz CR, Pala A. Adverse Events and Complications in Continuous Intra-arterial Nimodipine Infusion Therapy After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 12:812898. [PMID: 35250795 PMCID: PMC8895039 DOI: 10.3389/fneur.2021.812898] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
ObjectiveTo determine the frequency and severity of complications associated with the continuous intra-arterial infusion of nimodipine (CIANI) as a new treatment of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (SAH).MethodsPatients from two centers (n = 718) treated for SAH between 2008 and 2016 were included. Demographic and SAH-related parameters were evaluated, and also the frequency of adverse events (AEs) and complications including their severity (mild, moderate, and severe). Clinical outcome was analyzed using Glasgow Outcome Scale (GOS). The unfavorable outcome was defined as GOS 1 to 3, and favorable outcome as GOS 4 to 5. The Short-Form 36 (SF-36) health-related quality-of-life (QoL) questionnaire served as a QoL measurement.ResultsOf 718 patients, 65 (9%) were treated by CIANI and had a higher clinical or imaging grade of bleeding severity. Clinical deterioration while on treatment happened more often in patients who were treated with CIANI than in others. In patients with CIANI, 67% had AEs and/or complications during the treatment. Nimodipine-associated hypotension was seen in 8% (mild). Catheter-associated thrombus occurred in 9% (moderate). New intracerebral hemorrhage was found in 14% (moderate). A total of 6% treated by CIANI died during the treatment period (severe). More than one-third (39%) of patients of CIANI reached at least moderate disability, and 23% showed good recovery. Patients who received CIANI showed reduced QoL, but differences in mental and general health, and also pain were minimal.ConclusionPatients who received CIANI had higher rates of AEs and complications. However, this does not exclude the possibility that the use of CIANI might be helpful in patients with severe and therapy-refractory CV and DCI. Controlled and randomized studies would be helpful to clarify this question but they are methodologically and ethically challenging.
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Affiliation(s)
- Thomas Kapapa
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Ralph König
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Benjamin Mayer
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Michael Braun
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Bernd Schmitz
- Section Neuroradiology, University Hospital Ulm, Günzburg, Germany
| | - Silwia Müller
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
| | - Julia Schick
- Section Interdisciplinary Operative Intensive Care Medicine, University Hospital Ulm, Ulm, Germany
| | - Christian Rainer Wirtz
- Department of Neurosurgery, University Hospital Ulm, Ulm, Germany
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Andrej Pala
- Department of Neurosurgery, University of Ulm, Bezirkskrankenhaus Günzburg, Günzburg, Germany
- *Correspondence: Andrej Pala
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89
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Fung C, Z'Graggen WJ, Jakob SM, Gralla J, Haenggi M, Rothen HU, Mordasini P, Lensch M, Söll N, Terpolilli N, Feiler S, Oertel MF, Raabe A, Plesnila N, Takala J, Beck J. Inhaled Nitric Oxide Treatment for Aneurysmal SAH Patients With Delayed Cerebral Ischemia. Front Neurol 2022; 13:817072. [PMID: 35250821 PMCID: PMC8894247 DOI: 10.3389/fneur.2022.817072] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/24/2022] [Indexed: 11/22/2022] Open
Abstract
Background We demonstrated experimentally that inhaled nitric oxide (iNO) dilates hypoperfused arterioles, increases tissue perfusion, and improves neurological outcome following subarachnoid hemorrhage (SAH) in mice. We performed a prospective pilot study to evaluate iNO in patients with delayed cerebral ischemia after SAH. Methods SAH patients with delayed cerebral ischemia and hypoperfusion despite conservative treatment were included. iNO was administered at a maximum dose of 40 ppm. The response to iNO was considered positive if: cerebral artery diameter increased by 10% in digital subtraction angiography (DSA), or tissue oxygen partial pressure (PtiO2) increased by > 5 mmHg, or transcranial doppler (TCD) values decreased more than 30 cm/sec, or mean transit time (MTT) decreased below 6.5 secs in CT perfusion (CTP). Patient outcome was assessed at 6 months with the modified Rankin Scale (mRS). Results Seven patients were enrolled between February 2013 and September 2016. Median duration of iNO administration was 23 h. The primary endpoint was reached in all patients (five out of 17 DSA examinations, 19 out of 29 PtiO2 time points, nine out of 26 TCD examinations, three out of five CTP examinations). No adverse events necessitating the cessation of iNO were observed. At 6 months, three patients presented with a mRS score of 0, one patient each with an mRS score of 2 and 3, and two patients had died. Conclusion Administration of iNO in SAH patients is safe. These results call for a larger prospective evaluation.
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Affiliation(s)
- Christian Fung
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
| | - Werner J Z'Graggen
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stephan M Jakob
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Matthias Haenggi
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Rothen
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Michael Lensch
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Söll
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nicole Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
- Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Sergej Feiler
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Markus F Oertel
- Department of Neurosurgery, University Hospital Zurich, Zurich, Switzerland
| | - Andreas Raabe
- Department of Neurosurgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany
| | - Jukka Takala
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jürgen Beck
- Department of Neurosurgery, Medical Center, University of Freiburg, Freiburg, Germany
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90
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Lee D, Lee J, Kim KH, Kim JH, Lee J. Diffuse Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage in a 15-Year-Old Girl: A Case Report. FRONTIERS IN RADIOLOGY 2022; 1:774739. [PMID: 37492181 PMCID: PMC10365113 DOI: 10.3389/fradi.2021.774739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/20/2021] [Indexed: 07/27/2023]
Abstract
Diffuse cerebral vasospasm after subarachnoid hemorrhage (SAH) is a complication resulting in an ischemic condition presenting with altered mentality and followed by motor or speech impairment. It is uncommon in pediatric population and requires differential diagnosis from Moyamoya disease, which is relatively common in Korea. We report a case of a 15-year-old girl who was presented with a seizure and subsequent headache, poor oral intake, and altered mentality, who was finally diagnosed with sporadic vasospasm followed by multiple aneurysm ruptures. The patient had recurrent seizures and persistent headache at the time of transfer. On the second day after transfer, she showed focal motor weakness and dysarthria, and her symptoms gradually progressed, showing paraplegia and aphasia on the third hospitalization day. Brain magnetic resonance imaging and magnetic resonance angiography demonstrated diffuse narrowing cerebral vasospasm of bilateral middle cerebral arteries, anterior cerebral arteries, and distal internal carotid arteries and three unruptured aneurysms. The patient was treated with intravenous hydration and nimodipine to expand the narrowed vessels. After confirming that the vessels were enlarged, we successfully executed the endovascular coil embolization. Her neurological deficits were improved through medical, interventional, and rehabilitation treatments and fully restored 11 months after discharge.
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Affiliation(s)
- Dajeong Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jeehun Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keon Ha Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ji Hye Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jiwon Lee
- Department of Pediatrics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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91
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Factors Associated With Brain Tissue Oxygenation Changes After RBC Transfusion in Acute Brain Injury Patients. Crit Care Med 2022; 50:e539-e547. [PMID: 35132018 DOI: 10.1097/ccm.0000000000005460] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Anemia is common after acute brain injury and can be associated with brain tissue hypoxia. RBC transfusion (RBCT) can improve brain oxygenation; however, predictors of such improvement remain unknown. We aimed to identify the factors associated with PbtO2 increase (greater than 20% from baseline value) after RBCT, using a generalized mixed model. DESIGN This is a multicentric retrospective cohort study (2012-2020). SETTING This study was conducted in three European ICUs of University Hospitals located in Belgium, Switzerland, and Austria. PATIENTS All patients with acute brain injury who were monitored with brain tissue oxygenation (PbtO2) catheters and received at least one RBCT. INTERVENTION Patients received at least one RBCT. PbtO2 was recorded before, 1 hour, and 2 hours after RBCT. MEASUREMENTS AND MAIN RESULTS We included 69 patients receiving a total of 109 RBCTs after a median of 9 days (5-13 d) after injury. Baseline hemoglobin (Hb) and PbtO2 were 7.9 g/dL [7.3-8.7 g/dL] and 21 mm Hg (16-26 mm Hg), respectively; 2 hours after RBCT, the median absolute Hb and PbtO2 increases from baseline were 1.2 g/dL [0.8-1.8 g/dL] (p = 0.001) and 3 mm Hg (0-6 mm Hg) (p = 0.001). A 20% increase in PbtO2 after RBCT was observed in 45 transfusions (41%). High heart rate (HR) and low PbtO2 at baseline were independently associated with a 20% increase in PbtO2 after RBCT. Baseline PbtO2 had an area under receiver operator characteristic of 0.73 (95% CI, 0.64-0.83) to predict PbtO2 increase; a PbtO2 of 20 mm Hg had a sensitivity of 58% and a specificity of 73% to predict PbtO2 increase after RBCT. CONCLUSIONS Lower PbtO2 values and high HR at baseline could predict a significant increase in brain oxygenation after RBCT.
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Clough B, Tenii J, Wee C, Gunter E, Griffin T, Aiyagari V. Nimodipine in Clinical Practice: A Pharmacological Update. J Neurosci Nurs 2022; 54:19-22. [PMID: 34775392 DOI: 10.1097/jnn.0000000000000625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT INTRODUCTION: Enteral nimodipine provides a neuroprotective effect in patients who have experienced an aneurysmal subarachnoid hemorrhage (aSAH). Nimodipine remains the only US Food and Drug Administration-approved medication for aSAH. CONTENT: Nimodipine has been prescribed for patients with aSAH; however, little is known about factors to consider regarding dosing or patient-specific variables that may affect tolerability to nimodipine. Clinical impact of dose or dosing frequency changes has also been much debated based on risk of hypotension with currently approved dosing regimens. CONCLUSION: This review article addresses factors to consider for dosing and administration, pharmacokinetic and pharmacogenetic impact on nimodipine, and, finally, drug interaction considerations to assess as patients are initiated on enteral nimodipine for aSAH.
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93
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Uryga A, Nasr N, Kasprowicz M, Woźniak J, Goździk W, Burzyńska M. Changes in autonomic nervous system during cerebral desaturation episodes in aneurysmal subarachnoid hemorrhage. Auton Neurosci 2022; 239:102968. [DOI: 10.1016/j.autneu.2022.102968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/16/2021] [Accepted: 02/21/2022] [Indexed: 10/19/2022]
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Price RD, Bhurwani MMS, Sommer KN, Monteiro A, Baig AA, Davies JM, Siddiqui AH, Ionita CN. Initial investigation of the use of angiographic parametric imaging for early prognosis of delayed cerebral ischemia in patients with subarachnoid hemorrhage. PROCEEDINGS OF SPIE--THE INTERNATIONAL SOCIETY FOR OPTICAL ENGINEERING 2022; 12036:120361Q. [PMID: 35983497 PMCID: PMC9385186 DOI: 10.1117/12.2612081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
PURPOSE Subarachnoid Hemorrhage (SAH) is a lethal hemorrhagic stroke that account for 25% of cerebrovascular deaths. As a result of the initial bleed, a chain of physiological events are initiated which may lead to Delayed Cerebral Ischemia (DCI). As of now we have no diagnostic capability to identify patients which may present DCI a few weeks after initial presentation. We propose to investigate whether a data driven approach using angiographic parametric imaging (API) may predict occurrence of the DCI. MATERIALS AND METHODS Digital Subtraction Angiographic (DSA) sequences from 125 SAH patients were used retrospectively to perform API assessment of the entire brain hemisphere where the hemorrhage was detected. Four Regions of Interests (ROIs) were placed to extract five average API biomarkers in the lateral and AP DSAs. Data driven analysis using Logistic Regression was performed for various API parameters and ROIs to find the optimal configuration to maximize the prognosis accuracy. Each model performance was evaluated using area under the curve of the receiver operator characteristic (AUROC). RESULTS Data driven approach with API has a 60% accuracy predicting DCI occurrence. We determined that location of the ROI for extraction of the API parameters is very important for the data driven model performance. Normalizing the values using the inlet velocities for each patient yield higher and more consistent results. Single API biomarkers models had poor prediction accuracies, barely better than chance. CONCLUSIONS This effectiveness exploratory study demonstrates for the first time, that prognosis of the DCI in SAH patients, is feasible and warrants a more in-depth investigation.
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Affiliation(s)
- Roman D Price
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
| | - Mohammad Mahdi Shiraz Bhurwani
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
| | - Kelsey N Sommer
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- QAS.AI Incorporated, Buffalo NY 14203
| | - Andrei Monteiro
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14228
| | - Ammad A Baig
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14228
| | - Jason M Davies
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14228
- QAS.AI Incorporated, Buffalo NY 14203
- University Dept. of Biomedical Informatics, University at Buffalo, Buffalo, NY 14214
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14228
- University Dept. of Biomedical Informatics, University at Buffalo, Buffalo, NY 14214
| | - Ciprian N Ionita
- Department of Biomedical Engineering, University at Buffalo, Buffalo NY 14228
- Canon Stroke and Vascular Research Center, Buffalo, NY 14203
- University at Buffalo Neurosurgery, University at Buffalo Jacobs School of Medicine, Buffalo NY 14228
- QAS.AI Incorporated, Buffalo NY 14203
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95
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Uryga A, Nasr N, Kasprowicz M, Budohoski K, Sykora M, Smielewski P, Burzyńska M, Czosnyka M. Relationship Between Baroreflex and Cerebral Autoregulation in Patients With Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage. Front Neurol 2022; 12:740338. [PMID: 35095711 PMCID: PMC8790510 DOI: 10.3389/fneur.2021.740338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/02/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Common consequences following aneurysmal subarachnoid hemorrhage (aSAH) are cerebral vasospasm (CV), impaired cerebral autoregulation (CA), and disturbance in the autonomic nervous system, as indicated by lower baroreflex sensitivity (BRS). The compensatory interaction between BRS and CA has been shown in healthy volunteers and stable pathological conditions such as carotid atherosclerosis. The aim of this study was to investigate whether the inverse correlation between BRS and CA would be lost in patients after aSAH during vasospasm. A secondary objective was to analyze the time-trend of BRS after aSAH. Materials and Methods: Retrospective analysis of prospectively collected data was performed at the Neuro-Critical Care Unit of Addenbrooke's Hospital (Cambridge, UK) between June 2010 and January 2012. The cerebral blood flow velocity (CBFV) was measured in the middle cerebral artery using transcranial Doppler ultrasonography (TCD). The arterial blood pressure (ABP) was monitored invasively through an arterial line. CA was quantified by the correlation coefficient (Mxa) between slow oscillations in ABP and CBFV. BRS was calculated using the sequential cross-correlation method using the ABP signal. Results: A total of 73 patients with aSAH were included. The age [median (lower-upper quartile)] was 58 (50–67). WFNS scale was 2 (1–4) and the modified Fisher scale was 3 (1–3). In the total group, 31 patients (42%) had a CV and 42 (58%) had no CV. ABP and CBFV were higher in patients with CV during vasospasm compared to patients without CV (p = 0.001 and p < 0.001). There was no significant correlation between Mxa and BRS in patients with CV, neither during nor before vasospasm. In patients without CV, a significant, although moderate correlation was found between BRS and Mxa (rS = 0.31; p = 0.040), with higher BRS being associated with worse CA. Multiple linear regression analysis showed a significant worsening of BRS after aSAH in patients with CV (Rp = −0.42; p < 0.001). Conclusions: Inverse compensatory correlation between BRS and CA was lost in patients who developed CV after aSAH, both before and during vasospasm. The impact of these findings on the prognosis of aSAH should be investigated in larger studies.
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Affiliation(s)
- Agnieszka Uryga
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Nathalie Nasr
- INSERM UMR 1297, Institute of Cardiovascular and Metabolic Diseases (I2MC), Toulouse, France.,Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Karol Budohoski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Sykora
- Department of Neurology, St. John's Hospital, Vienna, Austria.,Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Małgorzata Burzyńska
- Department of Anaesthesiology and Intensive Care, Wroclaw Medical University, Wrocław, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
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Warner L, Bach-Hagemann A, Albanna W, Clusmann H, Schubert GA, Lindauer U, Conzen-Dilger C. Vascular Reactivity to Hypercapnia Is Impaired in the Cerebral and Retinal Vasculature in the Acute Phase After Experimental Subarachnoid Hemorrhage. Front Neurol 2022; 12:757050. [PMID: 35095718 PMCID: PMC8793938 DOI: 10.3389/fneur.2021.757050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Impaired cerebral blood flow (CBF) regulation, such as reduced reactivity to hypercapnia, contributes to the pathophysiology after aneurysmal subarachnoid hemorrhage (SAH), but temporal dynamics in the acute phase are unknown. Featuring comparable molecular regulation mechanisms, the retinal vessels participate in chronic and subacute stroke- and SAH-associated vessel alterations in patients and can be studied non-invasively. This study is aimed to characterize the temporal course of the cerebral and retinal vascular reactivity to hypercapnia in the acute phase after experimental SAH and compare the potential degree of impairment.Methods: Subarachnoid hemorrhage was induced by injecting 0.5 ml of heparinized autologous blood into the cisterna magna of male Wistar rats using two anesthesia protocols [isoflurane/fentanyl n = 25 (Sham + SAH): Iso—Group, ketamine/xylazine n = 32 (Sham + SAH): K/X—Group]. CBF (laser speckle contrast analysis) and physiological parameters were measured continuously for 6 h. At six predefined time points, hypercapnia was induced by hypoventilation controlled via blood gas analysis, and retinal vessel diameter (RVD) was determined non-invasively.Results: Cerebral reactivity and retinal reactivity in Sham groups were stable with only a slight attenuation after 2 h in RVD of the K/X—Group. In the SAH Iso—Group, cerebral and retinal CO2 reactivity compared to baseline was immediately impaired starting at 30 min after SAH (CBF p = 0.0090, RVD p = 0.0135) and lasting up to 4 h (p = 0.0136, resp. p = 0.0263). Similarly, in the K/X—Group, cerebral CO2 reactivity was disturbed early after SAH (30 min, p = 0.003) albeit showing a recovery to baseline after 2 h while retinal CO2 reactivity was impaired over the whole observation period (360 min, p = 0.0001) in the K/X—Group. After normalization to baseline, both vascular beds showed a parallel behavior regarding the temporal course and extent of impairment.Conclusion: This study provides a detailed temporal analysis of impaired cerebral vascular CO2 reactivity starting immediately after SAH and lasting up to 6 h. Importantly, the retinal vessels participate in these acute changes underscoring the promising role of the retina as a potential non-invasive screening tool after SAH. Further studies will be required to determine the correlation with functional outcomes.
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Affiliation(s)
- Laura Warner
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Annika Bach-Hagemann
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Gerrit A. Schubert
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Ute Lindauer
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen-Dilger
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- *Correspondence: Catharina Conzen-Dilger
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97
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DCI after Aneurysmal Subarachnoid Hemorrhage Is Related to the Expression of MFG-E8. BIOMED RESEARCH INTERNATIONAL 2022; 2021:6568477. [PMID: 35005020 PMCID: PMC8741362 DOI: 10.1155/2021/6568477] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 12/05/2021] [Accepted: 12/13/2021] [Indexed: 11/17/2022]
Abstract
Objective To explore the predictive value of milk fat globule epidermal growth factor 8 (MFG-E8) in the occurrence of delayed cerebral ischemia (DCI) after an aneurysmal subarachnoid hemorrhage (aSAH). Methods We recruited 32 patients with aSAH as the case group and 24 patients with unruptured aneurysms as the control group. Serum MFG-E8 levels were measured by western blot and enzyme-linked immunosorbent assay. We analyzed the relationship between MFG-E8 levels and the risk of DCI. Results The levels of serum MFG-E8 in the case group (mean = 11160.9 pg/mL) were significantly higher than those in the control group (mean = 3081.0 pg/mL, p < 0.001). MFG-E8 levels highly correlated with the World Federation of Neurosurgical Societies (WFNS) and modified Fisher scores (r = -0.691 and - 0.767, respectively, p < 0.001). In addition, MFG-E8 levels in patients with DCI (5882.7 ± 3162.4 pg/mL) were notably higher than those in patients without DCI (15818.2 ± 3771.6 pg/mL, p < 0.001). A receiver operating characteristic curve showed that the occurrence of DCI could effectively be predicted by MFG-E8 (area under the curve = 0.976, 95%CI = 0.850-1.000). Kaplan-Meier survival analysis showed a remarkable decrease in the incidence of DCI in case group individuals with high levels of MFG-E8 (≥11160.9 pg/mL, p < 0.001). Conclusion MFG-E8 may be a useful predictive marker for DCI after an aSAH and could be a promising surrogate end point.
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98
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Parasram M, Parikh NS, Merkler AE, Ch’ang JH, Navi BB, Kamel H, Zhang C, Murthy SB. Long-Term Risk of Ischemic Stroke among Elderly Survivors of Non-Traumatic Subarachnoid Hemorrhage. Cerebrovasc Dis 2022; 51:14-19. [PMID: 34265782 PMCID: PMC8760353 DOI: 10.1159/000517416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/12/2021] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Non-traumatic subarachnoid hemorrhage (SAH) is associated with poor long-term functional outcomes, but the risk of ischemic stroke among SAH survivors is poorly understood. OBJECTIVES The aim of this study was to evaluate the risk of ischemic stroke among survivors of SAH. METHODS We performed a retrospective cohort study using claims data from Medicare beneficiaries from 2008 to 2015. The exposure was a diagnosis of SAH, while the outcome was an acute ischemic stroke, both identified using previously validated ICD-9-CM diagnosis codes. We used Cox regression analysis adjusting for demographics and stroke risk factors to evaluate the association between SAH and long-term risk of ischemic stroke. RESULTS Among 1.7 million Medicare beneficiaries, 912 were hospitalized with non-traumatic SAH. During a median follow-up of 5.2 years (IQR, 2.7-6.7), the cumulative incidence of ischemic stroke was 22 per 1,000 patients per year among patients with SAH, and 7 per 1,000 patients per year in those without SAH. In adjusted Cox models, SAH was associated with an increased risk of ischemic stroke (HR, 2.0; 95% confidence interval, 1.4-2.8) as compared to beneficiaries without SAH. Similar results were obtained in sensitivity analyses, when treating death as a competing risk (sub HR, 3.0; 95% CI, 2.8-3.3) and after excluding ischemic stroke within 30 days of SAH discharge (HR, 1.5; 95% CI, 1.1-2.3). CONCLUSIONS In a large, heterogeneous national cohort of elderly patients, survivors of SAH had double the long-term risk of ischemic stroke. SAH survivors should be closely monitored and risk stratified for ischemic stroke.
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Affiliation(s)
- Melvin Parasram
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Judy H. Ch’ang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA,Correspondence to: Santosh Murthy, MD, MPH, 525 East 68th St, Suite F610, New York, NY USA 10065, Tel: 212-746-0382,
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QU X, SHANG F, XU Y, CHENG W, CHEN W, QI M, JIANG L, WANG N. The effect of step-wised protocol on critical care management of severe aneurysmal subarachnoid hemorrhage. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.38420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Xin QU
- Xuanwu Hospital of Capital Medical University, China
| | - Feng SHANG
- Xuanwu Hospital of Capital Medical University, China
| | - Yueqiao XU
- Xuanwu Hospital of Capital Medical University, China
| | - Weitao CHENG
- Xuanwu Hospital of Capital Medical University, China
| | - Wenjin CHEN
- Xuanwu Hospital of Capital Medical University, China
| | - Meng QI
- Xuanwu Hospital of Capital Medical University, China
| | - Lidan JIANG
- Xuanwu Hospital of Capital Medical University, China
| | - Ning WANG
- Xuanwu Hospital of Capital Medical University, China
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100
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Multidisciplinary and standardized management of patients with delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:2917-2926. [PMID: 36006507 PMCID: PMC9613736 DOI: 10.1007/s00701-022-05347-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/08/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The appropriate management of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) remains uncertain. We aimed to evaluate the effect of implementing a standardized protocol for detection and management of DCI after aSAH on cerebral infarction and functional outcome. METHODS We studied two cohorts of aSAH patients, one before (pre-implementation cohort: January 2012 to August 2014) and one after (post-implementation cohort: January 2016 to July 2018) implementation of a multidisciplinary approach, with standardized neurological and radiological assessment and risk-based medical treatment of DCI. We assessed the presence of new hypodensities on CT within 6 weeks after aSAH and categorized cerebral infarction into overall and DCI-related infarctions (hypodensities not within 48 h after IA repair and not attributable to aneurysm occlusion or intraparenchymal hematoma). Functional outcome was assessed at 3 months using the extended Glasgow outcome scale (eGOS), dichotomized into unfavorable (eGOS: 1-5) and favorable (eGOS: 6-8). We calculated odds ratios (OR) with corresponding 95% confidence intervals (CI's), and adjusted for age, WFNS grade, Fisher score, and treatment modality (aOR). RESULTS In the post-implementation (n = 158) versus the pre-implementation (n = 143) cohort the rates for overall cerebral infarction were 29.1% vs 46.9% (aOR: 0.41 [0.24-0.69]), for DCI-related cerebral infarction 17.7% vs. 31.5% (aOR: 0.41 [0.23-0.76]), and for unfavorable functional outcome at 3 months 37.3% vs. 53.8% (aOR: 0.30 [0.17-0.54]). For patients with DCI, the rates for unfavorable functional outcomes at 3 months in the post-implementation versus the pre-implementation cohort were 42.3% vs. 77.8% (aOR: 0.1 [0.03-0.27]). CONCLUSIONS A multidisciplinary approach with more frequent and standardized neurological assessment, standardized CT and CT perfusion monitoring, as well as tailored application of induced hypertension and invasive rescue therapy strategies, is associated with a significant reduction of cerebral infarction and unfavorable functional outcome after aneurysmal aSAH.
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